What are the symptoms of peripheral vascular disease?

Symptoms of Peripheral Vascular Disease

Peripheral vascular disease (PAD) presents with a spectrum of symptoms ranging from no symptoms at all (in up to 50% of patients) to classic intermittent claudication, atypical leg pain, ischemic rest pain, and in severe cases, nonhealing wounds or gangrene. 1

Classic Intermittent Claudication

Intermittent claudication is the hallmark symptom of PAD, but it only occurs in approximately 10-33% of patients with documented disease. 1

• Pain characteristics: Described as cramping, aching, pain, fatigue, or discomfort in the buttocks, thigh, calf, or foot that occurs consistently during walking or exercise 1
• Timing pattern: Does not start at rest, increases progressively with exercise intensity, and is relieved within approximately 10 minutes of rest 1
• Anatomic correlation: The location of arterial stenosis predicts symptom location 1:
  • Iliac artery disease → hip, buttock, thigh, and calf pain
  • Femoral/popliteal artery disease → calf pain
  • Tibial artery disease → calf pain or foot pain and numbness

Atypical Leg Symptoms

Most patients with PAD do not have classic claudication but still experience significant functional impairment. 1

• Symptom descriptors: Tingling, numbness, burning, throbbing, shooting, heaviness, or leg fatigue 1
• Atypical patterns: Exertional leg symptoms that may not limit walking or may take longer than 10 minutes to resolve after rest 1
• Prevalence: In one study of 460 PAD patients, only 32.6% had classic claudication, while 28.5% had atypical leg pain and 19.8% had no exertional leg pain 1

Asymptomatic Disease

Up to 50% of all patients with objectively documented PAD have no ischemic leg symptoms. 1

• Despite absence of symptoms, these patients still have significantly greater functional impairment and decline than people without PAD 1
• Asymptomatic PAD carries similar cardiovascular risk as symptomatic disease 1

Chronic Limb-Threatening Ischemia (CLTI)

CLTI represents the most severe manifestation of PAD, occurring in 11-20% of patients with known PAD. 1

• Ischemic rest pain: Pain affecting the forefoot that is present for more than 2 weeks, worsened with limb elevation (lying flat), and relieved by dependency (getting up, dangling legs) 1, 2
• Tissue loss: Nonhealing wounds, ulcers, or gangrene 1
• Prognosis: Historically associated with 25-35% one-year mortality and up to 30% amputation rate 1

Acute Limb Ischemia (ALI)

ALI presents with sudden decrease in arterial perfusion threatening limb viability, with symptoms present for less than 2 weeks. 1

• Classic "6 P's": Pain, pallor, pulselessness, poikilothermia (coolness), paresthesias, and potential for paralysis 1
• Incidence: Approximately 0.8 per 100 patient-years in patients with symptomatic PAD 1

Physical Examination Findings

Visual inspection and pulse examination are critical for diagnosis, as symptoms may be atypical or absent. 1

• Skin changes: Dependent rubor, pallor with elevation, absence of hair growth, dystrophic toenails 1
• Pulse abnormalities: Diminished or absent pulses at femoral, popliteal, dorsalis pedis, or posterior tibial sites 1
• Severe disease indicators: Distal hair loss, trophic skin changes, hypertrophic nails 1

Important Clinical Pitfalls

Do not assume absence of classic claudication excludes PAD—most patients have atypical or no symptoms. 1

Distinguish vascular claudication from pseudoclaudication (spinal stenosis, venous disease, arthritis, compartment syndrome) by the characteristic pattern of exercise-induced symptoms relieved promptly by rest without position change 1

In diabetic patients with peripheral neuropathy, symptoms are often atypical and vague—patients may report leg fatigue or inability to walk at normal pace rather than pain. 1

Rest pain that worsens when lying flat and improves with dependency suggests CLTI rather than simple claudication and requires urgent evaluation for revascularization. 2