What is peripheral artery disease?

Peripheral artery disease (PAD) is caused by atherosclerosis — fatty plaque buildup narrowing the arteries that supply the legs and feet. It reduces blood flow, causing leg pain on walking (claudication), wounds that won't heal, and — in severe cases — gangrene requiring amputation. PAD is also a marker of systemic atherosclerosis: patients with PAD have a substantially elevated risk of heart attack and stroke. It affects 237 million people globally, predominantly older adults with cardiovascular risk factors.

Why is PAD so undertreated globally?

PAD is dramatically underdiagnosed and undertreated for several reasons: it is largely asymptomatic or presents with atypical symptoms; the diagnostic test (ABI with Doppler) requires equipment not always available in primary care; vascular surgery and interventional radiology services for revascularisation are concentrated in referral hospitals; many patients and clinicians attribute leg pain to arthritis or "old age"; and the condition lacks the same public awareness as heart attack or stroke. In LMICs, 73% of PAD burden exists with severely limited access to both diagnosis and treatment.

Major risk factors: smoking (the most powerful modifiable risk factor — approximately 4-fold increased risk); diabetes (doubles PAD risk; peripheral neuropathy means pain is often absent until disease is advanced, leading to presentation with severe ischaemia); hypertension; dyslipidaemia; chronic kidney disease; and age (prevalence approximately 20% in adults over 70). The diabetic patient who smokes is at the highest risk of CLTI and amputation.

What is critical limb threatening ischaemia?

CLTI — the most severe form of PAD — is characterised by rest pain (ischaemic pain at rest, typically in the foot, worse at night), non-healing ulcers or wounds, or gangrene (tissue death), caused by inadequate blood supply at rest. Without revascularisation, major amputation risk exceeds 30-50% within 6 months. Major lower limb amputation carries 1-year mortality of approximately 30% — worse than many cancers. A "limb salvage" team (vascular surgeon, interventional radiologist, diabetologist, podiatrist, wound care nurse) achieves the best outcomes.

Risk factor modification: smoking cessation (most important); statin therapy; antihypertensive treatment; diabetes management; antiplatelet therapy. Medical therapy for claudication: supervised exercise therapy (first-line — most effective); cilostazol (PDE3 inhibitor — improves walking distance). Pharmacological: antiplatelet (aspirin or clopidogrel; rivaroxaban 2.5mg + aspirin in COMPASS trial for symptomatic PAD); high-intensity statins; SGLT-2 inhibitors (reduce cardiac events; empagliflozin reduces amputation risk). Revascularisation for CLTI or lifestyle-limiting claudication: endovascular (angioplasty/stenting for iliac and femoropopliteal disease); bypass surgery (preferred for complex disease or endovascular failure).

How does PAD relate to diabetes?

Diabetes dramatically worsens PAD outcomes: peripheral neuropathy (loss of protective sensation) means ischaemia often presents silently until severe infection or gangrene. Minor foot trauma → unhealed wound → infection → CLTI without classic claudication. The "diabetic foot" — combining neuropathy, ischaemia and infection — is the leading cause of non-traumatic amputation globally. Diabetic PAD tends to be more diffuse and involves below-knee vessels (more difficult to revascularise). Multidisciplinary diabetic foot care significantly reduces amputation rates.

How does GMJ News cover PAD?

GMJ News covers WHO and Lancet PAD burden data, COMPASS trial evidence, critical limb ischaemia and amputation prevention, diabetic foot care and the LMICs access gap. PAD is a major cardiovascular concern in Georgia — directly relevant to PHIG's cardiovascular programme and the Georgian Medical Journal.

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Peripheral Artery Disease

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Peripheral artery disease (PAD) — caused by atherosclerosis narrowing the arteries supplying blood to the legs — affects approximately 237 million people globally, causing leg pain on walking (claudication), wounds that fail to heal and — in severe critical limb threatening ischaemia (CLTI) — a risk of amputation, sepsis and death that carries a 1-year mortality comparable to many cancers (WHO/Lancet 2020). PAD is the most common cause of non-traumatic lower limb amputation globally. Over 73% of global PAD burden is in LMICs, where access to diagnosis and revascularisation is critically limited.

Key messages

237 million people — 73% in LMICs

Peripheral artery disease affects approximately 237 million people globally — with 73% of the burden in LMICs, where access to diagnosis and revascularisation is severely limited and amputation rates are dramatically higher (Lancet 2020 / WHO).

Leading cause of non-traumatic amputation

PAD — causing critical limb threatening ischaemia (CLTI) in severe cases — is the most common cause of non-traumatic lower limb amputation globally. Major amputation carries 1-year mortality comparable to many cancers (approximately 30%) and profoundly impairs quality of life.

Smoking and diabetes are key drivers

Smoking is the most powerful PAD risk factor (approximately 4-fold increased risk). Diabetes doubles PAD risk and dramatically worsens outcomes — diabetic patients with PAD have higher amputation rates due to peripheral neuropathy masking symptoms until disease is advanced.

ABI — the simple diagnostic test

The ankle-brachial index (ABI ≤0.90) — comparing ankle to arm blood pressure using a handheld Doppler — is the recommended diagnostic standard for PAD. Simple, non-invasive, cheap and accurate — yet dramatically underutilised in routine clinical practice.

Antiplatelet, statin, smoking cessation

Three evidence-based medical interventions reduce PAD cardiovascular and limb events: antiplatelet therapy (aspirin or clopidogrel — rivaroxaban 2.5mg BD + aspirin in COMPASS trial reduces major adverse limb events by 46%); high-intensity statins; and smoking cessation.

Revascularisation for advanced disease

Endovascular revascularisation (angioplasty/stenting) or surgical bypass restores blood flow in claudication and CLTI. A "limb salvage" multidisciplinary approach (vascular surgeon, interventional radiologist, diabetologist, podiatrist, wound nurse) reduces amputation rates in CLTI.

Key statistics

237M

people with PAD globally (Lancet 2020)

Lancet/WHO

73%

of PAD burden in LMICs

Lancet 2020

~30%

1-year mortality after major lower limb amputation

Lancet Diabetes

46%

reduction in major limb events with rivaroxaban + aspirin

COMPASS trial

higher PAD risk in smokers

WHO

≤0.90

ABI threshold for PAD diagnosis

ESC/AHA

PAD age-standardised prevalence per 1,000 population by region — Lancet 2020

Source: Lancet 2020 global PAD prevalence study. LMICs have the highest burden and fewest resources.

Glossary of key terms

Peripheral artery disease (PAD)
WHO/ESCAtherosclerotic narrowing of arteries supplying the limbs — primarily the lower extremities. Ranges from asymptomatic to intermittent claudication (ischaemic leg pain on walking) to critical limb threatening ischaemia (CLTI — rest pain, non-healing wounds, gangrene). Also causes mesenteric, renal and carotid artery atherosclerosis.

Ankle-brachial index (ABI)
ESC/AHAA non-invasive PAD diagnostic test — the ratio of ankle systolic blood pressure to arm systolic blood pressure measured with a continuous wave Doppler. ABI ≤0.90 defines PAD; ABI 0.91-0.99 borderline; ABI ≥1.40 non-compressible (calcified) arteries (common in diabetes). A simple, cheap, accurate test.

Critical limb threatening ischaemia (CLTI)
ESC/SVSSevere chronic limb ischaemia — defined by rest pain, non-healing ulceration or gangrene from inadequate arterial perfusion. High risk of major amputation within 6 months without revascularisation. Carries approximately 30% 1-year mortality. Requires urgent vascular surgery evaluation.

Claudication
WHO/ESCReproducible, exercise-induced calf (or thigh, buttock) pain that is relieved by rest — caused by muscle ischaemia from blood flow insufficient for exercise demands. A marker of PAD but also of systemic atherosclerosis risk.

Supervised exercise therapy
ESC/AHAStructured supervised exercise (walking programmes, treadmill training) is first-line treatment for intermittent claudication — improving walking distance by approximately 100-200% at 3-6 months. More effective than best medical therapy alone. Requires structured programme delivery.

Rivaroxaban + aspirin (COMPASS)
ESC/NEJMThe COMPASS trial showed that adding low-dose rivaroxaban (2.5mg twice daily) to aspirin (100mg) in patients with CAD or PAD reduced major adverse limb events (including major amputation) by 46% and major adverse cardiovascular events by 26% — at the cost of modestly increased bleeding. Now ESC Class I recommendation for symptomatic PAD.