Peripheral Arterial Disease — PAD

The patient says their legs hurt when they walk but feel better at rest. That pattern — intermittent claudication — is the signature of arterial insufficiency, and misreading it as venous disease changes everything.

Peripheral arterial disease (PAD) results from atherosclerotic narrowing of arteries supplying the lower extremities, progressively reducing perfusion. The hallmark symptom is intermittent claudication: cramping leg pain during activity that resolves within minutes of rest. As disease advances, pain occurs at rest — especially at night — and the patient may dangle the legs over the bedside for relief (dependent position uses gravity to aid perfusion). Assessment findings reflect ischemia: diminished or absent pedal pulses, cool and pale extremities that become dusky or cyanotic with elevation (elevation pallor) and reddish-blue with dependency (dependent rubor). Skin is thin, shiny, and hairless with thickened toenails. The ankle-brachial index (ABI) is the key diagnostic screening tool: normal is 1.0–1.3, and an ABI below 0.9 confirms PAD. Values below 0.4 indicate severe ischemia with risk of tissue loss. Nursing priorities include promoting circulation (walking programs, positioning with legs flat or slightly below heart level), meticulous foot care, smoking cessation education, and monitoring for wound complications. Never elevate legs above the heart — this worsens arterial perfusion. Buerger-Allen exercises (alternating elevation, dependency, and flat positioning) may be prescribed to stimulate collateral circulation.

Key Distinctions

Don't confuse arterial insufficiency (pale, cool, absent pulses, claudication with activity) with venous insufficiency (warm, edematous, brown discoloration, aching relieved by elevation). Students often elevate legs for all vascular problems — elevation helps venous disease but worsens arterial disease. An ABI above 1.3 isn't "extra healthy"; it signals calcified, noncompressible vessels (common in diabetes) and requires further workup.

Clinical Pearl

Arterial = pale, pulseless, painful with walking. Venous = edematous, warm, brown staining. Remember: Arterial hangs down for relief, Venous goes up.