Intermittent claudication

Peripheral arterial disease of the lower limbs, also known as intermittent claudication

In peripheral arterial disease of the lower limbs, changes accumulate in the walls of the arteries in the legs due to atherosclerosis. These changes may gradually narrow the arteries and weaken blood flow. The disease is part of a broader arterial condition and increases the risk of both heart attack and stroke. In some patients, the disease progresses so far that the risk of tissue necrosis and amputation increases.

Arterial disease is common and the leading cause of death worldwide. In Western countries, its prevalence is particularly high, which is related, among other things, to the high intake of saturated fats in the diet.

What symptoms does peripheral arterial disease of the lower limbs cause?

Most patients are asymptomatic, as mild changes do not cause noticeable sensations. If a person is not very physically active, the disease may progress quite far without symptoms.

The most typical initial symptom is pain while walking. Muscles need more oxygen during movement, but if an artery is narrowed, blood flow is insufficient. This leads to oxygen deficiency and muscle pain. The pain is most often felt in the calves or thighs, sometimes in the buttocks or feet. Sometimes the legs simply feel tired. Rest relieves the pain, and walking becomes possible again for a short time. This is called intermittent claudication. The more severe the disease, the shorter the distance the patient can walk without pain.

How do I know if my walking problems are caused by arterial disease?

Pain caused by arterial disease always begins during exertion and eases with rest. If symptoms improve with exercise, the cause is not arterial disease. The walking distance on level ground is usually roughly the same each time, but symptoms appear more quickly when walking uphill.

Spinal canal stenosis (spinal stenosis) can cause very similar claudication‑like symptoms, and the two cannot always be distinguished based on symptoms alone—examinations are needed.

Why do I have arterial disease?

The most important risk factors are:

• Smoking
• High cholesterol
• Diabetes
• High blood pressure

Age and genetics also play a role. Genetics explain why some people develop arterial disease more easily due to risk factors, while in others, for example smoking does not lead to the development of the disease.

The disease begins when LDL cholesterol accumulates in the arterial wall. Initially, a small fatty deposit forms, which grows and hardens as calcium builds up. If the plaque ruptures, platelets adhere to it and the artery may become acutely blocked, causing rapidly worsening symptoms.

What if arterial disease gets worse?

If risk factors are not treated, the changes worsen and blockages develop at multiple levels. As blood flow decreases, intermittent claudication progresses to rest pain. At first, the pain occurs at night when lying down lowers arterial pressure in the legs. Later, wounds may appear that do not heal, as well as tissue necrosis. This condition is chronic limb‑threatening ischemia, in which the risk of amputation is high without improving blood flow.

Why is early detection important?

The earlier arterial disease is detected, the better the chances of preventing progression. Good management of risk factors can slow or even stop the disease, preventing symptoms from ever appearing.

Peripheral arterial disease of the lower limbs often indicates other arterial diseases, such as coronary artery disease or carotid artery disease. Because of these, the risk of heart attack and stroke is significantly increased.

What does risk‑factor management mean?

Managing risk factors is essential for protecting the arteries of both the lower limbs and the entire body.

Cholesterol: For everyone diagnosed with atherosclerosis, lowering LDL cholesterol with medication is recommended. The target is below 1.4 mmol/l. Medication is usually required, sometimes more than one type.

Diet: low in salt and saturated fats, rich in vegetables, fruits, and fiber.

Blood pressure: should be below 130/80 mmHg.

Medication: if the disease causes symptoms, long‑term low‑dose aspirin or clopidogrel is recommended. In some cases, low‑dose rivaroxaban is added alongside aspirin.

Diabetes: good glucose control is important.

Smoking: quitting is crucial—effective medications are available to support cessation.

Exercise: regular walking is part of the treatment. Three one‑hour walks per week are recommended. During training, it is beneficial to walk until pain occurs and beyond several times. This improves metabolism and may enhance blood flow through collateral circulation.

Is intermittent claudication dangerous?

The symptom itself is not dangerous, and walking to the point of pain is even beneficial. However, the underlying arterial disease significantly increases the risk of heart attack and stroke. Therefore, treatment is important even if symptoms do not yet impair quality of life.

How is arterial disease diagnosed?

• Palpation of pulses gives a rough idea of the circulation.
• The ankle‑brachial index is measured during the visit, and its value predicts mortality risk.
• Ultrasound shows the structure and flow of the arteries and any blockages.
• Additional imaging (CT or MRI) is performed if procedures are being considered.
• Blood tests determine, among other things, cholesterol levels.

When is blood flow improved with a procedure?

The primary treatment is walking exercise and risk‑factor management. If symptoms still significantly impair daily life, procedures may be considered.

Endovascular treatments: balloon angioplasty and, if necessary, stent placement. These are now the most common treatments because they are less invasive than surgery. Patients can often go home the same day.

Bypass surgery: performed less frequently. It requires general anesthesia and a longer hospital stay. The risks are higher than with endovascular treatments.

Prognosis

When risk factors are well managed, disease progression slows significantly. However, arterial disease is inherently progressive, so regular annual check‑ups are necessary.

In the long term, about 5–10% of patients with intermittent claudication progress to limb‑threatening ischemia. In addition, all patients with arterial disease have a higher‑than‑normal risk of heart attack and stroke. Treatment is lifelong to prevent complications.

Summary

Arterial disease is common and often asymptomatic, but recognizing it is important. Managing risk factors reduces disease progression and prevents serious complications. Lifestyle changes, smoking cessation, and regular exercise are the cornerstones of treatment.

What does Sydänkeskus Helsinki offer?

The professionals at Heart Center Helsinki treat coronary artery disease and peripheral arterial disease of the lower limbs—these are the same disease in different arterial regions. Our vascular surgeons have decades of experience in diagnosis and treatment.

During a single appointment, examinations such as pressure measurements and ultrasound can be performed, and a treatment plan can be created at the same time. If walking exercise and risk‑factor management are not sufficient and symptoms impair daily life, we can assess the need for an invasive procedure. We offer endovascular treatments at Heart Center Helsinki.

The vascular surgeons working at the Heart Center have over 20 years of experience in both open and endovascular treatment of peripheral arterial disease of the lower limbs.