It’s a paradox for the medical community: On the one hand, peripheral artery disease can cause complications just as serious as other atherosclerotic diseases. On the other hand, PAD often goes undiagnosed and untreated, more so than coronary artery disease and cerebrovascular disease.
At Penn Medicine, care teams want to change the PAD dynamic by supporting the community podiatrists, endocrinologists, and primary care physicians who often encounter the first signs of the progressive disease.
An accredited and extensive vascular laboratory network already provides easy-to-access evaluations across southeastern Pennsylvania, southern New Jersey, and northern Delaware.
And now vascular surgeons at Penn Medicine are exploring therapies that can further extend treatment options for advanced PAD, building on the Division of Vascular Surgery and Endovascular Therapy’s early focus on catheter-based revascularization.
The surgeons are also leading the expansion of the Penn Advanced Limb Preservation (PALP) program, a unique effort that delivers the multispecialty care so critical to successful PAD outcomes.
“It’s a medically complex population,” explains vascular surgeon Elizabeth Genovese, MD, PALP co-director. “It’s not just about restoring blood flow through blocked arteries. There are so many aspects to care, and you have to address all of them.”
The Penn Medicine commitment comes at a critical juncture. An estimated 21 million Americans already live with PAD, reflecting an aging population and a surge in diabetes—key risk factors for the disease. That figure, from a 2023 paper in Vascular Disease Management, represents nearly 1 in 5 people 65 or older and could grow to 24 million by 2030.
Without concerted intervention, the projected PAD increase will put a significant share of the U.S. population at risk for the disease’s complications—loss of mobility, lower extremity amputations, and death.
”The consequences call for urgent action,” says vascular surgeon Julia Glaser, MD, the other PALP director. “Fortunately, early recognition and treatment can prevent progression, protect quality of life, and avoid serious complications.”
Warning signs go beyond claudication and can include chronic limb-threatening ischemia
PAD prevention—or possible diagnostic consideration—starts with the risk factors, Genovese and Glaser say. Diabetes, smoking, and a family history of PAD have the most impact and can lead to earlier onset. Hyperlipidemia and hypertension also play a role, as does race: Black Americans are three times more likely to develop PAD than non-Hispanic whites, even after adjusting for other risk factor prevalence.
In addition to diabetes, coronary artery disease, cerebrovascular disease, and chronic kidney disease represent common concomitant conditions.
Clinically, up to 40% of patients are asymptomatic. Other people may complain of intermittent claudication, lingering calf pain, pain in other leg muscles, or even leg pain that starts at rest. Less commonly, pain may develop in the hips, buttocks, or back.
Since atypical presentations can still lead to complications, that makes consideration of risk factors and concomitant disease particularly crucial for identifying possible PAD cases, the Penn Medicine physicians say.
In PAD’s most severe stage, chronic limb-threatening ischemia (CLTI), lower extremity ulcers can form—and may not heal. Subsequent gangrene and infection can present an amputation risk. Such cases require timely intervention to avoid amputation, Dr. Glaser explains.
”In these patients, time is of the essence,” she says. “Any physician concerned about CLTI should have a low threshold for sending their patient to a vascular surgeon.”
Ankle brachial index to effectively diagnose PAD
In the clinic, community physicians suspecting PAD can check for weak or absent pulses in the lower extremities—most efficiently in the dorsalis pedis. Ideally, exams should occur more often in people who smoke and have diabetes, particularly those with uncontrolled blood glucose or lower extremity complaints.
While concerning results do not always mean PAD, they can indicate that follow-up is appropriate. Penn Medicine’s vascular surgeons welcome inquiries about the need for further testing.
”Given the possible complications of PAD, we want to help identify as many cases as we can,” Dr. Glaser says.
Initial PAD evaluation begins with a resting ankle brachial index (ABI) test. Using Doppler ultrasound, providers compare systolic blood pressure between the ankles and arms—a noninvasive yet effective method for identifying PAD. For people with PAD symptoms but normal test results, providers may turn to exercise ABI testing.
Penn Medicine’s vascular labs provide access to ABI testing performed by registered technicians and interpreted by experienced team members across 27 counties. Community physicians can order standalone testing for patients or comprehensive evaluation by a vascular surgeon.
In addition to laboratory testing, Penn Medicine supports community events around Philadelphia to increase PAD screening and awareness. This work is crucial for addressing race-based PAD risk and disparities in outcomes.
Medical therapy and advanced PAD revascularization impacts outcomes
Noninvasive interventions such as structured exercise and smoking cessation and evidence-based medical therapy can help maintain leg function, lower the risk of cardiovascular events, and prevent disease progression.
For individuals with diabetes, glycemic control is critical. All PAD patients should receive statins, and those with symptoms should also receive antiplatelet therapy, according to joint guidelines from the American Heart Association and American College of Cardiology. Patients should also receive antihypertensive agents if warranted. The drug cilostazol can help relieve claudication.
As part of the full spectrum of PAD care offered, Penn Medicine specialists can help with smoking cessation and optimizing medical therapy. But the program specializes in referrals for advanced cases. Penn Medicine vascular surgeons offer the most options in the region for revascularization—either when refractory claudication interferes with daily life or more urgently when CLTI poses an amputation risk.
While open femoral-popliteal bypass and endarterectomy still serve many patients, the Penn Medicine team increasingly employs endovascular therapy, including in people with comorbidities that raise surgical risk. Techniques such as open or percutaneous deep vein arterialization and endovascular pedal access also provide options for patients who previously had no options because of anatomy and PAD progression.
Ongoing PAD clinical trials at Penn Medicine now look to unlock endovascular opportunities in the tibial arteries.
“There’s been a real push here to be at the forefront of using new technology,” Dr. Genovese explains. “We’re looking at the best ways to treat PAD, to get optimal outcomes for patients, prolong their interventions, and increase limb salvage rates.”
Much of that effort depends on a team approach, with regular meetings between Penn Medicine’s vascular surgeons, interventional cardiologists, and interventional radiologists to discuss complex revascularizations and harness collective expertise.
This collaboration also extends to PALP, with expedited access to endocrinologists, podiatrists, orthopedic surgeons, plastic surgeons, and infectious disease and hyperbaric medicine specialists. Studies show that the most effective CLTI care comes from such a team approach.
“PAD patients need a lot of help from a lot of different specialties,” Glaser says. “We have all these people thinking about their needs, to ensure we take the best care of them.”
Partnering with community physicians in PAD response
Penn Medicine makes it easy to refer patients for a PAD workup or consultation but still stay involved in their care. By confirming an accurate diagnosis and accessing the latest therapeutic approaches, community physicians can secure the best outcomes for their patients.
To transfer or refer a patient, call 877.937.PENN (7366) or visit http://pennmedicine.org/referrals.