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Peripheral Artery Disease

(PAD)

What Is Peripheral Artery Disease?

In the United States, more than 8 million people ages 40 and older have peripheral artery disease, or PAD. Also called peripheral arterial disease, PAD is caused by atherosclerosis, or plaque buildup, that reduces the flow of blood in peripheral arteries — the blood vessels that carry blood away from the heart to other parts of the body. This health topic focuses on the most common type of PAD, called lower extremity PAD, which reduces blood flow to the legs and feet.

You may have lower extremity PAD if you have muscle pain or weakness that begins with physical activity, such as walking, and stops within minutes after resting. About 1 in 4 people who have PAD experience these symptoms. But you may experience other symptoms or no symptoms at all. If you smoke or have high blood pressure or other risk factors for PAD, even without symptoms, ask your healthcare provider about getting tested. It is important to be aware that if you have lower extremity PAD, you may also have plaque buildup in other arteries leading to and from your heart and brain, putting you at higher risk of stroke or heart attack.

Early diagnosis and management of PAD can help treat your symptoms and reduce your risk for serious complications.

Symptoms

Peripheral artery disease (PAD) may not cause symptoms, or symptoms may be mild. PAD symptoms include:

Leg pain when walking.

Muscle pain or cramping in the arms or legs, often in the calf.

Muscle pain in the arms or legs that begins with exercise and ends with rest.

Painful cramping in one or both of the hips, thighs or calves after walking or climbing stairs or other activities.

Pain when using the arms, such as aching and cramping when knitting or writing.

Coldness in the lower leg or foot, especially when compared with the other side.

Leg numbness or weakness.

No pulse or a weak pulse in the legs or feet.

The muscle pain in peripheral artery disease may:

Be mild to extreme.

Wake you up from sleep.

Make it hard to walk or exercise.

Occur during rest or when lying down if the condition is severe.

Other symptoms of PAD may include:

Shiny skin on the legs.

Skin color changes on the legs.

Slow-growing toenails.

Sores on the toes, feet or legs that won't heal.

Hair loss or slower hair growth on the legs.

Erectile dysfunction.

Diagnosis

Your healthcare provider will diagnose peripheral artery disease (PAD) based on your medical and family history, a physical exam, and the results from tests and procedures.

Medical history and physical exam

To help diagnose PAD, your provider will want to learn about your symptoms, risk factors, personal health history, and family health history.

This discussion may include questions about the following:

Other medical conditions, including diabetes, heart disease, and chronic kidney disease

Pain or cramps in your legs while walking or exercising

Problems with your legs and feet, including swelling, redness, trouble with walking, and wounds that are slow to heal

Smoking, either current or past

Your family history of PAD, heart disease, and other blood vessel diseases

During an exam to look for signs of PAD, your provider will:

Check for weak pulses in your legs.

Listen for poor blood flow in your legs. Your provider will use a stethoscope to listen for an abnormal whooshing sound, called a bruit.

Look for problems on your legs and feet, including swelling, sores, or pale skin.

Conditions that can seem like PAD

Some conditions, such as arthritis or vein problems can cause leg pain, but the symptoms are different from those for PAD. A physical exam and your medical history can help your provider rule out these conditions.

However, problems with nerves can cause pain that may be confused with PAD. Sometimes a nerve is squeezed where it exits the spinal column. The result is pain that radiates, or spreads, from the hips or buttocks and down the leg.

To confirm that your pain is the result of PAD, your provider may ask you to stand up or change your position. Those movements often trigger nerve-related pain. In contrast, PAD pain is often brought on by leg exercise and is quickly relieved by rest with no need to change position.

Diagnostic tests and procedures

The ankle-brachial index (ABI) test is usually the first test used to diagnose PAD. The test compares blood pressure in your ankle with the blood pressure in your arm. Your provider uses a blood pressure cuff and ultrasounds device for this painless test.

A healthy ABI result is 1.00 or greater. If you have an ABI of less than 0.90 while resting, you may have PAD. An ABI of less than 0.40 is a sign of severe PAD. If there are problems with the arteries in your ankle, your provider may do a toe-brachial index (TBI) test instead, which measures the blood pressure in your big toe. A TBI less than 0.7 is abnormal. Be aware of your ABI, just as you know and keep track of your blood pressure numbers.

To diagnose PAD, your provider may also order some of the following tests and procedures:

Blood tests check your cholesterol, triglyceride, and blood sugar levels.

An exercise ABI test shows the severity of your leg symptoms and the level of physical activity that produces them. Your provider will do the ABI test after having you walk on a treadmill. This test may help them diagnose PAD when you have symptoms but your resting ABI test result is only slightly low. A drop of 20% or more in a post-exercise ABI is abnormal.

A 6-minute walking test measures how far you can walk in a hallway in 6 minutes. Your provider may do this test to see how much PAD affects your ability to function and how serious your PAD is.

Doppler ultrasound locates areas of reduced blood flow or blockages and measures how fast blood is flowing through the arteries. A handheld device is passed over your skin, and a computer converts sound waves into pictures of the blood flow in your arteries. Ultrasound can help diagnose PAD and monitor how well treatments for the condition have worked.

Segmental Doppler pressure testing checks different parts of your legs for narrowed or blocked arteries. This method is similar to ABI testing but uses blood pressure cuffs placed at thigh, calf, and ankle levels. The ultrasound device amplifies the sounds of blood flow in your arteries, making it easier to measure the blood pressure in these areas of your leg.

Your provider may also order an imaging test using angiography to get a better picture of the blood vessels in your legs and feet. There are several types of angiography:

Computed tomography angiography (CTA) allows providers to see the arteries in your legs and feet. A special dye is injected, and then X-rays are taken to show the location and extent of any blood vessel blockages.

Magnetic resonance angiography (MRA) examines the structure of your leg arteries. MRA tests may not be safe for people who have metal implants in their body.

Catheter-based angiography lets providers see inside the arteries of your legs. A doctor inserts a catheter, or tube, into an artery in your groin and guides it to the affected area. A special dye is released through the catheter and then X-rays are taken. Your provider may suggest this procedure for serious pain in the legs or feet or when treatments for PAD have not worked or other testing has not been helpful.

Causes and Risk Factors

What causes PAD?

Atherosclerosis is the main cause of PAD.

Atherosclerosis is a disease in which a waxy substance called plaque builds up on the inner lining of arteries. Plaque is made up of fat, cholesterol, fibrous tissue, and calcium. In PAD, plaque may reduce or fully block the flow of oxygen-rich blood through arteries to the body’s vital organs and the limbs.

This health topic focuses on PAD in the legs and feet, but other types of PAD block blood flow to the brain, kidneys, or the intestines. A person may have atherosclerosis in just a single artery or in many.

What raises the risk of PAD?

You may have a higher risk of lower extremity PAD because of your age, family history and genetic, lifestyle habits, other medical conditions, race, ethnicity, and sex. The risk factors for PAD are mostly the same as those for coronary heart disease and carotid artery disease, which are also caused by atherosclerosis.

Age

You can develop PAD at any age, but your risk goes up as you get older. Most people in the United States who have PAD are age 65 or older.

Worldwide, the age group for PAD is younger (ages 45 to 49) in countries with lower incomes when compared with high-income countries.

Family history and genetics

A family history of PAD, heart disease, stroke, or blood vessel disease, such as some types of vasculitis, raises your risk of PAD. Researchers are studying genes variations that seem to increase the risk of PAD or could make the disease worse.

Genetic studies have found that certain gene variations are found in different types of atherosclerotic diseases, such as PAD, carotid artery disease, and coronary heart disease. An example is the gene variation that is found in factor V Leiden disorder, a specific gene mutation that leads to an increased risk of blood clots.

Lifestyle habits

Over time, unhealthy lifestyle habits can lead to plaque buildup in the leg and foot arteries, causing PAD. These habits may include the following:

Smoking or regularly breathing in secondhand smoke damages your blood vessels, raises your blood pressure, and causes unhealthy cholesterol levels. The nicotine in tobacco also makes your blood vessels tighten and reduces blood flow in your legs. Quitting smoking is a very important step in lowering your risk of PAD.

Not getting enough physical activity can make other PAD risk factors worse.

Stress can make your arteries tighten and narrow.

Eating foods high in saturated fats and following other unhealthy eating patterns can also increase your risk of PAD. Butter, palm and coconut oils, cheese, and red meat have high amounts of saturated fat.

Other medical conditions

Medical conditions that raise your risk of developing PAD include:

Diabetes

Chronic kidney disease

Disorders that cause blood clots, such as thrombocytosis or antiphospholipid syndrome

Fibromuscular dysplasia, a condition that occurs when cells in the artery walls grow too much, making the artery narrow

High blood pressure

Metabolic syndrome

Obesity

Unhealthy blood cholesterol levels or high blood triglycerides

Also, if you had preeclampsia or gestational diabetes during pregnancy, you have a higher risk of developing PAD later in life.

Race or ethnicity

African American people have a higher risk of PAD than people of other races or ethnicities. African Americans are also more likely to have complications of PAD, such as problems walking or loss of a limb.

Additionally, American Indian women have a higher risk of PAD than white or Asian American women do. Hispanic or Latino people and white people have similar risk levels. However, NHLBI research found that rates of lower extremity PAD are higher among Hispanic and Latino adults who have highly sedentary lifestyles, even when they do not have any other risk factors.

Sex

Men and women have a similar risk of developing PAD, but PAD affects men and women differently.

Women are more likely than men to have PAD without symptoms. However, women also frequently have more PAD complications, such as problems walking.

How can you prevent PAD?

To help you prevent PAD, your provider may talk to you about heart-healthy lifestyle changes and managing conditions that may lead to PAD.

Heart-healthy lifestyle changes include quitting smoking, choosing a heart-healthy eating pattern (such as the DASH eating plan), being physically active, aiming for a healthy weight, and managing stress.

Follow your provider’s advice about preventing and treating conditions that raise your risk of PAD, such as diabetes, high blood pressure, and high blood cholesterol.

Treatment

The goals of treatment for peripheral artery disease (PAD) are:

Manage symptoms, such as leg pain, so exercise is comfortable.

Improve artery health to reduce the risk of heart attack, stroke and other complications.

Treatment for peripheral artery disease may include:

Lifestyle changes.

Medicine.

Surgery.

Lifestyle changes can help improve symptoms, especially if you have early peripheral artery disease. Such changes include:

Don't smoke or use tobacco.

Get regular exercise.

Eat a healthy diet.

Heart-healthy lifestyle changes

Your provider may recommend that you adopt lifelong heart-healthy lifestyle changes:

Quit smoking. Smoking is the main risk factor of PAD. Quitting can reduce your symptoms and your risk of complications. It is also important to avoid secondhand smoke. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute’s Your Guide to a Healthy Heart. Although these resources focus on heart health, they include basic information about how to quit smoking. For free help and support to quit smoking, call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT.

Choose heart-healthy foods, such as those in the DASH eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, sodium, added sugars, and alcohol.

Aim for a healthy weight. If you have overweight, losing just 3% to 5% of your current weight can help you manage some PAD risk factors, such as high blood cholesterol and diabetes. Losing even more weight can lower your blood pressure.

Get regular physical activity. Staying physically active can help you manage PAD risk factors such as high blood cholesterol, high blood pressure, and overweight or obesity. Before starting any exercise program, ask your provider what level of physical activity is right for you.

Manage stress. Learning how to manage stress, relax, get good-quality sleep, and cope with problems can improve your emotional and physical health.

Exercise programs

Physical activity often works well to relieve PAD symptoms and improve your ability to walk and carry out daily activities. Regular physical activity can improve the circulation in your legs. Exercise can reduce inflammation and help your blood vessels work better.

Supervised exercise

Your provider may recommend a supervised exercise program that takes place in a clinic or a hospital. The exercise program may be part of a more complete cardiac rehabilitation program.

PAD exercise programs usually meet at least 3 times a week and last between 3 months and 9 months. The most common type of exercise in these programs is treadmill walking. Other programs may use a device to exercise the upper body. Talk with your provider about your options for exercise programs.

Home exercise programs

Your provider may recommend a home-based exercise program with coaching that is similar to a supervised exercise program in a clinic. Home-based programs usually involve walking outside instead of on a treadmill. Your provider will talk with you to help you understand how to follow the program. Each exercise session lasts 30 to 50 minutes. The goal is to work up to at least 30 minutes of continuous walking.

These programs include health coaching or activity monitors. Some home-based programs include regular check-ins with a coach by telephone. Talk with your provider regularly about your progress.

Medicines

If you have symptoms or complications of peripheral artery disease (PAD), you may need medicines.

Medicine to treat peripheral artery disease may include:

Statins. These are medicines to lower "bad" cholesterol. They help reduce plaque buildup in the arteries. The drugs also lower the risk of heart attacks and strokes.

Blood pressure medicines. Uncontrolled high blood pressure can make arteries stiff and hard. This can slow the flow of blood. If you have high blood pressure, your healthcare professional may suggest medicines to control it. Ask your healthcare team what your blood pressure should be.

Diabetes medicine. Diabetes makes you more likely to get PAD. Talk with your healthcare team about your blood sugar goals and how to reach them.

Medicines to prevent blood clots. Reduced blood flow in PAD can cause blood clots. Aspirin or another medicine, such as clopidogrel (Plavix), may be used to prevent blood clotting.

Leg pain medicine. A medicine called cilostazol can be used to treat leg pain in people with peripheral artery disease. The medicine increases blood flow to the area.

Procedures or surgery

Sometimes, a surgery or procedure is needed to treat peripheral artery disease (PAD) or its symptoms.

Thrombolytic therapy. If a blood clot is blocking an artery, medicine may be given directly into the affected artery to dissolve the clot.

Angioplasty and stent placement. If a narrowed artery is causing PAD leg pain, this treatment may help. A tiny balloon on a tube, called a catheter, is placed in the artery. The balloon inflates, which makes the artery wider. This improves blood flow. A small wire mesh tube, called a stent, may be placed in the artery to keep the artery open.

Bypass surgery. This surgery creates a new path for blood to flow around a blocked or partially blocked artery. A surgeon takes a healthy blood vessel from another part of the body. The vessel is connected below the blocked artery. The new pathway improves blood flow to the muscle.

Living With

PAD is a lifelong medical condition. Once you have been diagnosed with PAD, you will see a healthcare provider regularly who specializes in vascular (blood vessel) diseases. You will need to take steps to prevent complications. Learn more about the warning signs of a medical emergency related to PAD below.

How can PAD affect your health?

PAD can lead to complications, such as the following:

Trouble managing daily activities without help because of reduced mobility

Chronic (long-term) poor blood flow in your leg: This is called critical limb ischemia and is another complication of PAD. Symptoms may include pain during rest, sores, infections, and death of tissue, called gangrene, because of lack of blood flow. Gangrene is a severe complication that may require amputation (surgical removal) of the affected body part.

Serious infections: These can develop as a result of sores on your feet that then get infected. Infections in the foot can usually be treated with antibiotics, but you may have to be treated in the hospital if the infection is serious. The infection can also spread to your tissues and muscles, to the bone, or into the bloodstream. Infections in the bloodstream need to be treated right away in the hospital. The risk of these complications is higher for people who have PAD and diabetes.

A sudden drop in blood flow to your leg: This is called acute limb ischemia and is a serious medical emergency. Call 9-1-1 or seek medical help right away if you suddenly lose feeling in your foot and cannot move it and if it is blue or paler and colder than the other foot. Quick treatment may save your limb.

People who smoke or have diabetes have a much higher risk of complications from PAD, including the risk of losing a limb. Lower your risk by quitting smoking and managing your diabetes.

If you have PAD, you probably have plaque buildup in your other arteries, including arteries in your heart and brain. Over time, plaque buildup can lead to coronary heart disease, heart attack, or stroke. If you have PAD, talk to your healthcare provider about ways to lower your risk of these conditions.

Manage your condition

It is important to get routine medical care and to take all medicines as your provider prescribes them.

Talk with your provider about how often you should schedule office visits and blood tests or other tests.

Call your provider’s office between visits if you start to have leg pain that does not go away after a few minutes of rest or if any other PAD symptoms get worse. Changes in symptoms could be a sign of PAD complications.

Get recommended vaccines, including the pneumococcus and influenza (flu) shots, every year at the start of flu season. Anyone who lives with you or whom you see often should also get regular vaccines.

Follow up with your doctor regularly to check your risk factors, monitor symptoms, and assess your legs and feet.

Lifestyle and home remedies

There are things you can do to help manage peripheral artery disease (PAD). Try these tips to manage PAD and stop symptoms from getting worse:

Don't smoke or use tobacco. Smoking damages the arteries. It increases the risk of peripheral artery disease. If you have PAD, smoking can make the condition worse. If you smoke and need help quitting, ask your care team about methods that can help.

Get regular exercise. Regular exercise is an important part of peripheral artery disease (PAD) treatment. Exercise helps improve blood flow to the arms and legs. So it can improve symptoms of PAD.

Usually, healthcare professionals recommend supervised exercise therapy for people with PAD. It's a program of exercise and education. It can help increase the distance you can walk pain-free.

Eat nutritious foods. Choose plenty of fruits, vegetables and whole grains. Reduce sugar, salt and saturated fats.

Check medicine labels. Products that contain pseudoephedrine (Advil Cold and Sinus, Claritin D, others) are often used to treat a stuffy nose due to allergies or colds. But this ingredient tightens blood vessels. It may increase PAD symptoms.

Check leg position. Try sleeping with the head of the bed raised a few inches. Keeping the legs below the level of the heart usually reduces pain. Some people find that hanging their legs over the edge of the bed or walking may temporarily reduce leg pain.

Foot care

It's important to take good care of your feet. PAD can make it harder for cuts and sores on the lower legs and feet to heal. This is especially true if you have PAD and diabetes.

Here is how to properly care for your feet:

Wash your feet every day. Dry them completely.

Use moisturizer on the feet to prevent cracks that can lead to infection. But don't moisturize between the toes. This can help fungus grow.

Wear thick, dry socks and well-fitting shoes.

Quickly treat any fungal infections of the feet, such as athlete's foot.

Take care when trimming your toenails.

Check your feet daily for cuts, sores or other injuries. See a healthcare professional if you find any.

Have a foot doctor, called a podiatrist, treat bunions, corns or calluses.

Women and PAD

Some conditions during pregnancy, such as preeclampsia, a high-blood pressure disorder, or gestational diabetes, high blood sugar during pregnancy, can raise a woman’s risk of developing PAD later in life.

PAD symptoms may be worse for women than for men. Women who have PAD often cannot walk as far or as fast as men who have PAD. They also report lower quality of life than men do, possibly because walking and other daily activities are hard. Depression is also more common in women with PAD than it is in men with the same disease.

Diseases linked with PAD

People who have PAD often have lifestyle habits and other factors, such as family history, that make it more likely they have developed or will develop other diseases related to atherosclerosis. Those diseases may include:

Coronary Artery Disease, when plaque builds up in the arteries of the heart

Diseases that affect the arteries of the brain, including stroke and vascular dementia

Heart attack

Carotid artery disease, which affects the arteries in the neck

Atrial fibrillation, a type of irregular heart rhythm or arrythmia

Heart failure

Chronic kidney disease

Sleep apnea

If you have PAD with symptoms, your provider may want to use ultrasound to screen you for abdominal aortic aneurysm.

Control your blood pressure

If you have high blood pressure, there are some steps you can take to prevent or delay complications caused by high blood pressure:

Follow your treatment plan.

Get regular follow-up care.

Learn how to monitor your condition at home.

Tell your provider if you are planning to become pregnant. They may adjust your treatment plan as needed to lower or control your high blood pressure.

Follow your diabetes care plan

If you have diabetes, your provider will recommend lifestyle changes, including a special eating plan, and may prescribe medicines to manage blood sugar levels. Managing diabetes carefully can lower your risk of complications.

Be alert for sores on your feet or legs and call your provider if you see signs of an infection, such as redness, swelling, pain, or pus, or if you have a fever or chills. To treat sores, your provider may prescribe antibiotics, clean the sores, remove dead tissue with surgery, and apply medicines and bandages to the area.

Manage your blood cholesterol levels

If you have unhealthy levels of blood cholesterol, it is important that you continue your treatment. Follow-up care depends on your cholesterol levels, your risk of complications such as a heart attack or a stroke, and how you respond to treatment.

Take care of your mental health

Living with PAD may cause fear, anxiety, depression, and stress. You may worry about having heart problems or making lifestyle changes that are necessary for your health. Some people become depressed because of problems with walking and taking part in daily activities. PAD might also lead to worry about the risk of amputation.

By lowering stress levels and learning coping skills, you may be able to live longer and improve your quality of life. Talk with your healthcare provider about how you feel. They may recommend you take some steps to help you manage stress, such as the following:

Join a patient support group. Taking this step may help you adjust to living with PAD. You can find out how other people manage similar symptoms. Your provider may be able to recommend local support groups, or you can check with an area medical center.

Seek support from family and friends. Letting your loved ones know how you feel and what they can do to help you can help relieve stress and anxiety.

Talk to a professional counselor. If you have depression or anxiety, your provider may also recommend medicines or other treatments that can improve your quality of life.

Know when to call for help

PAD puts you at high risk of serious health problems. If you think that you are having symptoms of PAD, check with your provider. For the following conditions, call 9-1-1 right away. Every minute matters.

Acute limb ischemia

Acute limb ischemia is a medical emergency that must be treated rapidly to avoid amputation or other serious problems. Seek medical help right away if any of the following occur:

You cannot feel or move your foot.

Your leg or foot hurts or feels like “pins and needles” while resting.

One foot is paler or colder than the other.

Bloodstream infection

When bacteria enter the blood from an infected sore, they can cause a bloodstream infection. Symptoms include fever and chills. Intravenous (IV) antibiotics need to be given right away in a hospital.

If a blood infection is not treated in time, or if the immune system can’t control the infection, the body’s inflammatory response can lead to septic shock, which is dangerously low blood pressure; organ failure; or even death.

Bone infections

If you develop deep ulcers over bones, you are at risk for a bone infection called osteomyelitis. Symptoms include bone pain; excessive sweating; fever and chills; swelling, redness, pain, and warmth at the site of infection; and an open wound that may show pus.

Treatment includes antibiotics, surgery to remove infected bone, and procedures to improve blood flow. You may need to stay in the hospital for treatment.

Cellulitis

Cellulitis is a skin infection that can spread to the deep tissues of the skin and muscle. Symptoms include areas of the skin that are warm, swollen, and tender. Cellulitis can also cause fever, chills, swollen lymph nodes, and blisters.

Your provider may prescribe antibiotics to take by mouth. If the infection gets worse or you get very sick, you may need to stay in the hospital for treatment.

Preparing for your appointment

If you have leg pain or other symptoms of peripheral artery disease (PAD), make an appointment for a health checkup. You may need to see a doctor trained in blood vessel diseases, called a vascular specialist.

Here's some information to help you get ready for your appointment.

What you can do

Learn what you need to do before your appointment. Ask if there's anything you need to do in advance, such as restrict your diet. For example, you may be told not to eat or drink for a few hours before a cholesterol test.

Write down any symptoms you're having, including any that may seem unrelated to peripheral artery disease.

Write down your medical information, including other conditions you have and any family history of heart disease.

Bring a list of medicines with you to your appointment. Include supplements and any medicines bought without a prescription. Also include dosages.

Ask a family member or friend to go with you to the appointment, if possible. An extra person can help you remember details from the appointment.

Write down questions to ask your healthcare team.

For peripheral artery disease (PAD), some basic questions to ask your healthcare professional are:

What's the most likely cause of my symptoms?

Are there other possible causes?

What types of tests do I need? Do these tests require any special preparation?

Is peripheral artery disease temporary or long lasting?

What treatments are available? Which do you recommend?

What are the side effects of the treatment you are suggesting?

Are there any options to the treatment that you're suggesting?

What can I do on my own that might help me get better?

I have other health conditions. How can I best manage these conditions together?

Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

Don't hesitate to ask any other questions.

What to expect from your doctor

A healthcare professional who sees you for peripheral artery disease (PAD) might ask:

When did the symptoms start?

Do you always have symptoms, or do they come and go?

How bad are your symptoms?

Do your symptoms get worse when you exercise?

Do your symptoms get better when you're resting?

Did you or do you smoke or use tobacco? If yes, how often?

What you can do in the meantime

If you smoke, quit. Smoking increases the risk of peripheral artery disease (PAD) and related conditions such as stroke and heart attack. Smoking also can make existing PAD worse. If you need help quitting, ask your care team for methods that can help.

Eating less saturated fat and adding more fruits and vegetables to your diet are other things you can do to help prevent or manage PAD.

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