• Recent

Peripheral Arterial Disease (PAD)

Clinical guideline [CG147] Peripheral arterial disease: diagnosis and management. Published: Aug 2012. Last updated: Dec 2020

Background Information

The following terms are commonly misused, they are not interchangeable. 
Peripheral Arterial Disease Presence of atherosclerotic obstruction in the peripheral arteries of the lower limb.
Can be symptomatic or asymptomatic
Chronic limb ischaemia Symptomatic presentation of peripheral arterial disease 
Can present as different severity:
  • Asymptomatic
  • Intermittent claudication
  • Chronic limb-threatening ischaemia (old term: critical limb ischaemia)
Acute limb ischaemia Sudden (signs and symptoms develop over <2 weeks) decrease in limb perfusion that threatens limb viability

Presence of CV risk factors:

  • Smoking
  • Diabetes
  • Hyperlipidaemia
  • Hx of coronary artery disease / cerebrovascular disease 
 

Symptoms: 

  • Asymptomatic 
  • Intermittent claudication: (angina of the leg)
    • Lower limb pain with walking (a predictable distance)
    • Relieved by rest 
    • Can be reproduced by walking the same distance 
  • Chronic limb-threatening ischaemia (old term: critical limb ischaemia)
    • Lower limb pain at rest 
    • Worse at night – possibly relieved with leg hanging out of bed / sleeping in a chair 
 

On examination:

  • Diminished or absent pulse 
  • Cool skin 
  • Features suggest critical limb ischaemia
    • Loss of hair 
    • Shiny skin 
    • Tissue loss – ulcer or gangrene 
    • Skin pallor on limb elevation (+ve Buerger sign) 
 

Pain with walking that is relieved by rest = intermittent claudication 
Pain at rest +/- ulcer or gangrene = chronic limb-threatening ischaemia (critical limb ischaemia)

Guidelines

1st line: measure ABPI (ankle brachial pressure index)

  • ABPI: ankle systolic BP / brachial systolic BP

Interpretation: 
 
ABPI Interpretation
>1.4 May suggest arterial calcification ( typically diabetes)
Unable to rule in or out PAD
1.0 - 1.4 Normal
≤0.9 PAD
<0.5 Chronic limb-threatening ischaemia 

**NICE states that an ABPI of 0.91 – 0.99 cannot definitively rule in or rule out PAD. Further investigation is necessary if there is significant clinical suspicion. 

 

Do not exclude a diagnosis of peripheral arterial disease in people with diabetes based on normal or raised ABPI alone


Imaging should be performed if revascularisation is being considered:

  • 1st line: duplex ultrasound 
  • 2nd line: MR angiography with contrast 
  • 3rd line: CT angiography

 

Intermittent claudication:
  • 1st line: supervised exercise programme 
  • 2nd line: revascularisation 
    • Angioplasty + stenting (bare metal) – avoid in aorto-iliac and femoro-popliteal disease 
    • Bypass surgery
  • 3rd line: naftidrofuryl oxalate  
 

Chronic limb-threatening ischaemia (critical limb ischaemia):

  • Refer to vascular specialist 
  • Revascularisation – angioplasty + stenting (bare metal) or bypass surgery 

  • Lifestyle changes + treat comorbidities 
  • Atorvastatin 80mg 
  • Clopidogrel 
 
Author: Dalila Marra
Editor: 
Reviewer: