Index

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

1^st 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:

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

Intermittent claudication:

1^st line: supervised exercise programme
2^nd line: revascularisation
- Angioplasty + stenting (bare metal) – avoid in aorto-iliac and femoro-popliteal disease
- Bypass surgery
3^rd line: naftidrofuryl oxalate Vasodilator (5-HT2 receptor antagonist)

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
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