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  4. Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD)

NICE clinical guideline [CG147] Peripheral arterial disease: diagnosis and management. Last updated: Dec 2020

Background Information

The following terms are commonly misused, but not interchangeable
 
Term Description
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 severities:
  • 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

Patients with PAD often have concomitant cardiovascular risk factors:

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

There are 3 main presentations of PAD:[ref]
 
Presentation Features
Asymptomatic n/a
Intermittent claudication Essentially angina of the legs:
  • Lower limb pain with walking (a predictable distance)
  • Relieved by rest 

Location of pain:
  • Aortoiliac disease (Leriche syndrome) → triad of buttock / hip / thigh claudication + erectile dysfunction + absent / diminished femoral pulses
  • Femoropopliteal disease → calf claudication (most common)
  • Infrapopliteal disease → foot claudication
Chronic limb-threatening ischaemia (critical limb ischaemia - old term)
  • Lower limb pain at rest (typically affects toes and forefoot first)
  • Worse at night – possibly relieved with leg hanging out of bed / sleeping in a chair 

Possible examination findings include:[ref]
  • Diminished or absent lower limb 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) 
 
 
Key exam presentations:
  • Pain with walking that is relieved by rest = intermittent claudication 
  • Pain at rest +/- ulcer or gangrene = chronic limb-threatening ischaemia (critical limb ischaemia)

Guidelines

Approach:
  • 1st line: ABPIAnkle-brachial pressure index (in clinic)
  • Then, perform imaging in secondary care if revascularisation is being considered
 

How to measure:
  • Similar to measuring a clinic BP, instead of using a stethoscope a Doppler is used
  • BP cuff placed on the arm and ankle
  • Use Doppler to locate the pulse
  • Inflate the cuff until the pulse is no longer audible on Doppler
  • Deflate the cuff slowly and note the pressure (systolic BP) when Doppler is audible again


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 

 

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

As diabetes can cause arterial calcification, which makes arteries more incompressible thus a falsely high ABPI reading.

Imaging should be performed if revascularisation is being considered:

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

  • 1st line: supervised exercise programme 
 
  • ​​​​​2nd line: revascularisation (see below for choosing approaches)
    • Endovascular approach - angioplasty + stenting 
    • Open approach - bypass surgery
 
  • 3rd line: naftidrofuryl oxalate
 

NICE did not make any specific recommendations on choosing between endovascular vs open revascularisation approaches. Selected points from the 2024 ACC/AHA guidelines:[ref]

Endovascular revascularisation (angioplasty + stenting) is generally 1st line.

Open revascularisation is preferred as 1st line in

  • Multilevel occlusions 
  • Long-segment occlusions
  • Lesions involving the common femoral artery and profunda femoris artery origin

  • Refer all patients to vascular specialist
  • Offer revascularisation to all patients
    • Recent trials suggest that open revascularisation is superior to endovascular in those with chronic limb-threatening ischaemia, especially if there is a suitable autogenous vein (e.g. great saphenous vein)

Offer all the following:
  • Lifestyle changes + treat comorbidities 
  • Atorvastatin 80mg PO OD
  • Clopidogrel 75mg PO OD

References

Author: Dalila Marra
Reviewer: 
Last edited: 06/09/25