AKT · Cardiovascular/Vessels, aorta & venous

Peripheral arterial disease

Atherosclerotic stenosis/occlusion of limb arteries → chronic limb ischaemia

Overview

Atherosclerotic narrowing of the lower-limb arteries causing chronic ischaemia. Intermittent claudication (calf/thigh pain on walking, relieved by rest) is the early stage; critical limb ischaemia (rest pain, ulceration, gangrene) is limb-threatening. An ankle-brachial pressure index confirms it. Management is aggressive cardiovascular risk reduction plus supervised exercise, with revascularisation for critical/lifestyle-limiting disease.

Recognise

Intermittent claudication: cramping calf (or thigh/buttock) pain on walking a reproducible distance, relieved by rest
Examination: weak/absent pulses, cool pale leg, hair loss, arterial (punched-out, painful) ulcers, prolonged capillary refill
Critical limb ischaemia: rest pain (worse lying flat, eased hanging the leg out of bed), ulceration, gangrene; ABPI <0.5

Red flags

Critical limb ischaemia (rest pain, tissue loss, ABPI <0.5) → urgent vascular referral for revascularisation
Sudden onset of the 6 Ps → acute limb ischaemia (a different emergency)

Differentials & how to tell them apart

Spinal/neurogenic claudicationpain on standing/extension relieved by bending forward, not strictly distance-related; normal pulses

Acute limb ischaemiasudden 6 Ps — embolic/thrombotic emergency

Venous claudication / DVTbursting pain, swelling, venous signs

Investigations

Ankle-brachial pressure index (1.4 falsely high in calcified diabetic vessels); duplex ultrasound; CT/MR angiography for revascularisation planning; assess full CV risk (lipids, HbA1c, smoking).

Management

Risk-factor modification (statin + clopidogrel + stop smoking) + supervised exercise

1Confirm with ABPI. Foundation = stop smoking, statin, antiplatelet (clopidogrel) and a supervised exercise programme; control diabetes and BP.Gate: Critical limb ischaemia (rest pain, ulceration, gangrene, ABPI <0.5) → urgent vascular referral for revascularisation/limb salvage — not just exercise advice.
2Lifestyle-limiting claudication refractory to conservative therapy → angioplasty/stent or bypass; consider naftidrofuryl if surgery not chosen.

Cardiovascular risk modification: stop smoking, statin (atorvastatin 80 mg), antiplatelet (clopidogrel), treat diabetes/BP — the foundation — reduces MI/stroke as well as limb events

Supervised exercise programme — first-line for intermittent claudication — improves walking distance

Naftidrofuryl oxalate — if exercise and risk-factor control insufficient and surgery not chosen

Revascularisation (angioplasty/stent or bypass) — for critical limb ischaemia or lifestyle-limiting claudication refractory to conservative measures

Key points

Cramping calf pain on walking, relieved by rest, with weak pulses = intermittent claudication → ABPI, then statin + clopidogrel + stop smoking + supervised exercise. Rest pain/ulceration/gangrene with ABPI <0.5 = critical limb ischaemia → urgent revascularisation.

Monitor & prognosis

Walking distance, ABPI, CV risk factors; wound surveillance in critical ischaemia.

Claudication is mainly a marker of systemic atherosclerosis (high MI/stroke risk); critical ischaemia threatens the limb.

Source: NICE CG147 (peripheral arterial disease)