Peripheral arterial disease

Clinical features

Acute limb ischaemia

• Occurs due to thrombus (acute on chronic) or emboli
• 6 P’s: Pale, Pulseless, Paraesthesia, Paralysis, Pain, Perishingly cold

Intermittent claudication

• Calf pain on exertion which is relieved by rest (check claudication distance)

Critical ischaemia

• Chronic rest pain (often at night, relieved by hanging legs over bed)
• Tissue loss (e.g. arterial ulcers, gangrene)

Investigations

• Ankle-brachial pressure index
  • <0.9 = intermittent claudication
  • <0.6 = rest pain
  • <0.3 = critical ischaemia
  • NB: ABPI may be falsely elevated in patients with calcified arteries.
• Imaging
  • Duplex ultrasound (first line imaging)
  • MR or CT angiography (second line imaging, MR preferred but CT more widely available)  
  • Catheter angiography (third line)
• Bloods: lipid levels, fasting glucose, FBC (rule out anaemia), U&Es (to check renal function prior to contrast), coagulation screen
• ECG: to look for AF as a cause of emboli

Management

• Risk factor control
  • Antiplatelet therapy (aspirin or clopidogrel)
  • Lipid lowering therapy (statin)
  • Smoking cessation
  • Diet, weight management and exercise
  • BP and diabetes control
• Supervised exercise regimen (for intermittent claudication)
• Naftidrofuryl oxalate (for intermittent claudication) – rarely successful
• Revascularisation for acute ischaemia
  • Percutaneous catheter-directed thrombolytic therapy
  • Percutaneous transluminal angioplasty (stent)
  • Surgical embolectomy
• Revascularisation for chronic ischaemia
  • Percutaneous transluminal angioplasty (stent) – if possible (i.e. short segment, not at knee joint, good run-off)
  • Vascular bypass grafting
• Debridement/amputation for gangrene or non-viable limbs

Reference: NICE ‘CG147 Peripheral arterial disease: diagnosis and management’ 2020

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Vascular bypass procedures

Axillofemoral

Femorofemoral

Iliofemoral

Iliofemoral

Femoropopliteal

Some questions

What are the risk factors for peripheral arterial disease?

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What is Leriche syndrome?

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Try an OSCE station

1. Peripheral arterial exam
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