Peripheral arterial disease

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The peripheral arterial focussed examination covered here!

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

Vascular bypass procedures

Some questions

What are the risk factors for peripheral arterial disease?

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What is Leriche syndrome?

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