Arterial large vessel disease

Peripheral Arterial Disease (PAD) includes disorders that obstruct arterial blood flow, excluding the coronary and intracranial circulations.

Peripheral Arterial Disease affecting the legs is of overwhelming importance and is the focus of this section.

There are several stages in the severity of PAD in the lower limb: (1)

• intermittent claudication:
  • pain, usually in the calf, that is precipitated by walking
• rest pain:
  • pain, usually in the foot, that is worse elevated in bed at night and is relieved by lowering the leg
• arterial ulceration of the leg and foot
• gangrene of the leg and foot

Rest pain, ulceration or gangrene indicates critical limb ischaemia. Critical limb ischaemia has a high risk of amputation and death.

Mild symptoms are generally managed in primary care, with referral to secondary care when symptoms do not resolve or deteriorate (2)

• there are several treatment options for people with intermittent claudication
  • include advice to exercise, management of cardiovascular risk factors (for example, with aspirin or statins) and vasoactive drug treatment (for example, with naftidrofuryl oxalate)
• people with severe symptoms that are inadequately controlled are often referred to secondary care for assessment for endovascular treatment (such as angioplasty or stenting), bypass surgery, pain management and/or amputation.

Notes:

• intermittent claudication is the commonest manifestation of PAD (1)
  • claudication is in itself a relatively benign symptom, with only about 2% of claudicants going on to require a major amputation
    • however it is a marker of considerably increased future cardiovascular risk - 20-30% of claudicants will be dead by 5 years mostly due to cardiovascular events including myocardial infarction
• increased cardiovascular risk is not confined to the symptomatic population, as asymptomatic patients with PAD also have an increased risk of death
• incidence of peripheral arterial disease increases with age (2)
  • population studies have found that about 20% of people aged over 60 years have some degree of peripheral arterial disease
  • incidence is also high in people who smoke, people with diabetes and people with coronary artery disease
  • in most people with intermittent claudication the symptoms remain stable, but approximately 20% will develop increasingly severe symptoms with the development of critical limb ischaemia

Reference:

1. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J. 2018 Mar 1;39(9):763-816.
2. NICE (March 2018). Lower limb peripheral arterial disease: diagnosis and management