Diagnosis

• Secondary prevention of cardiovascular disease advice and support
  • Smoking cessation
  • Diet weight management
  • Lipid modification
  • Prevention of diabetes
  • Prevention of high blood pressure
• Assess if patients have symptoms of peripheral artery disease; diabetes & non healing wounds on leg; need compression hosiery; considered for intervention in leg or foot
• Ask about symptoms including leg claudication, and critical limb ischaemia
• Assess femoral, popliteal and foot pulses
• If critical limb ischaemia ensure MDT review before treatment

Investigation

• Measure ankle brachial pressure index: record systolic blood pressure with appropriately sized cuff in both arms and dorsalis pedis and posterior tibial arteries, taking measurements using a Doppler probe
• Calculate ABPI by dividing the highest ankle pressure over the highest arm pressure
• Duplex ultrasound as first line imaging
• Contrast enhanced CT if have PAD and need further imaging or CT angiography if contra-indicated

Management

Intermittent Claudication

• Conservative: 2 hr supervised exercise weekly for 3 mths, and encourage to exercise to point of maximal pain
• Angioiplasty should be offered once advice on modifiable risk factors reinforced and for whom exercise therapy has not led to satisfactory improvement and imaging confirmed suitable
• Primary stent (bare metal) placement considered for complete aorto-iliac occlusion, but not femoro-popliteal disease
• By-pass grafting offered only where angioplasty unsuccessful in life limiting disease and imaging confirmed suitable, using an autologous vein where possible
• Naftidrofuryl oxalate may be offered if exercise not helped and angioplasty / surgery declined

Critical Limb ischaemia

• Angioplasty or by-pass grafting taking into account co-morbidities, vein availability, patient preference, disease pattern
• Only offer primary stent placement in complete aorto-iliac occlusion, using bare metal stent
• Pain management: WHO ladder with laxatives and anti-emetics, and referral to pain management team if pain persists and not able to revascularise
• Amputation once all options to revascualrise have been exhausted

NICE Source: CG147 Peripheral arterial disease: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.