Peripheral Arterial Disease: Diagnosis and Management in Secondary Care

Overview

This specialist Guidelines summary covers diagnosing and managing peripheral arterial disease (PAD) in people aged 18 and over. Rapid changes in diagnostic methods, endovascular treatments, and vascular services associated with new specialties in surgery and interventional radiology have resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation.

This summary includes recommendations on assessing for PAD, imaging for revascularisation, managing intermittent claudication, managing critical limb ischaemia, and preventing cardiovascular disease in people with PAD.

This summary is intended for use by secondary care cardiologists. Please refer to the full guideline for further information.

Information Requirements

• Offer all people with peripheral arterial disease oral and written information about their condition. Discuss it with them so they can share decision‑making, and understand the course of the disease and what they can do to help prevent disease progression. Information should include:
  • the causes of their symptoms and the severity of their disease
  • the risks of limb loss and/or cardiovascular events associated with peripheral arterial disease
  • the key modifiable risk factors, such as smoking, control of diabetes, hyperlipidaemia, diet, body weight and exercise (see the section, Secondary Prevention of Cardiovascular Disease in People with Peripheral Arterial Disease)
  • how to manage pain
  • all relevant treatment options, including the risks and benefits of each
  • how they can access support for dealing with depression and anxiety.
    
    Ensure that information, tailored to the individual needs of the person, is available at diagnosis and subsequently as required, to allow people to make decisions throughout the course of their treatment. 
     
• NICE has produced guidance on the components of good patient experience in adult NHS services. Follow the recommendations in NICE's guideline on patient experience in adult NHS services. 

Secondary Prevention of Cardiovascular Disease in People With Peripheral Arterial Disease

• Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance on:
  • smoking cessation
  • diet, weight management and exercise
  • lipid modification and statin therapy
  • the prevention, diagnosis and management of diabetes
  • the prevention, diagnosis and management of high blood pressure
  • antiplatelet therapy. 

Diagnosis

• Assess people for the presence of peripheral arterial disease if they:
  • have symptoms suggestive of peripheral arterial disease or
  • have diabetes, non‑healing wounds on the legs or feet or unexplained leg pain or
  • are being considered for interventions to the leg or foot or
  • need to use compression hosiery. 
• Assess people with suspected peripheral arterial disease by:
  • asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia
  • examining the legs and feet for evidence of critical limb ischaemia, for example ulceration
  • examining the femoral, popliteal and foot pulses
  • measuring the ankle brachial pressure index (see the recommendation immediately following). 
• Measure the ankle brachial pressure index in the following way:
  • the person should be resting and supine if possible.
  • record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis and, where possible, peroneal arteries.
  • take measurements manually using a doppler probe of suitable frequency in preference to an automated system.
  • document the nature of the doppler ultrasound signals in the foot arteries.
  • calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure. 

Diagnosing Peripheral Arterial Disease in People With Diabetes

• Do not exclude a diagnosis of peripheral arterial disease in people with diabetes based on a normal or raised ankle brachial pressure index alone. 
• Do not use pulse oximetry for diagnosing peripheral arterial disease in people with diabetes. 

Imaging for Revascularisation

• Offer duplex ultrasound as first‑line imaging to all people with peripheral arterial disease for whom revascularisation is being considered. 
• Offer contrast‑enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation. 
• Offer computed tomography angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) if contrast‑enhanced magnetic resonance angiography is contraindicated or not tolerated. 

Management of Intermittent Claudication

Supervised Exercise Programme

• Offer a supervised exercise programme to all people with intermittent claudication. 
• Consider providing a supervised exercise programme for people with intermittent claudication which involves:
  • 2 hours of supervised exercise a week for a 3‑month period
  • encouraging people to exercise to the point of maximal pain. 

Angioplasty and Stenting

• Offer angioplasty for treating people with intermittent claudication only when:
  • advice on the benefits of modifying risk factors has been reinforced (see the section, Secondary Prevention of Cardiovascular Disease in People with Peripheral Arterial Disease) and
  • a supervised exercise programme has not led to a satisfactory improvement in symptoms and
  • imaging has confirmed that angioplasty is suitable for the person. 
• Do not offer primary stent placement for treating people with intermittent claudication caused by aorto‑iliac disease (except complete occlusion) or femoro‑popliteal disease. 
• Consider primary stent placement for treating people with intermittent claudication caused by complete aorto‑iliac occlusion (rather than stenosis). 
• Use bare metal stents when stenting is used for treating people with intermittent claudication. 

Bypass Surgery and Graft Types

• Offer bypass surgery for treating people with severe lifestyle‑limiting intermittent claudication only when:
  • angioplasty has been unsuccessful or is unsuitable and
  • imaging has confirmed that bypass surgery is appropriate for the person. 
• Use an autologous vein whenever possible for people with intermittent claudication having infra‑inguinal bypass surgery. 

Naftidrofuryl Oxalate

• Consider naftidrofuryl oxalate for treating people with intermittent claudication, starting with the least costly preparation, only when:
  • supervised exercise has not led to satisfactory improvement and
  • the person prefers not to be referred for consideration of angioplasty or bypass surgery.
    
    Review progress after 3–6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit. 

Management of Critical Limb Ischaemia

• Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made. 

Revascularisation

• Offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including:
  • comorbidities
  • pattern of disease
  • availability of a vein
  • patient preference. 
• Do not offer primary stent placement for treating people with critical limb ischaemia caused by aorto‑iliac disease (except complete occlusion) or femoro‑popliteal disease. 
• Consider primary stent placement for treating people with critical limb ischaemia caused by complete aorto‑iliac occlusion (rather than stenosis). 
• Use bare metal stents when stenting is used for treating people with critical limb ischaemia. 
• Use an autologous vein whenever possible for people with critical limb ischaemia having infra‑inguinal bypass surgery. 

Management of Critical Limb Ischaemic Pain

• Offer paracetamol, and either weak or strong opioids depending on the severity of pain, to people with critical limb ischaemic pain.
• To support discussions with patients about the benefits and harms of opioid treatment, and safe withdrawal management, see:
  • NICE's guideline on medicines associated with dependence or withdrawal symptoms
  • NICE guideline on shared decision making
  • the section on medication review in NICE's guideline on medicines optimisation.
• Offer drugs such as laxatives and anti‑emetics to manage the adverse effects of strong opioids, in line with the person's needs and preferences. 
• Refer people with critical limb ischaemic pain to a specialist pain management service if any of the following apply:
  • their pain is not adequately controlled and revascularisation is inappropriate or impossible
  • ongoing high doses of opioids are required for pain control
  • pain persists after revascularisation or amputation. 
• Do not offer chemical sympathectomy to people with critical limb ischaemic pain, except in the context of a clinical trial. 

Major Amputation

• Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.