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Peripheral arterial disease

Peripheral arterial disease ( PAD ) is a progressive disorder charecterized by stenosis and / or occlusion of large and medium sized arteries , other than those that supply the heart ( Coronary artery disease , CAD ) , or the brain
 ( cerebrovascular disease ) Ju Shu et al 2018

Peripheral arterial disease 
( acronym PAD used here ) is a marker of ↑↑ ed risk of CV events -even if asymptomatic PAD is caused most commonly by atherosclerosis ( leading to stenosis and occlusion ) of non-cerebral and non-coronary arteries PAD is very common -studies quote prevalence as
○ about 20 % of people aged over 60 have some degree of PAD ( NICE 2012 )
○ affects 13 % of Western population aged more than 50 ( BMJ 2018 )

PAD is a marker of ↑↑ ed risk of CV events -even if asymptomatic ( can be asymptomatic in up to 50 % ) PAD is caused most commonly by atherosclerosis
 ( leading to stenosis and occlusion ) of non-cerebral and non-coronary arteries Among PAD patients about 30-40 % have evidence of coronary artery disease and 15-25 % have significant carotid stenosis following adjustment for known CV risk factors , PAD is associated with an increased risk of coronary artery and cerebrovascular disease morbidity and mortality Substantial risk of mortality
In a study ( James Willey et al 2017 ) nearly 30 % of PAD patients died within 3.8 years of diagnosis Patients with PAD are generally less aggressively managed compared to CAD patients

Risk factors –Smoking People with coronary artery disease Diabetes Age – ↑↑es with age Male sex Black ethnicity High fasting serum cholesterol Hypertension Chronic kidney disease High serum homocysteine

Risk factors are common for PAD
 , heart disease and stroke
 PAD increases risk of all cause
 mortality

Present with symptoms suggestive of PAD or Diabetic and non healing wounds on the legs or feet or unexplained leg pain or Being considered for interventions to the leg or foot or Need to use compression hosiery

The most common symptoms of PAD is intermittent claudication , atypical leg pain or impaired mobility Calf is the most commonly reported area of pain or discomfort Diabetic and non healing wounds on the legs or feet or unexplained leg pain Diagnosis can be difficult as patients may not have symptoms or have atypical symptoms Patients may also report lower extremity pain which may be due to other causes as lumbosacral radiculopathy Atypical presentation includes pain not requiring cessation of physical activity , pain lasting longer than 10 minutes after stopping the physical activity and pain that occurs both at rest and exertion

History –Which leg Pain only on walking -distance able to walk
Document the distance Pain resolves with rest Pain worse walking uphill quickly Associated numbness / pain Location of pain Symptoms Impact on quality of life

Examination-Assess for risk factors BMI Peripheral pulses
including abdominal aorta Peripheral sensation Full examination of leg and check for
○ hair loss
○ discoloration of toes
○ ulcer
○ gangrene
○ temperature difference ( eg coldness )

investigations –BP
 ABPI ( ankle brachial pressure index ) request in all suspected PAD cases
○ Value of < 0.9 diagnostic of PAD
○ Arterial calcification for eg in pts with diabetes or renal failure – may give false readings
○ Normal ABPI in presence of tissue loss does not rule out critical limb ischaemia ( refer urgently )

NICE advices not to exclude a diagnosis of PAD in people with diabetes based on a normal or raised ABPI alone 
Toe brachial index- is an alternative
 Blood profile ( FBC, U-Es , glucose or Hba1c , lipids
, LFT , TFT , Thrombophilia profile ( if less than 50 ) ECG

Intermittent claudication-Cramp/aching and burning in leg muscles Pain on walking after a set distance Pain is relieved within minutes of rest No resting pain Pain not made worse by position Site of pain can give information about level of occlusion -Supervised exercise Programme
If not available adv to exercise 30 min x 3-5/ week , walking until the onset of symptoms , then rest to recover Refer for revascularization if no benefit with exercise Consider naftidrofurly oxalate if no improvement with exercise or person does not wish revascularization Review in 3-6 months and do not continue prescribing if no improvement in symptoms DVLA advice – as below

Critical limb ischaemia-Severe form of PAD One or more of
○ ulceration
○ gangrene
○ rest pain for > 2 weeks ABPI < 0.5 Considerable morbidity and mortality Pain often does not respond to opiate analgesia
Can be difficult to differentiate from neuropathy Pain worsens with elevation of foot and improves with dependency- reason why patients describe hanging their leg over the edge of bed to relieve the pain Absence of pedal pulses Foot often cool and red which blanches with pressure or elevation – called dependent rubor. Refer urgently to a vascular multidisciplinary team Manage pain and consider referral to pain management service if
○ difficult to manage
○ revascularization inappropriate or not possible
○ pain persists following revascularization or amputation
Treat neuropathic pain as per NICE guidance
 Gen advice to avoid infection , nail cutting DVLA -bus , coach or lorry drivers need to contact DVLA and inform about their PAD
Taxi drivers should inform local authority

 

Acute limb ischamia-Pain – constant and persistent Pulseless – absent ankle pulses Pallor ( or cyanosis or mottling ) Power loss or paralysis Paraesthesia or ↓↓ sensation or numbness Perishing with cold.due to embolus -Acute onset -seconds or minutes Profound ischaemia Skin changes as
marbling
fine reticular blanching
fixed mottling Usually no hx of claudication and pulses present in the other leg. Due to thrombosis -Insidious onset (over days ) Ischaemia less severe- due to collateral circulation Usually hx of claudication and pulses in other leg may be absent-urgent hospital admission

Place on disease register and ensure annual review

risk factor modification-Explain link between PAD and smoking and offer / refer smoking cessation at every opportunity
Compared to former smokers -pts who cont to smoke face higher risk of amputation and death Antiplatelets- clpidogrel first line
Offer aspirin if allergic Statin – offer statins ( reduces all cause mortality )
NICE recommends reducing non-HDL cholesterol in those with PAD by 40 % Optimise diabetes management Hypertension -to lower CV risk aim for bp < 130/80 Weight loss ( if obese )

Critical limb ischaemia Acute limb ischaemia Diabetic foot ulcer and PAD Claudication significantly affecting quality of life and no improvement after 3/12 of supervised exercises therapy

Vasoactive drugs
○ Naftidofuryl oxalate
○ Cilostazol
 Revascularization


LINKS AND RESOURCES

PATIENT INFORMATION

A comprehensive complete review for the patient from The National Heart Lung and Blood Institute -recommend all patients to read https://www.nhlbi.nih.gov/health-topics/peripheral-artery-disease

Circulation Foundation has a section on PAD for patients ( the video doesn’t work when checked in Dec 2019 ) https://www.circulationfoundation.org.uk/help-advice/peripheral-arterial-disease

NICE printable information for patients on Lower limb peripheral arterial disease via the Vascular Society website https://www.vascularsociety.org.uk/patients/conditions/7/peripheral_arterial_disease

Vascular Society webpage on PAD https://www.vascularsociety.org.uk/patients/conditions/7/peripheral_arterial_disease

BUPA has a useful page on PAD for patients https://www.bupa.co.uk/health-information/heart-blood-circulation/peripheral-arterial-disease

The British Heart Foundation has all the information your patient may need about PAD https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/peripheral-arterial-disease

A useful resource for patients in the US comes from Society for Vascular Surgery with an explanatory video by Dr Anil Hingorani https://vascular.org/patient-resources/vascular-conditions/peripheral-arterial-disease

Peripheral Vascular Disease Screening Questionnaire https://sa1s3.patientpop.com/assets/docs/46417.pdf

INFORMATION FOR HEALTHCARE PROFESSIONALS

NICE guideline on PAD https://www.nice.org.uk/guidance/cg147

RACGP article Peripheral arterial disease Diagnosis and management in general practice https://www.racgp.org.au/afp/2013/june/peripheral-arterial-disease-diagnosis/ 

American College of Cardiology / American Heart Association guidelines on PAD https://ahajournals.org/doi/10.1161/CIR.0000000000000470

European Society of Cardiology & European Society for Vascular Surgery guidance on peripheral arterial disease https://www.ejves.com/article/S1078-5884(17)30454-9/pdf

Ankle Brachial Pressure Index– how to measure and other useful information by BPAC New Zealand https://bpac.org.nz/BPJ/2014/April/ankle-brachial.aspx

Open access article from The Journal of Nurse Practitioners Update : Diagnosis and Management of Peripheral Arterial Disease  – a good read https://www.npjournal.org/article/S1555-4155(18)30645-7/fulltext

 

References

  1. Guideline for the diagnosis and management of patients with peripheral arterial disease ( PAD ) Professor G Stansby  Norther England Strategic Clinical Networks Clinical Updates 
  2. Peripheral artery disease  BMJ 2018 ;360 :j5842
  3. Joseph Karam and Elliot J. Stephenson (2017) Critical Limb Ischemia: Diagnosis and Current Management. Journal of the Minneapolis Heart Institute Foundation: Fall/Winter 2017, Vol. 1, No. 2, pp. 124-129
  4. Diagnosis and management of peripheral arterial disease BMJ 2012 ;345:e5208
  5. Peripheral arterial disease CKS NICE September 2015
  6. Peripheral arterial disease : diagnosis and management NICE Clinical Guideline 147 Aug 2012
  7. Peripheral arterial disease : identification and management Dr A Sharma GP Online March 2016
  8. Dhaliwal, Gurbir, and Debabrata Mukherjee. “Peripheral arterial disease: Epidemiology, natural history, diagnosis and treatment.” The International journal of angiology : official publication of the International College of Angiology, Inc vol. 16,2 (2007): 36-44. doi:10.1055/s-0031-1278244 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733014/
  9. Shu, Jun, and Gaetano Santulli. “Update on peripheral artery disease: Epidemiology and evidence-based facts.” Atherosclerosis vol. 275 (2018): 379-381. doi:10.1016/j.atherosclerosis.2018.05.033 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113064/
  10. Schorr, Erica N et al. “Characterization of the peripheral artery disease symptom experience.” Geriatric nursing (New York, N.Y.) vol. 36,4 (2015): 293-300. doi:10.1016/j.gerinurse.2015.03.004
  11. Epidemiology of lower extremity peripheral artery disease in veterans Willey, James et al. Journal of Vascular Surgery, Volume 68, Issue 2, 527 – 535.e5 https://www.jvascsurg.org/article/S0741-5214(18)30044-2/fulltext
  12. Epidemiology of Peripheral Artery Disease Michael H. Criqui  and Victor Aboyans https://doi.org/10.1161/CIRCRESAHA.116.303849 Circulation Research. 2015;116:1509–1526 ( abstract )

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