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Peripheral Arterial Disease


This guideline applies to adults aged 18 and over.

 

Introduction

Early identification and management of PAD in primary care is important to improve symptoms and reduce cardiovascular risk, with specialist referral needed for advanced disease or treatment-resistant symptoms.

 

In scope

  • Assessment, management and referral of peripheral arterial disease in primary care including:
    • Acute limb ischaemia
       
    • Chronic limb threatening ischaemia 
       
    • Intermittent claudication

 

Not in scope

 

Red Flags

  • Acute limb ischaemia
    • Symptoms or signs suggestive of acute limb ischaemia. Any of the “6 P’s”
      • Pain, Pallor, Pulselessness, Perishing cold, Paraesthesia, Paralysis.
  • Chronic limb threatening ischaemia
    • Ischaemic rest pain
      • Often worse at night and described as burning/ cramping/ aching, people may report sleeping with their leg hanging out of the bed to relieve symptoms
      • Most commonly in the toe or forefoot (can also be in the heel/ sole/ ankle/ calf/ thigh/ buttock in more proximal disease)
      • Note: people with limited mobility or with diabetic neuropathy may not have a prior history of claudication1
    • Arterial ulceration/ tissue loss/ gangrene:
      • Usually in the foot at distal pressure areas such as the end of toes or heels
    • Dependant rubor (reddish purple, “sunset” discolouration that resolves when the leg is elevated)
       
    • Absent foot pulses
  • Rapidly deteriorating infected leg wounds in a peripheral arterial disease patient
     
  • A sudden worsening in claudication symptoms that is becoming critical e.g. claudication distance has shortened to a few metres over a short period
     



Investigations required prior to referral

When PAD is suspected in primary care, perform Ankle-Brachial Pressure Index (ABPI) if feasible to support diagnosis and assess severity before referral (unless red flag features present)

 

ABPI should be interpreted as follows:1

* Do not exclude a diagnosis of peripheral arterial disease in people with a normal or raised ABPI if they have symptoms of PAD (particularly if there is a background of diabetes, vasculitis or CKD) — if there is any doubt about the diagnosis, refer for assessment


 

Management Optimisation in Primary Care

Primary care management of peripheral arterial disease broadly focuses on two parallel goals:

  • Reducing cardiovascular risk(secondary prevention)
     
  • Improving limb symptoms such as claudication (see below) and ulcers (Leg Ulcer Pathway updated.doc)


 

Secondary Prevention

All patients with confirmed or suspected PAD should receive secondary prevention measures and lifestyle support as per NICE guidance which can be found here.


 

Claudication management

  • Exercise – there is no local supervised exercise programme as advised by NICE for the management of intermittent claudication
    • consider suggesting unsupervised exercise (using clinical judgement and considering the person's motivation and comorbidities).
    • See useful patient information leaflet from the circulation foundation
  • Medication – there are limited pharmaceutical options for the treatment of claudication symptoms.
    • Naftidrofuryl oxalate can be considered ONLY when:
      • supervised exercise has not led to a satisfactory improvement, AND
      • the person prefers not to be referred for consideration of angioplasty or bypass surgery
      • This medication is likely to be of most benefit to patients who have moderate claudication (e.g. can walk 200-400 yards before symptoms)
      • Caution with hyperoxaluria or recurrent calcium containing kidney stones

 

Referral

Emergency Referral

  • If acute limb ischaemia contact the vascular on-call and admit immediately via ED / 999*
     
  • If chronic limb threatening ischaemia with tissue loss/ ulceration AND spreading infection such as wet gangrene or ascending cellulitis admit via general surgical admissions/ ED/ 999 depending on clinical assessment
     
  • If rapidly worsening condition in PAD where clinical assessment suggests that a delay in treatment could lead to limb loss within hours or days (e.g. acute onset rest pain or gangrene) contact the on-call vascular team to discuss and arrange admission or very urgent outpatient review

*For severely frail patients where it is unclear if surgical intervention would be appropriate e.g. extremely frail patient with an acute ischaemic toe contact the on-call vascular surgeon to discuss before admitting


 

Urgent Referral Criteria

  • Sign or symptoms suggestive of chronic limb threatening anaemia
     
  • Significant and rapidly worsening claudication symptoms (e.g. claudication distance has significantly shortened over a short time)


 

Routine Referral

  • Stable intermittent claudication that:
    • significantly limits lifestyle despite optimal conservative management. This means the patient has tried risk factor modification and exercise therapy, but still has severe walking limitation (e.g. pain after <100m, affecting daily life).
    • Refer only if the patient is medically fit and would consider revascularization
  • Diagnostic uncertainty or need for confirmation of PAD – e.g. the patient has symptoms suggestive of PAD but ABPI could not be done or was inconclusive
     
  • Non healing ulcers that meet lower limb pathway criteria –  Leg Ulcer Pathway updated.doc

 

Information required with referral

  • Description of symptoms
     
  • ABPIs if done
     
  • Brief description of fitness/ willingness for surgery
     
  • Patient profile

 


Supporting information

For Professionals

 

For patients

 

References

 

Page Review Information

Review date

05 September 2025

Next review date

05 September 2027

Clinical editor

Dr Jack Munro-Berry

Contributors

Mr Ken McCune, Consultant Vascular Surgeon, Royal Cornwall Hospitals NHS Trust