Makindo Medical Notes

Peripheral Vascular Disease (PVD), more accurately termed Peripheral Arterial Disease (PAD), is a manifestation of systemic atherosclerosis affecting the arteries of the limbs, most commonly the legs. It is strongly associated with coronary artery disease, cerebrovascular disease, and increased cardiovascular mortality. Prevalence increases with age, diabetes, smoking, and hypertension, making it a major public health concern in the UK.

🧬 Pathophysiology

• ⚡ Atherosclerosis is the primary mechanism → lipid deposition, inflammation, smooth muscle proliferation, and fibrous cap formation in medium/large arteries.
• 🩸 Progressive luminal narrowing ➝ reduced blood flow ➝ ischaemia, particularly during exertion.
• 💥 Plaque rupture may cause thrombosis and acute limb ischaemia.
• 🦵 Microvascular dysfunction contributes to poor tissue perfusion even when large arteries are patent.
• 🔁 Collateral circulation may develop but is often insufficient in advanced disease.

⚠️ Risk Factors

• 🚬 Smoking (most important modifiable risk).
• 🩸 Diabetes mellitus (accelerates atherosclerosis).
• 📉 Hypertension, hyperlipidaemia, obesity, metabolic syndrome.
• 👴 Age, male sex, family history of premature vascular disease.
• 🧑‍⚕️ Other: CKD, sedentary lifestyle, poor diet.

🩺 Clinical Features

• 🚶 Intermittent claudication: reproducible calf/thigh/buttock pain on exertion, relieved by rest.
• 🌙 Rest pain: severe pain in foot/toes at night, relieved by hanging foot over bed (critical ischaemia).
• 🦶 Tissue loss: ulcers (classically “punched out”), gangrene.
• 📉 Other signs: absent pulses, bruits, cool peripheries, hair loss, pale skin, slow capillary refill.
• 🧠 Many patients are asymptomatic but at high risk of MI/stroke.

❓ Key History Points

• ⏱️ Onset, duration, progression of claudication symptoms.
• 📍 Location of pain (buttock = iliac disease, calf = femoral/popliteal, foot = tibial).
• 🚶 Walking distance before symptoms (claudication distance).
• 🩸 Past vascular history: MI, stroke, angina.
• 💊 Risk factors: smoking, diabetes, hypertension, lipids.

🔍 Clinical Examination

• 👀 Inspect: skin changes (atrophy, hair loss, pallor, dependent rubor), ulcers, gangrene.
• ✋ Palpate: femoral, popliteal, posterior tibial, dorsalis pedis pulses.
• 👂 Auscultate: bruits over femoral/iliac arteries.
• 🦵 Buerger’s test: leg elevation → pallor; dependency → rubor.

🔬 Investigations

• 🧪 Bloods: FBC, U&E, HbA1c, lipid profile, TFT (exclude contributing causes).
• 📉 ABPI (ankle-brachial pressure index):
  • Normal: 1.0–1.4
  • PAD: <0.9
  • Severe PAD/critical ischaemia: <0.5
• 📊 Duplex Doppler ultrasound: first-line imaging.
• 🖼️ CT angiography / MR angiography: if considering intervention.
• 🚑 Digital subtraction angiography: gold standard, usually when planning surgery/angioplasty.

🛠️ Management

Management is both symptomatic (limb salvage) and systemic (CV risk reduction).

1️⃣ Conservative

• 🚭 Smoking cessation (single most effective intervention).
• 🏃 Supervised exercise therapy: improves claudication distance via collateral development.
• 🍏 Risk factor modification: diet, weight reduction, glycaemic control, lipid lowering.

2️⃣ Medical

• 💊 Antiplatelets: Aspirin or clopidogrel (reduces CV events).
• 💊 Statin therapy (NICE recommends high-intensity statin e.g., atorvastatin 80 mg).
• 💊 Antihypertensives (ACE inhibitors protective).
• 💊 Cilostazol (phosphodiesterase inhibitor) may improve claudication symptoms (not first line in UK).

3️⃣ Interventional

• 🩺 Indications: lifestyle-limiting claudication refractory to conservative therapy, critical limb ischaemia (rest pain, ulcers, gangrene).
• 🔧 Endovascular: angioplasty ± stenting (first-line for focal disease).
• 🔨 Surgical: bypass grafting (e.g., fem-pop bypass) or endarterectomy for extensive disease.
• ✂️ Amputation: last resort in irreversible gangrene or failed revascularisation.

🚩 Red Flags

• Night/rest pain requiring dangling leg ➝ critical limb ischaemia.
• Non-healing ulcers or gangrene.
• Rapidly worsening symptoms.
• Signs of acute limb ischaemia: 6 Ps (pain, pallor, pulselessness, perishingly cold, paraesthesia, paralysis).

📚 Teaching Pearls

• Most patients with PVD die of cardiac or cerebrovascular disease, not limb loss ➝ treat risk factors aggressively.
• ABPI unreliable in diabetes due to calcified vessels; toe pressure or duplex may be needed.
• Critical limb ischaemia is defined by rest pain >2 weeks, ulcers, or gangrene with ABPI <0.5.
• Multidisciplinary care (vascular surgeons, diabetologists, podiatrists, rehab) improves outcomes.

📚 References

• NICE CG147 – Peripheral Arterial Disease
• NICE CKS – PAD
• NICE – Intermittent Claudication

Cases

• Case 1 — Intermittent Claudication: A 66-year-old man with hypertension and a 40-pack-year smoking history develops calf pain after walking 200 metres, relieved by rest. Legs are cool with weak dorsalis pedis pulses. Plan: Lifestyle changes (stop smoking, exercise programme), antiplatelet therapy, statin, and assess ABPI for severity.
• Case 2 — Critical Limb Ischaemia: A 74-year-old woman presents with rest pain in her foot at night, requiring her to hang it over the bed, with dusky toes and a small non-healing ulcer. Plan: Urgent vascular referral, analgesia, optimise cardiovascular risk factors, and consider revascularisation (angioplasty, bypass); amputation if non-salvageable.
• Case 3 — Acute Limb Ischaemia: A 62-year-old man with atrial fibrillation presents with sudden severe pain, pale cold leg, and loss of sensation and power. No pulses below femoral artery. Plan: Immediate hospital admission, IV heparin, urgent vascular surgery (embolectomy/thrombectomy), and supportive care to prevent limb loss.