Peripheral arterial disease (PAD)
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Peripheral Arterial Disease (PAD)
Peripheral Arterial Disease (PAD)is a chronic atherosclerotic condition in which arterial narrowing reduces blood flow to the limbs, most commonly the legs.
Definition:
Progressive stenosis or occlusion of peripheral arteries due to plaque formation, leading to impaired tissue perfusion.
Key risk factors:
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Chronic atherosclerotic arterial disease
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Reduced blood flow to the lower limbs
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Progressive narrowing or blockage of peripheral arteries
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Impaired tissue perfusion
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Most commonly affects the legs
Clinical presentation:
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Intermittent claudication: exertional calf, thigh, or buttock pain relieved by rest
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Rest pain in advanced disease
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Non-healing ulcers or gangrene in critical limb ischaemia
Diagnosis:
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Ankle–Brachial Pressure Index (ABPI <0.9 diagnostic)
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Duplex ultrasound for anatomical mapping
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CT or MR angiography if intervention is planned
Management strategy:
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Risk modification
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Smoking cessation
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Statin therapy
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Antiplatelet therapy
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Blood pressure and glycaemic control
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Structured walking programme
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Revascularisation (for lifestyle-limiting or limb-threatening disease)
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Endovascular angioplasty ± stenting
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Surgical bypass
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Hybrid procedures
Prognostic significance:
PAD is a systemic atherosclerotic marker. Cardiovascular mortality risk is substantially elevated, making aggressive risk-factor management essential.
Bottom line:
PAD is limb ischaemia caused by arterial atherosclerosis. Early detection and risk management prevent progression; revascularisation restores function in advanced cases.
Intermittent claudication:
Intermittent claudication is exertional limb pain caused by inadequate arterial blood flow due to peripheral arterial disease.
Definition:
Reproducible muscle pain or cramping during walking or exercise that resolves with rest, resulting from demand–supply mismatch in oxygen delivery to skeletal muscle.
Typically patients can walk a certain distance before they develop pain or tightness in the calf muscle. Eventually this becomes so severe that they have to rest. After couple of minutes the pain goes away and they can start walking again. Sometimes they can walk the same distance but typically this becomes shorter. The symptoms tend to be worse walking uphill.
Mechanism:
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Atherosclerotic arterial narrowing limits blood flow
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Exercise increases oxygen demand
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Ischaemia triggers pain
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Rest restores perfusion and relieves symptoms
Typical features:
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Calf pain is most common (femoropopliteal disease)
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Thigh or buttock pain suggests aortoiliac disease
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Predictable walking distance before onset
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Rapid relief within minutes of stopping
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No pain at rest in uncomplicated disease
Clinical importance:
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Hallmark symptom of peripheral arterial disease
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Marker of systemic atherosclerosis and elevated cardiovascular risk
Assessment:
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Ankle–Brachial Pressure Index (ABPI <0.9)
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Duplex ultrasound to localise disease
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Exercise ABPI testing if resting values are normal but symptoms persist
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CT Angiogram
Management:
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Smoking cessation
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Antiplatelet and statin therapy
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Supervised walking programme
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Risk factor optimisation
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Revascularisation if symptoms are lifestyle-limiting despite best medical therapy
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Rest Pain
Ischaemic rest pain is persistent limb pain occurring at rest due to critically reduced arterial perfusion. It represents advanced peripheral arterial disease and is a defining feature of chronic limb-threatening ischaemia (CLTI).
Definition:
Continuous or near-continuous pain in the foot or distal leg, present at rest for more than two weeks, caused by insufficient blood flow to meet baseline metabolic demand.
Pathophysiology:
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Severe multilevel arterial occlusive disease
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Critically low distal perfusion pressure
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Nerve and tissue ischaemia even without exertion
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Often worsens when the limb is elevated and improves when depe
Clinical features:
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Burning or aching pain in the forefoot or toes
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Typically worse at night in bed
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Patients may hang the leg over the side of the bed for relief
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Associated with cold, pale foot and absent pulses
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Frequently coexists with tissue loss (ulcers or gangrene)
Diagnostic indicators:
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ABPI typically <0.4
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Toe pressures <30 mmHg
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Transcutaneous oxygen tension (TcPO₂) markedly reduced
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Duplex/CTA/MRA to map occlusive disease
Clinical significance:
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Medical emergency in vascular practice
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High risk of limb loss without urgent revascularisation
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Also indicates very high cardiovascular mortality risk
Management approach:
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Analgesia and limb protection
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Optimisation of antiplatelet and statin therapy
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Urgent revascularisation (endovascular, surgical, or hybrid)
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Amputation only if revascularisation is not feasible or infection is uncontrolled
Ischaemic Ulceration and Gangrene
Ischaemic ulceration and gangrene represent the end-stage spectrum of peripheral arterial disease and are core components of chronic limb-threatening ischaemia (CLTI). They indicate tissue necrosis resulting from critically inadequate arterial perfusion.
Definition:
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Ischaemic ulceration:
Full-thickness skin loss caused by sustained hypoperfusion. Typically occurs on toes, heels, or pressure points. Ulcers have a punched-out appearance, pale base, minimal granulation tissue, and are often painful. -
Gangrene:
Irreversible tissue death due to complete loss of blood supply.-
Dry gangrene: mummified, black, shrivelled tissue without infection
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Wet gangrene: necrosis with superimposed infection, swelling, and systemic sepsis risk
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Pathophysiology:
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Severe multilevel arterial occlusion
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Critically low tissue oxygenation
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Cellular death and loss of skin integrity
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Secondary infection common in advanced disease
Clinical features:
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Non-healing ulcers lasting >2 weeks
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Black eschar or necrotic tissue
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Cold, pulseless foot
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Often accompanied by ischaemic rest pain
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High risk of rapid deterioration if infected
Diagnostic parameters:
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ABPI usually <0.4
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Toe pressure <30 mmHg
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TcPO₂ markedly reduced
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Vascular imaging required for revascularisation planning
Management strategy
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Immediate priorities
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Urgent vascular assessment
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Infection control and debridement if required
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Broad-spectrum antibiotics if wet gangrene suspected
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Analgesia and limb protection
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Definitive treatment
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Rapid revascularisation (endovascular or surgical bypass)
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Minor or major amputation if tissue is non-salvageable
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Optimisation of cardiovascular risk therapy
Prognosis:
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Without revascularisation, major amputation risk exceeds 40–50% at 6 months
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Mortality risk is high due to systemic atherosclerotic burden
Bottom line:
Ischaemic ulceration and gangrene are manifestations of limb-threatening arterial insufficiency. They constitute a vascular emergency requiring urgent revascularisation to prevent limb loss and reduce mortality.
Peripheral Arterial Disease (PAD) Pathway.
1.
Consultation .
At the initial consultation you will be asked questions about your symptoms, walking distance, rest pain, and any previous vascular treatment.
You will also be asked about your medical history, smoking history, diabetes, blood pressure, medications including blood thinners, and any allergies.
2.
Examination & Ultrasound.
Your legs will then be examined to assess circulation, skin changes, ulceration, colour changes, temperature, and pulses.
Ultrasound and Assessment
You may undergo vascular assessment including:
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Ankle–Brachial Pressure Index (ABPI)
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Duplex ultrasound for anatomical mapping
If intervention is being considered, further imaging such as CT angiography or MR angiography may be required.
3.
Treatment Discussion.
We will then discuss in detail with you the various treatment options outlining the advantages and disadvantages of all.
You will be provided with an information leaflet for the treatments suitable for you.
At this stage we can either book you in for a suitable date for your treatment or you can contact us again via phone or email if you would like treatment to be arranged.