Peripheral Arterial Disease (PAD) is a chronic atherosclerotic disease affecting arteries outside the heart, most commonly in the lower limbs. It shares common risk factors with coronary artery disease such as smoking, diabetes, high cholesterol, and hypertension. PAD can cause intermittent claudication pain in calf muscles with walking that resolves with rest, or critical limb ischemia with rest pain and tissue loss. Diagnosis involves clinical examination, ankle-brachial pressure index measurement, and imaging tests. Treatment focuses on risk factor modification through lifestyle changes and medications to improve blood flow and prevent limb loss.

1. Peripheral Arterial
Disease
Dr. Shilpasree Saha (PT),
Assistant Professor, NIHS

2. Introduction
◦ PVD is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion.
◦ It shares common risk factors with coronary artery disease: namely, smoking, diabetes mellitus,
hyperlipidemia and hypertension.
◦ Commonly affected abdominal aorta, iliac arteries, lower limbs and occasionally upper extremities.

3. Risk factors
◦ Risk factors include:
◦ Tobacco use
◦ Diabetes mellitus
◦ Hypertension
◦ HIV
◦ High cholesterol
◦ Age more than 50 years
◦ Elevated homocysteine levels (High homocysteine levels may mean you have a vitamin deficiency. Elevated
homocysteine increases your risks for dementia, heart disease and stroke.)
◦ BMI greater than 30
◦ Family history of cardiovascular disease

4. Chronic lower limb arterial disease
◦ PAD affects the leg eight times more often than the arm.
◦ The lower limb arterial tree comprises the aorto-iliac, (‘inflow’), femoro-popliteal and infra-popliteal
(‘outflow’) segments. One or more segments may be affected in a variable and asymmetric manner.
◦ Lower limb ischaemia presents as two distinct clinical entities: intermittent claudication (IC) and critical limb
ischaemia (CLI).

5. Ankle–brachial pressure index
◦ The presence and severity of ischaemia can be
determined by clinical examination and
measurement of the ankle–brachial pressure
index (ABPI), which is the ratio between the
(highest systolic) ankle and brachial blood
pressures.
◦ In healthy adults, the ABPI is over 1.0, in IC
typically 0.5–0.9 and in CLI usually below 0.5.

7. Clinical features of chronic lower limb
ischaemia
◦ Pulses: diminished or absent
◦ Bruits: denote turbulent flow but bear no relationship to the severity of the underlying disease
◦ Reduced skin temperature
◦ Pallor on elevation and rubor on dependency (Buerger’s sign)
◦ Superficial veins that fill sluggishly and empty (‘gutter’) upon minimal elevation
◦ Muscle-wasting
◦ Skin and nails: dry, thin and brittle
◦ Loss of hair

8. Intermittent claudication
◦ This term describes ischaemic pain affecting the muscles of the leg upon walking.
◦ The pain is usually felt in the calf because the disease most commonly affects the superficial femoral artery.
◦ However, the pain may be felt in the thigh or buttock if the iliac arteries are involved.
◦ Typically, the pain comes on after a reasonably constant ‘claudication distance’ and rapidly subsides on
stopping walking. Resumption of walking leads to a return of the pain.

9. Critical limb ischaemia
◦ This is defined as rest (night) pain, requiring opiate analgesia, and/or tissue loss (ulceration or gangrene),
present for more than 2 weeks, in the presence of an ankle BP of less than 50 mmHg.
◦ Rest pain only, with ankle pressures above 50 mmHg, is known as subcritical limb ischaemia (SCLI).
◦ The term severe limb ischaemia (SLI) is used to describe both CLI and SCLI. Whereas IC is usually due to
single-segment plaque, SLI is always due to multilevel disease.
◦ Many patients with SLI have not previously sought medical advice for IC, principally because they have other
comorbidity that prevents them from walking to a point where claudication pain might develop. In contrast
to patients with IC, those with SLI are at high risk of losing their limb, and sometimes their life, in a matter
of weeks or months without surgical bypass or endovascular revascularization by angioplasty or stenting.

12. Investigation & Treatment
◦ MRI or CT with intravenous injection of contrast agents. Intra-arterial digital subtraction angiography (IA-
DSA) is usually reserved for those undergoing endovascular revascularization.
◦ Smoking cessation
◦ Regular exercise (30 mins of walking, three times per week)
◦ Antiplatelet agent (aspirin 75 mg or clopidogrel 75 mg daily)
◦ Reduction of cholesterol (diet and statin therapy)
◦ Diagnosis and treatment of diabetes mellitus (all should have fasting glucose measured)
◦ Diagnosis and treatment of frequently associated conditions (e.g. hypertension, anaemia, heart failure)

13. Buerger’s disease (thromboangiitis
obliterans)
◦ This is an inflammatory obliterative arterial disease
that is distinct from atherosclerosis and usually
presents in young (20–30 years) male smokers.
◦ It characteristically affects distal arteries, giving rise
to claudication in the feet or rest pain in the fingers
or toes.
◦ Wrist and ankle pulses are absent but brachial and
popliteal pulses are present.
◦ Disease also affects the veins, giving rise to
superficial thrombophlebitis.
◦ It often remits if the patient stops smoking;
sympathectomy and prostaglandin infusions may be
helpful. Major limb amputation is the most frequent
outcome if patients continue to smoke.

14. Chronic upper limb arterial disease
◦ In the arm, the subclavian artery is the most common site of disease, which may manifest as:
◦ Arm claudication (rare).
◦ Atheroembolism (blue finger syndrome). Small emboli lodge in digital arteries and may be confused with
Raynaud’s phenomenon but, in this case, the symptoms are unilateral. Failure to make the diagnosis may
eventually lead to amputation.
◦ Subclavian steal. When the arm is used, blood is ‘stolen’ from the brain via the vertebral artery. This leads to
vertebro-basilar ischaemia, which is characterised by dizziness, cortical blindness and/or collapse. Where
possible, subclavian artery disease is treated by means of angioplasty and stenting, as surgery (e.g. carotid–
subclavian bypass) can be difficult.

15. Raynaud’s phenomenon and Raynaud’s disease
◦ Cold (and emotional) stimuli may trigger
vasospasm, leading to the characteristic sequence
of digital pallor due to vasospasm, cyanosis due
to deoxygenated blood, and rubor due to reactive
hyperaemia.

16. Primary Raynaud’s phenomenon
(or disease)
1) This affects 5–10% of young women aged
15–30 years in temperate climates and may
be familial.
2) It does not progress to ulceration or
infarction, and significant pain is unusual.
3) The underlying cause is unclear.
4) No investigation is necessary. The patient
should be reassured and advised to avoid
exposure to cold.
5) Long-acting nifedipine may be helpful but
sympathectomy is not indicated.
Secondary Raynaud’s
phenomenon
(or syndrome)
1) This occurs in older people in association
with connective tissue disease, vibration-
induced injury and thoracic outlet
obstruction.
2) It is often associated with fixed
obstruction of the digital arteries, fingertip
ulceration, and necrosis and pain.
3) The fingers must be protected from cold
and trauma, infection requires treatment
with antibiotics, and surgery should be
avoided if possible. Vasoactive drugs have
no clear benefit. Sympathectomy helps for
a year or two. Prostacyclin infusions are
sometimes beneficial.