3.1. Peripheral Arterial Disease (PAD)

📄 Definition

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis causing stenosis or occlusion of arteries, primarily affecting the lower limbs. It ranges from asymptomatic disease to critical limb ischaemia.

⚠️ Classification

  • Asymptomatic PAD: reduced pulses, ABPI <0.9 but no symptoms

  • Intermittent Claudication: reproducible leg pain with exertion, relieved by rest

  • Critical Limb Ischaemia (CLI): chronic pain at rest, ulceration, or gangrene

🛡️ Risk Factors – Mnemonic: ATHEROSE

  • Age >60

  • Tobacco use (most significant modifiable)

  • Hypertension

  • Elevated cholesterol

  • Renal impairment (CKD)

  • Obesity

  • Sedentary lifestyle

  • Endocrine: Diabetes mellitus

Investigations 

🥇 First-Line

  • ABPI (Ankle-Brachial Pressure Index):

    • <0.9 = diagnostic of PAD

    • <0.5 = severe disease

  • Duplex Doppler Ultrasound – assess blood flow and stenosis

🥈 Second-Line

  • MR Angiography or CT Angiography – pre-intervention planning

  • Bloods: FBC, U&Es, HbA1c, Lipids, LFTs, ESR/CRP

  • ECG – evaluate cardiovascular risk

📋 Clinical Features – 

Mnemonic: 6 Ps (acute) and CLAUDICATE (chronic)
Acute Limb Ischaemia – 6 Ps:

  • Pain

  • Pallor

  • Pulselessness

  • Paralysis

  • Paraesthesia

  • Perishing cold

Chronic PAD – Mnemonic: CLAUDICATE

  • Cramping calf pain

  • Loss of hair

  • Abnormal pulses

  • Ulcers (arterial)

  • Dry, shiny skin

  • Intermittent claudication

  • Cool peripheries

  • ABPI <0.9

  • Toe pallor

  • Erectile dysfunction (Leriche syndrome)

Management – Mnemonic: PAD CARE

  • Prevention – smoking cessation, weight reduction, exercise

  • Antiplatelet – clopidogrel first-line

  • Dual risk factor control – manage BP, lipids, diabetes

  • Cilostazol (for symptom relief in intermittent claudication)

  • Angioplasty or stenting – severe symptoms or CLI

  • Revascularisation – surgical bypass if angioplasty not feasible

  • Education – foot care, PAD risk understanding

⚠️ Complications

  • Critical limb ischaemia

  • Amputation

  • Ulceration

  • Cardiovascular morbidity (MI, stroke)

🔺 Last updated in line with NICE CG147 – Peripheral arterial disease: diagnosis and management

Published: August 2012 • Last updated: October 2020
Last reviewed: August 2025
✅ PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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