Peripheral Arterial Disease

Clinical Guidance

Intermittent Claudication is a common presentation of peripheral arterial disease in primary care.  If Intermittent Claudication is suspected, then this should be confirmed by ABPI's either in primary care or by referral to Vascular Studies - see referrals section below. 

Surgical Vascular interventions are often not required or not effective in the long term and conservative management in primary care can be tried initially prior to consideration of referral.

Please also refer to the NICE guidelines (web page) on management of peripheral arterial disease.

Management in primary care

If there are no red flags (see below) then initial management should be in primary care. This should include:

• Modification of Vascular Risks - Including smoking cessation, lifestyle modification, statins, anti-platelets and screening and management of diabetes and high blood pressure.
• Unsupervised Exercise -This involves advice to exercise for approximately 30 minutes, three to five times per week, walking until the onset of symptoms, then resting to recover. Further information can be found in this Intermittent Claudication patient leaflet.
• Supervised Exercise - Requires patients to attend the BRI twice weekly for 12 weeks. Referrals can be made to the Vascular Clinical Nurse Specialist team via the Vascular RAS on eRS who will refer on to this clinic if appropriate.
• Vasodilators - Mr Marcus Brooks (vascular surgeon at NBT) does not advocate the use of Vasodilators (Naftidrofuryl Oxalate) which probably only have minimal effect)

Specialist Advice - FAQs

Advice provided by Marcus Brooks (Consultant Vascular Surgeon at NBT)

Question - What is the cut off ABPI for referral of patients with Intermittent Claudication?

There is no cut off value for ABPI's when deciding on referral.  The benefit of an ABPI is that if this is normal then it excludes the diagnosis of PAD.  A level less than 0.9 is diagnostic.  If the ABPI is very low (< 0.3) or the pulses cannot be detected then this should raise the possibility of critical limb ischaemia. 

Referral should be for people with lifestyle limiting symptoms or patients who would benefit from and have agreed to attend (twice weekly at BRI for 12 weeks) intermittent claudication exercise classes.

Question - What is the significance of an elevated APBI and is this ever an indicator of Vascular Disease? 

The normal range for ABPI is up to 1.1.   Ratios above this, suggest arteriosclerosis (hardening of the arteries - i.e. in diabetics) and can be a sign of peripheral vascular disease, more likely when a very high ratio.  The key differentiator is the signal, if this is monophasic it indicates vascular disease.  The truth is in diabetics we often need a Duplex to differentiate calcified from stenotic arteries.

Question - If a patient has claudication type symptoms but normal APBIs, is a vascular referral ever warranted or can the GP safely look elsewhere for a cause of the symptoms?

An arterial cause is only 100% excluded by normal post exercise ABPIs. This is because iliac disease and early SFA disease can cause symptoms of intermittent claudication with normal ABPI at rest.  We use a treadmill and then repeat ABPI.  I advise this in any patient in whom the diagnosis of PAD is considered likely with normal resting ABPI.  In primary care, patient could be asked to walk up and down until they have symptoms, it can be useful in addition to document exactly what the symptoms are, or be referred to their local vascular studies unit.  In the most extreme case, professional cyclists with external iliac endointimal fibrosis, their symptoms only come on with vigorous exercise and they have to bring a bike in to be tested.

Red Flags

See CKS - Diagnosis of Peripheral Arterial Disease for advice on when to suspect acute or critical limb ischaemia.

If Acute Limb Ischaemia is suspected then arrange emergency admission. Features include:

• Pain — constantly present and persistent.
• Pulseless — ankle pulses are always absent.
• Pallor (or cyanosis or mottling).
• Power loss or paralysis.
• Paraesthesia or reduced sensation or numbness.
• Perishing with cold.

 If Critical Limb Ischaemia is suspected then refer URGENTLY to Vascular team. Features include:

• Rest pain, which may be described as relentless, unbearable, or burning. This may be worse at night because the elevation of the leg in bed further limits perfusion. People may report sleeping with the leg hanging out of bed, or sleep in a chair. Rest pain is usually preceded by a history of intermittent claudication but occasionally is not (for example intermittent claudication may not have been clinically apparent in a person with limited mobility).
• Dependent rubor (red or purple colour of the leg when not elevated), early pallor on elevation of the extremity, and reduced capillary refill.
• Skin changes (not always a feature), including impaired wound healing, ischaemic ulcers, and gangrene.
• Absent foot pulses.

Urgent patients can be referred to Vascular Surgery RAS which is now available via eRS. Referrals should be marked urgent. They will then be reviewed in Secondary Care and booked into the HOT Clinic if appropriate (do not send via Referral Service to avoid any potential delays). 

The vascular network office can also be contacted via telephone 0117 414 0798 or by discussion with either the General Surgery/Vascular Surgery Registrar on call or the Vascular Consultant on call – both can be contacted via NBT switchboard on 0117 9505050.

Many patients with vascular disease require emergency or urgent specialist care (see page 4 of the Directory below). Such patients should be referred as per these pathways by telephone, referapatient® or NHS e-RS Triage service. The specialist service during periods of ‘surge’ will be consultant led and referrals for advice are welcomed. Patients are at risk of life or limb loss or stroke when urgent vascular intervention is deferred.

Referral Guidance

Vascular Studies

Vascular studies can be requested directly in the following ways:

• NBT ICE - search for ABPI and tick the US ABPI box (also listed under the Vascular tab) if wanting to screen for PAD or for compression.
• UHBW ICE - search for ABPI and tick the APBI +- exercise testing box.
• eRS to the Vascular Surgery Triage Service  at the BRI, Southmead, Weston or Bath. Referrals will be triaged on  a daily basis by the vascular team and booked into appropriate clinics. Please include all relevant clinical and contact details in referrals to help facilitate the triage process.

Vascular Outpatient Referral

If symptoms are not controlled with management in primary care then a referral to the nurse led vascular clinic via eRS may be appropriate.

The vascular consultants also run outpatient clinics accessed via eRS in the following locations:

• Southmead Hospital
• Bristol Royal Infirmary
• Royal United Hospital Bath
• Weston General Hospital
• Cossham Community Hospital
• Melksham Community Hospital

All vascular referrals should now be sent via eRS to the Vascular Surgery Triage Service. Referrals will be triaged on  a daily basis by the vascular team and booked into appropriate clinics. Please include all relevant clinical and contact details in referrals to help facilitate the triage process. There is a Vascular Hot Clinic at Southmead Hospital for patients requiring urgent review but not necessarily admission.

Useful Links

NICE Guidelines for the Management of Peripheral Arterial Disease (web page)

Please see the local Vascular Directory of Services

Vascular Services Network - for clinicians

Vascular Network Office contact details:

Telephone: 0117 4140798
 Email: Nbn-tr.bbwvascularnetwork@nhs.net

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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