PassFinals
Vascular Surgery

Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis in which lower-limb arterial flow cannot meet demand, causing intermittent claudication or, when tissue perfusion is inadequate at rest, chronic limb-threatening ischaemia.

In a nutshell

PAD causes exertional leg pain when arterial supply cannot meet exercise demand. Diagnose with history, examination and ABPI; use duplex then MRA or CTA when planning revascularisation. Treat all patients with cardiovascular secondary prevention and supervised exercise. Persistent lifestyle-limiting claudication may need revascularisation; rest pain, ulceration or gangrene requires urgent vascular MDT assessment for CLTI.

Classic presentation

Reproducible calf pain on walking that settles with rest, with reduced pulses and a low ABPI; advanced disease causes forefoot rest pain, non-healing ulcers or gangrene.

Key points

  • Claudication is exertional, reproducible muscle pain relieved by rest; neurogenic claudication is usually posture-dependent and improves with spinal flexion.
  • ABPI below 0.9 supports PAD, but a normal or raised ABPI does not exclude PAD in diabetes or arterial calcification.
  • Duplex is first-line imaging when revascularisation is considered; use contrast-enhanced MRA, or CTA if MRA is contraindicated or not tolerated.
  • Offer all people with PAD secondary cardiovascular prevention: smoking cessation, antiplatelet treatment where indicated, lipid modification, blood-pressure and diabetes management.
  • Offer supervised exercise to everyone with intermittent claudication; NICE describes about 2 hours weekly for 3 months, working towards maximal tolerable pain.
  • Offer angioplasty only after risk-factor advice and supervised exercise have not provided satisfactory improvement and imaging confirms suitability; consider bypass when angioplasty is unsuitable or unsuccessful.
  • Rest pain, ulceration or gangrene is CLTI and requires urgent vascular MDT assessment, wound/pain care and consideration of revascularisation.
  • NICE is updating CLTI recommendations for drug-eluting stents and drug-coated balloons; do not teach a fixed device choice as universally correct.
  • Sudden worsening with pallor, coldness, sensory loss or weakness is acute limb ischaemia and needs an emergency vascular pathway.

First-line investigation

Clinical vascular examination and Doppler ABPI; do not exclude PAD from a normal or raised ABPI alone in diabetes.

Management

Confirm and stage

  • Take a claudication/CLTI history, examine pulses and tissue, measure Doppler ABPI, and escalate same-day if acute ischaemia is suspected.1,2,6

Reduce cardiovascular risk

  • Offer smoking cessation, antiplatelet treatment where indicated, lipid modification, blood-pressure and diabetes management, diet, weight and activity support.1,4,3

Exercise for claudication

  • Offer a supervised exercise programme, commonly 2 hours weekly for 3 months, progressing walking towards maximal tolerable pain with rest intervals.1,7,3

Revascularise selectively

  • Use duplex then MRA or CTA for planning; consider angioplasty or bypass for persistent lifestyle-limiting claudication and urgent revascularisation planning for CLTI.1,5

Protect the threatened limb

  • CLTI needs vascular MDT, wound and pain care, infection assessment and a documented limb-salvage or palliation plan; acute deterioration needs emergency ALI referral.1,5,2

Safety-net and review

  • Review symptoms, function, wounds, treatment adherence and cardiovascular risk; give urgent return advice for sudden pain, pallor, coldness, numbness, weakness, infection or tissue deterioration.1,2,3

Exam traps

  • A normal ABPI does not exclude PAD in diabetes because arterial calcification can produce a falsely reassuring result.
  • Do not jump straight to angioplasty for claudication: exercise and risk-factor management come first.
  • Rest pain, ulceration and gangrene are not uncomplicated claudication; they indicate CLTI and urgent vascular referral.
  • A painful ischaemic ulcer needs perfusion assessment before compression or debridement decisions.
  • Do not confuse acute limb ischaemia with chronic PAD: sudden pain, pallor, coldness, paraesthesia or weakness is an emergency.
  • PAD is a systemic atherosclerotic marker, so cardiovascular prevention is as important as improving walking distance.

Illustrations

Supply-demand mismatch in claudicationGraph showing oxygen demand rising with exercise against a fixed, stenosis-limited maximal supply, illustrating why pain appears at a reproducible walking distance.PassFinals · original
Progression from claudication to chronic limb-threatening ischaemiaDiagram illustrating progression from asymptomatic disease through intermittent claudication to rest pain, ulceration and gangrene as perfusion falls.PassFinals · original
Ischaemic arterial ulceration and toe necrosisClinical photograph of a distal arterial ulcer over a pressure point with a pale base, showing tissue loss that requires vascular assessment.Bondegezou, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE CG147: Peripheral arterial disease: diagnosis and management (CG147 recommendations; current page reviewed 27 April 2026)Published 8 Aug 2012 | Updated 11 Dec 2020
  2. NICE CKS: Peripheral arterial disease (Current NICE CKS topic for assessment and management)
  3. NHS: Peripheral arterial disease treatment (NHS exercise, smoking, medicines and revascularisation information, reviewed 10 April 2026)Updated 10 Apr 2026
  4. NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification (NG238 recommendations)Published 14 Dec 2023
  5. NICE CG147: April 2026 exceptional surveillance decision (Update planned for drug-eluting stents and drug-coated balloon angioplasty in femoropopliteal CLTI)Published 27 Apr 2026
  6. NHS: Peripheral arterial disease diagnosis (NHS diagnosis and ABPI information, reviewed 10 April 2026)Updated 10 Apr 2026
  7. NICE QS52: Peripheral arterial disease quality standard (Quality statement 3: supervised exercise programmes)Published 21 Jan 2014

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.