Peripheral Vascular Disease

Overview – Peripheral Vascular Disease

Peripheral vascular disease (PVD), also known as peripheral arterial disease, refers to the obstruction of peripheral arteries, excluding those of the coronary circulation, aortic arch, or brain. It commonly arises due to atherosclerosis and is a key cause of chronic limb ischaemia, resulting in leg pain, ulcers, and potential limb loss. Recognising PVD is crucial due to its strong association with cardiovascular disease and its potentially life-threatening acute complications such as critical limb ischaemia.

Definition

  • Peripheral vascular disease is the obstruction or narrowing of peripheral arteries, leading to reduced blood flow, usually affecting the lower limbs.
  • It excludes arterial disease of the coronaries, aortic arch, and cerebral vessels.

Aetiology

Pathophysiology

  • Atherosclerotic plaque formation → progressive arterial narrowing → reduced distal perfusion
  • → Chronic limb ischaemia and complications:
Peripheral Vascular Disease
https://www.ncbi.nlm.nih.gov/books/NBK519606/

Clinical Features

Chronic PVD

  • Intermittent Claudication:
    • Pain, cramping, or weakness in the legs with exertion
    • Typically calf pain, relieved by rest (within 2–3 minutes)
    • Reproducible at the same walking distance
  • Rest Pain: Sign of advanced disease
  • Other signs:
    • Weak or absent distal pulses
    • Skin changes: hair loss, shiny/atrophic skin
    • Ulcers, gangrene
    • Evidence of systemic atherosclerosis (e.g. impotence, cardiovascular disease)

Acute Arterial Occlusion (Critical Limb Ischaemia)

  • Sudden onset of limb-threatening ischaemia
  • Causes: embolus, thrombus, trauma
  • The 6 Ps:
    • Pain
    • Pallor
    • Paraesthesia
    • Paralysis
    • Polar (cold limb)
    • Pulselessness

Investigations

Non-Invasive

  • ABI (Ankle-Brachial Index):
    • ABI < 0.9 is abnormal
    • ABI < 0.3 = severe ischaemia → rest pain and critical limb threat
  • Doppler ultrasound
  • CT angiogram with contrast

Invasive

  • Femoral angiography (DSA) – Gold standard
  • Carotid artery duplex (to assess concurrent cerebrovascular disease)

Management

Conservative

  • Smoking cessation
  • Reduce alcohol intake
  • Control diabetes, hypertension, and cholesterol
  • Regular exercise improves symptoms in up to 70%

Medical

  • Lipid lowering: Statins, fibrates, bile acid resins (e.g. cholestyramine), ezetimibe
  • Antihypertensives: Beta-blockers, ACE inhibitors or ARBs, calcium channel blockers
  • Diabetes control
  • Champix (varenicline) for smoking cessation

Surgical

  • Angioplasty (with or without stenting)
  • Bypass grafting (e.g. femoral-popliteal bypass)
  • Endarterectomy
  • Amputation (if irreversible ischaemia)

Acute Limb Ischaemia

Causes

  • Embolism (80–90% cardiac origin):
  • Thrombosis:
    • In-situ clot in atherosclerotic vessel
    • Gradual onset with history of claudication
  • Trauma:
    • Iatrogenic, catheterisation, injections, immobilisation

Investigations

  • CXR, ECG
  • Arteriography to localise lesion

Management

  • Immediate IV heparin
  • Urgent revascularisation:
    • Embolectomy for embolic cause
    • Bypass for thrombosis
  • Continue anticoagulation post-op (warfarin for 3 months)
  • Amputation if limb is non-viable

Complications

Differential Diagnosis

  • Chronic venous insufficiency
  • Diabetic neuropathy
  • Spinal stenosis
  • Deep vein thrombosis (DVT)
  • Musculoskeletal pain

Summary – Peripheral Vascular Disease

Peripheral vascular disease is a chronic, progressive narrowing of peripheral arteries, most commonly due to atherosclerosis. It manifests as intermittent claudication, rest pain, and critical limb ischaemia in severe cases. Early recognition and management — from lifestyle changes and medications to surgical intervention — are vital to prevent amputation or mortality. For a broader context, see our Cardiovascular Overview page.

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