Medically Fit For Exams
Medically Fit For Exams

Peripheral Arterial Disease


  • Narrowing (and non-compliance) of peripheral arteries
  • Usually a result of atherosclerosis
  • Mainly affects the legs, where blood supply can’t meet demands of the tissues


Risk factors

  • Smoking
  • Obesity
  • Hypertension
  • Sedentary lifestyle
  • Diabetes
  • High total cholesterol
  • Low HDL


Differential diagnosis

  • DVT or venous-thromboembolic disease (VTD)
  • Muscle injury
  • Sensory/peripheral neuropathy (diabetic)
  • Nerve pain



  • 12-14% of general population
  • About 20% over 75
  • Co-existent CAD (coronary artery disease) and cerebrovascular disease (CVD) are very common



  • Atherosclerosis in larger vessels
    • Result of high lipid and LDL cholesterol levels, build-up of fatty streaks and progression into atherosclerotic plaques
    • Rupture of these is involved in ACS and stroke
  • Arteriolosclerosis in smaller vessels
    • These are a result of high blood pressure (hyaline deposits)
  • Hardening and decreased compliance of vessels, resulting in greater peripheral resistance and reduced blood flow


Clinical features

  • Intermittent claudication – pain in the calves (or thigh or buttock) on exertion
  • Ischemic pain pattern – sharp pain brought on by exercise, and relieved by resting
  • Pain frequent at night or when legs are up – no gravity to aid in arterial blood flow
    • Relieved by hanging legs off the side of the bed
  • Arterial ulcers
    • Punched out appearance
    • Usually on distal digits or lateral malleolus
  • Temperature change
  • Colour change
  • Reduced hair and nail growth



  • Arteriolosclerosis – hardening/thickening of arteriole walls
    • Hyaline arteriolosclerosis – laying down of glassy protein and other molecules in the vessel wall
      • Is a normal part of ageing, but increased in hypertension and diabetic microangiopathy
    • Hyperplastic arteriolosclerosis – layer-like thickening of arteriole walls, due to damage and hyperplasticity, may lead to fibrinoid deposits and necrosis of vessel walls. Occurs in accelerated hypertension
  • Atherosclerosis/arteriosclerosis – hardening/thickening of artery walls
    • Fatty streaks – deposits of fat-filled macrophages: foam cells, often in response to endothelial damage
    • Progression to plaques, might be triggered by damage
      • caused by deposits of lipoproteins (LDL) in the vessel wall,
      • platelet adhesion,
      • monocyte adhesion (and differentiation into macrophages and foam cells)
      • lipid and inflammatory cell accumulation (CD4 cells: chronic inflammation) in intima layer
      • Smooth muscle and extracellular matrix proliferation
    • Plaques more likely to form at ‘turbulent’ areas



  • Buerger’s test: lift up leg until goes white (normal leg shouldn’t go white after 2 minutes), hang off side of bed and see if goes a normal pink, or a dark dusky pink (bad)
  • ABPI (ankle-brachial pressure index) – ratio between blood pressure in leg and in arm
    • Take brachial blood pressure in both arms and use the highest
    • Take blood pressure in both ankles, using dorsalis pedis or posterior tibial pulses
    • Calculate ABPI for both legs
  • Angiography – catheter inserted into femoral artery, contrast inserted, and imaging (X-ray) done to assess blood flow
    • Digital subtraction angiography: Xray taken before and after contrast to get an image purely of blood flow
  • Duplex ultrasound – two elements provide a picture of blood flow: normal ultrasound, with colour aspect showing the speed of flow superimposed

APBI pressure index table


  • Lifestyle modification
    • Weight loss
    • Smoking cessation
    • More exercise
    • Improve diet – lower salt and fat content
  • Pharmacological
    • Statins – reduce blood lipid/cholesterol levels
    • Anti-hypertensives (ACE inhibitors, CCBs, diuretics etc)
    • Vasodilators (eg NO)
    • Anti-platelets – eg clopidogrel and aspirin to reduce risk of cardiovascular complications
  • Surgery
    • Angioplasty – catheter fed in to remove blockage and/or place stent to keep lumen open
    • Surgical bypass – vessel taken from elsewhere, and used to replace damage vessel. Prosthetic tubes can be used
      • Often done in critical limb ischemia
    • Amputation – If the vasculature is sufficiently damaged, and tissue ischemia has occurred
      • Is rare
      • Priority is to maintain knee joint



  • Risk of death is about 3 times high in those with PAD
  • Having PAD is classified as being a coronary heart risk: >20% chance of having an event in the next 10 years
Peripheral arterial disease.docx
Microsoft Word document [126.4 KB]

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