Peripheral Vascular Disease

Definition/diagnostic criteria Peripheral vascular disease, also known as peripheral arterial disease (PAD), is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs. PVD primarily affects the legs, and its hallmark symptom is leg pain when walking (claudication).

Epidemiology PVD affects approximately 20% of individuals over the age of 60 in the UK, with a higher prevalence in males and in those with a history of smoking or diabetes. The prevalence increases with age and is often underdiagnosed due to the asymptomatic nature of the disease in its early stages.

Diagnosis
Clinical features: The classical symptom of PVD is intermittent claudication, characterised by pain and cramping in the legs that starts with exercise and is relieved with rest.

• Advanced PVD can lead to critical limb ischemia, presenting as rest pain, ulcers or gangrene.
• Physical examination may reveal diminished or absent peripheral pulses, bruits, pallor on elevation of the limbs, and dependent rubor.

Investigations:

• The ankle-brachial pressure index (ABPI) is the primary diagnostic test, with values <0.9 confirming PVD.
• Duplex ultrasound is also a key diagnostic tool, used for mapping the location and severity of artery narrowing.
• Further imaging, like CT angiography or MR angiography, may be necessary in complex cases or prior to intervention.

Treatment The management of PVD involves lifestyle modifications, pharmacotherapy and, in some cases, revascularisation procedures.

• Lifestyle interventions include smoking cessation, exercise and dietary modifications.
• Pharmacologically, antiplatelet agents like aspirin or clopidogrel and lipid-lowering therapy (statins) are recommended to reduce the risk of cardiovascular events.
• Antihypertensive drugs are used to control blood pressure when necessary.
• In cases of severe claudication or critical limb ischemia, revascularisation procedures such as angioplasty or bypass surgery may be necessary. The choice of procedure depends on the location and extent of arterial disease, patient comorbidity and life expectancy.

Prognosis The prognosis of PVD is closely linked to the overall cardiovascular risk profile of the individual. While the peripheral manifestations of the disease can lead to significant morbidity, including pain and limited mobility, the major concern is the increased risk of cardiovascular events such as myocardial infarction and stroke. With proper management, including lifestyle changes and pharmacotherapy, the progression of PVD can be slowed, and the risk of cardiovascular events can be reduced.