Peripheral vascular disease: what it is, symptoms and treatment

Peripheral vascular disease is the name many people search for, but the NHS and NICE use the term peripheral arterial disease (PAD). NICE CKS defines it as a narrowing or blockage of the peripheral arteries that affects the blood supply to the lower limbs.

The NHS explains that it is usually caused by a build-up of fatty deposits (atheroma, made of cholesterol and other waste substances) in the walls of the leg arteries. This makes the arteries narrower and restricts blood flow to the legs, a process called atherosclerosis.

Because the same process can affect arteries elsewhere, the NHS says the blockages can also affect the arteries supplying the heart and brain. Having PAD is therefore treated as a sign that your blood vessels are unhealthy, not just a leg problem.

The NHS says many people with PAD have no symptoms. The classic symptom is intermittent claudication: a painful ache in the legs when walking that usually disappears after a few minutes of rest. It can affect one or both legs and range from mild to severe. NICE CKS describes it as a cramp-like pain in the calf, thigh or buttock on walking that is relieved by resting.

The NHS lists other possible symptoms, below. It adds that symptoms often develop slowly, and that if they develop quickly or suddenly get worse it could be a sign of a serious problem needing immediate treatment. Many people mistakenly think leg pain on exercise is just part of growing older, but the NHS says there is no reason why an otherwise healthy person should experience it.

• Hair loss on the legs and feet

• Numbness or weakness in the legs

• Brittle, slow-growing toenails

• Ulcers (open sores) on the feet and legs that do not heal

• Skin turning paler than usual or blue, which may be harder to see on brown and black skin

• Shiny skin

• Erectile dysfunction in men

• Shrinking (wasting) of the leg muscles

NICE CKS describes a continuum. Asymptomatic PAD is considered an early stage that may progress to claudication or to chronic limb-threatening ischaemia. The table below summarises the terms you may hear from a GP or vascular team.

NICE CKS says PAD of the lower limbs is most commonly caused by atherosclerosis. The NHS lists the factors that raise the chance of PAD and other cardiovascular disease: smoking (the most significant), type 1 and type 2 diabetes, high blood pressure, high cholesterol and growing older.

This overlap is why treating PAD focuses on the whole circulation. The NHS says poorly controlled diabetes can make PAD symptoms worse and raise the chance of other cardiovascular disease.

The NHS says see a GP if you have recurring leg pain when exercising. The GP will examine your legs, looking for shiny skin, brittle toenails, hair loss, a very weak or undetectable leg pulse and leg ulcers, and may ask about your personal and family history.

The key test is the ankle brachial pressure index (ABPI). Blood pressure is measured in the arms and ankles with a cuff and a Doppler probe, and the ankle result is divided by the arm result. The NHS says healthy circulation gives a result of 1 or almost 1, and a result below 1 suggests PAD. NICE CKS says an ABPI of 0.79 or lower suggests PAD. The test may be done at your surgery or by a podiatry service, and sometimes after exercise on a treadmill or bike.

The NHS says further testing is usually only needed if the diagnosis is uncertain, or if the blood supply restriction is severe enough that treatment such as surgery may be needed. Hospital tests include an ultrasound scan of the leg arteries and an angiogram using a CT or MRI scan.

The NHS says the two most important lifestyle changes are exercising more regularly and stopping smoking. NICE recommends supervised exercise as one of the first steps, usually 2 hours of supervised exercise a week for 3 months. Walking is one of the best exercises: walk until the pain becomes intolerable, rest until it goes, then repeat for at least 30 minutes in total, several times a week. The NHS also advises a balanced diet, managing weight and cutting down on alcohol.

Medicines treat the underlying causes. The NHS lists statins if LDL cholesterol is high, antihypertensives such as ACE inhibitors for blood pressure, and medicines to reduce blood clots (low-dose aspirin, clopidogrel or rivaroxaban). Naftidrofuryl oxalate may be offered for exercise-triggered leg pain, normally for around 3 to 6 months to see whether it helps.

Revascularisation may be recommended if leg pain prevents everyday activities or other treatments have not worked. The NHS describes angioplasty (widening the artery with a tiny balloon) and a bypass graft. Angioplasty is less invasive, usually done under local anaesthetic as a day procedure and is generally preferred unless unsuitable or previously unsuccessful. Bypass results are generally considered longer-lasting. A team of specialist surgeons, doctors and nurses discusses the options with you.

The NHS says the benefits of exercise are quickly lost if it is not frequent and regular, so it advises aiming to exercise daily for the rest of your life. The pain during the stop-start walking pattern can be upsetting, and the NHS acknowledges that the course is challenging but should improve your symptoms.

Stopping smoking matters most. The NHS says research has found that people who smoke after receiving a PAD diagnosis are much more likely to have a heart attack and die from a complication of heart disease than people who quit. It also says to look after your mental wellbeing, because PAD can cause severe pain and disrupt your life, and to manage diabetes properly if you have it.

If blood flow to the legs becomes severely restricted, critical limb ischaemia (CLI) can develop. The NHS describes it as an extremely serious complication that can be challenging to treat. An angioplasty or bypass graft is usually recommended, although these may not always be successful or possible, and in a few cases amputation may be required.

The NHS lists the symptoms of CLI: severe burning pain in the legs and feet that continues at rest, skin turning pale, shiny, smooth and dry, wounds and ulcers that do not heal, loss of muscle mass, and toes or lower limbs that become cold and numb, turn red and then black, or swell and produce smelly pus (gangrene). If you think you are developing CLI, contact a GP immediately; if that is not possible, call 111 or use 111 online.

NICE CKS says people with suspected acute limb ischaemia need an emergency assessment by a vascular specialist, so a leg that suddenly becomes painful, pale, cold or numb should be treated as an emergency. Call 999 or go to A&E if you cannot reach urgent care quickly.

Most people are diagnosed in primary care, where a GP or podiatry service can carry out the ABPI. If a procedure is being considered, or the blood supply is severely restricted, you are referred to a vascular team. NICE CKS says people with chronic limb-threatening ischaemia should be urgently referred to a vascular multidisciplinary team, and that people with claudication should be referred for consideration of angioplasty or bypass if risk-factor advice and a supervised exercise programme have not given a satisfactory improvement.

Some people choose to see a vascular specialist privately or arrange scans privately. The tests and procedures are the same; the differences are in waiting times and cost, so confirm what is included before booking.