Peripheral vascular disease (PVD) refers to a circulation disorder that affects blood vessels outside the heart and brain, most commonly arteries supplying the legs. It occurs when arteries become narrowed or blocked, usually due to atherosclerosis, leading to reduced blood flow. PVD can significantly impair quality of life and is associated with increased risk of heart attack and stroke.
Causes
- Atherosclerosis (most common cause)
- Diabetes mellitus
- Smoking
- Hypertension
- High cholesterol levels
- Inflammatory conditions (e.g., vasculitis)
- Blood clots (thrombosis)
- Arterial trauma or injury
- Radiation exposure affecting blood vessels
Pathophysiology
PVD primarily results from atherosclerosis, where fatty deposits (plaques) build up inside arterial walls. This causes narrowing and hardening of the arteries, limiting blood flow to the limbs. As the condition progresses, tissues receive less oxygen, especially during physical activity, leading to pain (claudication). In severe cases, critical limb ischaemia develops, with constant pain, ulcers, and risk of limb loss.
Signs and Symptoms
- Intermittent claudication (cramping leg pain during walking, relieved by rest)
- Weak or absent pulses in the legs or feet
- Coldness in the lower leg or foot, particularly when compared to the other side
- Numbness or weakness in the legs
- Sores on toes, feet, or legs that do not heal
- Shiny skin or hair loss on the legs
- Colour changes in the skin (pale, bluish, or dark)
- In severe cases, gangrene (tissue death)
Risk Factors
- Smoking (strongest risk factor)
- Diabetes mellitus
- Age over 50 years
- High blood pressure
- High blood cholesterol levels
- Obesity
- Family history of vascular disease
- Sedentary lifestyle
- Chronic kidney disease
Investigation (Imaging or Labs)
- Ankle-Brachial Pressure Index (ABPI): simple non-invasive test comparing blood pressure in the ankle with that in the arm; an ABPI less than 0.9 indicates PVD
- Doppler ultrasound: assesses blood flow and identifies narrowed or blocked arteries
- Magnetic Resonance Angiography (MRA) or CT Angiography: provides detailed images of blood vessels
- Conventional angiography: gold standard for visualising arterial blockages, especially when planning surgery
- Blood tests: lipid profile, blood glucose, renal function, and inflammatory markers
- Electrocardiogram (ECG): to detect coexisting heart disease
Management
1. Non-Pharmacological Management
- Smoking cessation: most crucial lifestyle change to prevent disease progression
- Exercise therapy: supervised walking programmes improve claudication distance and overall vascular health
- Dietary changes: low-fat, high-fibre diets to control cholesterol and weight
- Foot care: important in diabetic patients to prevent ulcers and infections
- Patient education: about recognising symptoms of worsening disease
2. Pharmacological Management
- Antiplatelet therapy: aspirin or clopidogrel to reduce cardiovascular events (NICE recommends single antiplatelet therapy routinely)
- Statins: to lower cholesterol and stabilise atherosclerotic plaques
- Statins: to lower cholesterol and stabilise atherosclerotic plaques
- Glycaemic control: in diabetic patients to reduce complications
- Cilostazol: can be considered to improve walking distance in some cases of intermittent claudication, but not first-line according to NICE
3. Surgical Management
- Angioplasty and stenting: minimally invasive procedures to open narrowed arteries
- Bypass surgery: using a graft to redirect blood around a blockage
- Endarterectomy: surgical removal of plaque from an artery
- Amputation: in cases of irreversible critical limb ischaemia with gangrene or infection
Complications
- Critical limb ischaemia (constant pain, ulcers, risk of amputation)
- Limb amputation
- Myocardial infarction (heart attack)
- Stroke
- Poor wound healing and infections
- Severe disability and reduced quality of life
References
- National Institute for Health and Care Excellence (NICE) Peripheral Arterial Disease: Diagnosis and Management (CG147)
- Royal College of Physicians Clinical Guidelines for Peripheral Vascular Disease
- General Medical Council (GMC) Good Medical Practice Guidance
- European Society of Cardiology (ESC) Guidelines on Peripheral Arterial Diseases (adapted to UK practice)