Guidance

Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Information requirements

  • Offer all people with peripheral arterial disease oral and written information about their condition. Discuss it with them so they can share decision‑making, and understand the course of the disease and what they can do to help prevent disease progression. Information should include:

    • the causes of their symptoms and the severity of their disease

    • the risks of limb loss and/or cardiovascular events associated with peripheral arterial disease

    • the key modifiable risk factors, such as smoking, control of diabetes, hyperlipidaemia, diet, body weight and exercise (see also recommendation on the secondary prevention of cardiovascular disease below)

    • how to manage pain

    • all relevant treatment options, including the risks and benefits of each

    • how they can access support for dealing with depression and anxiety.

      Ensure that information, tailored to the individual needs of the person, is available at diagnosis and subsequently as required, to allow people to make decisions throughout the course of their treatment.

Secondary prevention of cardiovascular disease in people with peripheral arterial disease

  • Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance (see related NICE guidance) on:

    • smoking cessation

    • diet, weight management and exercise

    • lipid modification and statin therapy

    • the prevention, diagnosis and management of diabetes

    • the prevention, diagnosis and management of high blood pressure

    • antiplatelet therapy.

Diagnosis

  • Assess people for the presence of peripheral arterial disease if they:

    • have symptoms suggestive of peripheral arterial disease or

    • have diabetes, non‑healing wounds on the legs or feet or unexplained leg pain or

    • are being considered for interventions to the leg or foot or

    • need to use compression hosiery.

  • Assess people with suspected peripheral arterial disease by:

    • asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia

    • examining the legs and feet for evidence of critical limb ischaemia, for example ulceration

    • examining the femoral, popliteal and foot pulses

    • measuring the ankle brachial pressure index (see recommendation below).

  • Measure the ankle brachial pressure index in the following way:

    • The person should be resting and supine if possible.

    • Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis and, where possible, peroneal arteries.

    • Take measurements manually using a Doppler probe of suitable frequency in preference to an automated system.

    • Document the nature of the Doppler ultrasound signals in the foot arteries.

    • Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure.

Imaging for revascularisation

  • Offer contrast‑enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.

Management of intermittent claudication

  • Offer a supervised exercise programme to all people with intermittent claudication.

Management of critical limb ischaemia

  • Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.

  • Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.

  • National Institute for Health and Care Excellence (NICE)