PERIPHERAL ARTERIAL DISEASE
Nyan Soe Lwin
Year 3, Doctor of Medicine
University of Melbourne

DISCLAIMERS
• The following presentation is prepared by a medical student for
the sole purpose of peer-to-peer medical education.
• The content has not been reviewed or endorsed by a medical
practitioner or an educational body.

OVERVIEW
• Definition
• Lower Limb Anatomy Review
• Clinical Features – Hx and Examination findings
• Diagnosis – Investigations
• Management

PERIPHERAL ARTERIAL
DISEASE - OVERVIEW
• Narrowing (stenosis or occlusion) of and
reduced blood flow to the peripheral
vasculatures
• Can affect any vessels in the lower limbs
• Mainly due to atherosclerosis

L O W E R
L I M B
A N A T O M Y
Source: Moore’s Anatomy

L O W E R
L I M B
A N A T O M Y
Source: Moore’s Anatomy

AETIOLOGY
Atherosclerosis
• Structural issues: aortic coarctation, arterial fibrodysplasia, arterial tumours,
popliteal artery entrapment syndrome
• Thromboembolic events: embolism, thrombosis
• Vasospasm, trauma
• Buerger’s disease
Rare/less common causes:

RISK FACTORS
Smoking Diabetes
Hyperlipidaemia Obesity
Hx of CAD Hypertension
Renal
Impairment
Older age

CLINICAL
FEATURES
Asymptomatic – up to 50%
Intermittent Claudication
Absent Pulses
Trophic Changes
Rest Pain

CLAUDICATION
• Claudication
• Cramping pain +/- paraesthesia
in the lower limbs
• Site of pain usually indicative site
of lesion (distal to lesion)
• Aorto-iliac  hip/buttock
pain +/- sexual dysfunction
• Fem-pop  calf pain
• Tib-fib  foot claudication
• Worse on exertion, relieved with
rest
• Due to increased oxygen
demand
Source: https://www.bmj.com/content/bmj/suppl/2018/02/01/bmj.j5842.DC1/morr041877.wi.pdf

CLAUDICATION
• Claudication
• Cramping pain +/- paraesthesia
in the lower limbs
• Site of pain usually indicative site
of lesion (distal to lesion)
• Aorto-iliac  hip/buttock pain
+/- sexual dysfunction
• Fem-pop  calf pain
• tib-fib  foot claudication
• Worse on exertion, relieved with
rest
• Due to increased oxygen
demand
Source: Bailey and Love’s Short Practice of Surgery

TROPHIC CHANGES
• Trophic Changes
• Relates to tissue loss or atrophy due to ischaemia
• Ulcers
• Gangrene/necrosis
• Shiny, hairless leg
• Pale legs

REST PAIN
• Rest Pain
• Sign of late-stage disease or critical limb ischaemia
• Pain worse with lying down
• Improved with feet hanging over the bed

DIAGNOSIS
• Ankle-Brachial Pressure Index (ABPI)
• Ratio of ankle SBP : brachial SBP
• Higher values  calcification
• Lower values  stenosis
• Alternative: Toe-Brachial Pressure
• Criteria:
• 0.9 – 1.2 : normal
• 0.4 – 0.9 : mild to moderate PAD
• < 0.4 : severe PAD
• >1.3 : calcification

DIAGNOSIS
• Duplex Ultrasound
• colour-coded duplex ultrasound
• Allows for localization of the site of stenosis and visualization
of turbulence and blood flow velocity

DIAGNOSIS
• Digital Subtraction
Angiography (DSA)
• Gold standard of diagnosis
• Injection of radio-opaque dye
• Images are digitalized –
background ‘noise’ digitally
removed –e.g. fats, bones, soft
tissue)
• Magnetic Resonance
Angiography (MRA) or
Computed Tomography
Angiography (CTA)
• Use of CT or MRI technology

DIAGNOSTIC CRITERIA AND
CLASSIFICATIONS
• Fontaine Classification

DIAGNOSTIC CRITERIA AND
CLASSIFICATIONS
• Rutherford’s Scale

CRITICAL LIMB
ISCHAEMIA
• Severe compromise of arterial flow to the
extremities due to chronic limb ischaemia
• Can be defined by 1 or more of:
• Ischaemic REST PAIN of > 2 weeks in
duration
• Ischaemic lesions – ulcers, gangrenes
• ABPI < 0.5

ACUTE LIMB
ISCHAEMIA
• Sudden decrease in limb perfusion
threatening the viability of the limb
• MEDICAL EMERGENCY!!
• Aetiology
• Thrombosis – PAD, stents/grafts
• Embolism – distal sources e.g. AF, post-MI,
cholesterol, aneurysms
• Trauma
• Others: vasoactive drugs, shock

ACUTE LIMB
ISCHAEMIA
• Clinical Features: 6 Ps
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
• Poikilothermia (Perishingly Cold)

ACUTE LIMB
ISCHAEMIA
• Clinical Features: 6 Ps
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
• Poikilothermia (Perishingly Cold)

Source: https://www.bmj.com/content/bmj/suppl/2018/02/01/bmj.j5842.DC1/morr041877.wi.pdf

MANAGEMENT
• Conservative Management
• Lifestyle Modification
• Smoking cessation
• Regular exercise
• Weight loss

MANAGEMENT
• Medical Management
• Cholesterol Management
• Statins
• Anti-platelets
• Aspirin, clopidogrel
• Anti-hypertensives
• ACEIs/ARBs, β-blockers, CCBs
• Optimise diabetes control
• Metformin +/- 2nd line
• +/- insulin

MANAGEMENT
• Surgical Management
• Endovascular Revascularisation
• Angioplasty +/- stent

MANAGEMENT
• Surgical Management
• Open By-pass Revascularisation
• Iliofemoral, femoralpopliteal,
femoraltibial
• Different types of grafts:
• Arterial, venous (greater
saphenous vein), synthetic
Dacron graft

MANAGEMENT
• Surgical Management
• Open By-pass Revascularisation
• Iliofemoral, femoralpopliteal,
femoraltibial
• Different types of grafts:
• Arterial, venous (greater
saphenous vein), synthetic
Dacron graft

MANAGEMENT
• Surgical Management
• Endarterectomy
• Surgical removal of atherosclerotic
plaque

MANAGEMENT
• Surgical Management
• Amputation
• Indications:
• Gangrene
• Sepsis
• Severe rest pain
• Paralysis
• Unreconstructable critical leg
ischaemia

COMPLICATIONS
• Gangrene
• Sepsis
• Acute Limb Ischaemia
• Amputation
• Reduced mobility and quality of life

QUESTIONS?