Peripheral arterial disease

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

Peripheral arterial disease (PAD) encompasses a spectrum from asymptomatic disease through to limb-threatening ischaemia. This pathway covers arterial referrals into vascular services for PAD and suspected chronic limb-threatening ischaemia (CLTI). It distinguishes time-sensitive urgent referrals from conditions suitable for routine clinic appointments.

Clinical spectrum:

  • Asymptomatic PAD — incidental finding (reduced ABPI, absent pulses); manage risk factors in primary care
  • Intermittent claudication (IC) — muscle pain (calf, thigh, or buttock) brought on by exercise and relieved by rest; first-line management is primary care-based; only refer if fails first-line treatment or meets referral criteria
  • Chronic limb-threatening ischaemia (CLTI) — rest pain, non-healing wounds below the knee, or gangrene; urgent vascular referral required
  • Acute limb ischaemia — vascular emergency; immediate ED or on-call vascular contact

PAD is a strong marker of systemic cardiovascular risk — all patients require cardiovascular risk factor optimisation regardless of referral decision.

Do not miss: Acute limb ischaemia (sudden pain, pallor, pulselessness, paraesthesia, paralysis, cold limb) → 999 / Emergency Department immediately.

Assessment

Symptoms — ask about:

  • Muscle pain in calf, thigh, or buttock brought on by exercise and relieved by rest (intermittent claudication)
  • Constant pain in the foot or toes, typically worse at night and relieved by hanging the leg dependent (rest pain — indicates CLTI)
  • Non-healing wound more than 2 weeks duration below the knee
  • Cardiovascular risk factors: smoking, diabetes, hypertension, hyperlipidaemia

Examination

  • Colour and temperature of feet
  • Peripheral pulses: femoral, popliteal, dorsalis pedis, posterior tibial
  • Abdominal palpation for aneurysm
  • Trophic changes: skin atrophy, hair loss, dystrophic nails, ulceration, gangrene

ABPI measurement

  • Normal: 0.9–1.4
  • Claudication range: typically 0.5–0.9 → routine referral if <0.9
  • CLTI range: <0.5 → urgent referral
  • >1.4 in diabetic, end-stage renal, or extremely elderly patients suggests calcification and the result is unreliable — refer if symptomatic

Baseline investigations

  • Fasting lipid profile
  • HbA1c
  • FBC, U&E

Emergency — act immediately

Discuss urgently with Hairmyres on-call vascular reg/cons, or send to Emergency Department if:

  • Acute limb ischaemia — sudden limb pain, pallor, pulselessness, paraesthesia, paralysis, perishingly cold
  • Severe infection or sepsis with systemic signs

Primary care management

If intermittent claudication is present, first-line management should be based in primary care. Referral to vascular is only needed if the patient fails to respond to first-line treatment or meets referral criteria.

Lifestyle modification

  • Smoking cessation — strongest modifiable intervention; offer pharmacotherapy
  • Encourage walking — exercise to the point of claudication and through the pain (supervised exercise programme 2 hrs/week for minimum 3 months where available)
  • Weight reduction
  • Blood pressure control (British Hypertension Society guidelines)
  • Glycaemic optimisation

Antiplatelet therapy

  • Clopidogrel 75mg daily (preferred antiplatelet in PAD)

Lipid-lowering

  • Atorvastatin 80mg daily for patients with PAD and total cholesterol >3.5 mmol/L

Vasoactive therapy

  • Consider naftidrofuryl oxalate 100mg three times daily initially, increasing to 200mg three times daily; if no benefit after 3 months at either dose, stop (NICE TA223)

Before referring, ask: Is this patient suitable for a vascular referral that might end in surgery? Consider the patient's overall fitness, frailty, and wishes. If unsure, email the vascular service first: dg.vascularservice@nhs.scot

Who to refer

Same day — Emergency Department or Hairmyres on-call vascular

  • Acute limb ischaemia: sudden pain, pallor, pulselessness, paraesthesia, paralysis, cold limb
  • Severe infection or sepsis with systemic signs in a limb with suspected ischaemia

Contact: Hairmyres on-call vascular reg/cons, or send directly to Emergency Department

Urgent outpatient (suspected CLTI)

  • Rest pain: constant foot or toe pain, worse at night, relieved by dependent position
  • Non-healing wound more than 2 weeks below the knee
  • Gangrene on the foot
  • ABPI <0.5

Routine outpatient (claudication)

  • Quality of life severely affected, or claudication distance less than 40 metres
  • ABPI less than 0.9
  • ABPI greater than 1.4 in diabetic, end-stage renal disease, or extremely elderly patients — result unreliable; refer if symptomatic
  • Failed first-line treatment: supervised exercise, risk factor modification, naftidrofuryl

Include in all vascular referrals

  • ABPI result with date
  • Baseline bloods: lipids, HbA1c, FBC, U&E
  • Current medications (antiplatelet, anticoagulant, statin)
  • Cardiovascular history and comorbidities
  • Smoking status
  • Functional status and quality of life impact

Who not to refer

  • Mild to moderate claudication with ABPI 0.9–1.3, acceptable quality of life, and no red flag features — manage in primary care
  • Before completing at least 3 months of first-line treatment: supervised exercise, smoking cessation, cardiovascular risk factor optimisation, clopidogrel, high-intensity statin, naftidrofuryl if appropriate
  • Patients where you do not suspect poor arterial supply — consider an alternative referral pathway (venous, musculoskeletal, neurological)
  • Very frail patients or those with significant comorbidities where vascular intervention would not be appropriate — discuss informally with the team before referring: dg.vascularservice@nhs.scot
  • Venous leg ulceration — not an arterial vascular referral; confirm ABPI ≥0.8 before applying compression bandaging

Editorial Information

Last reviewed: 29/04/2026

Next review date: 28/04/2028

Version: 1.0

Reviewer name(s): Julie Rutherford.