Peripheral Arterial Disease (PAD)
NICE clinical guideline [CG147] Peripheral arterial disease: diagnosis and management. Last updated: Dec 2020
Minor changes and restructuring to the ‘Definition’ and ‘Clinical Features’ sections have been made.
Date: 13/11/25
Background Information
Definitions
PAD is defined by the presence of atherosclerotic obstruction in the peripheral arteries of the lower limb
The clinical presentation of PAD can be categorised into 4 subsets: [Ref]
- Asymptomatic
- Chronic symptomatic PAD
- Chronic limb-threatening ischaemia (old term: critical limb ischaemia)
- Acute limb ischaemia: sudden (<2 weeks) decrease in limb perfusion that threatens limb viability (covered in a separate article)
Clinical Features
Patients with PAD often have concomitant cardiovascular risk factors:
- Smoking
- Diabetes
- Hyperlipidaemia
- History of coronary artery disease / cerebrovascular disease
There are 3 main clinical manifestations of chronic PAD: [Ref]
| Presentation | Symptoms | Signs |
|---|---|---|
| Asymptomatic | Note that these patients may self-limit and adapt their activity to remain below their ischemic threshold to avoid leg pain |
|
| Chronic symptomatic PAD | Most commonly presents as intermittent claudication (“angina of the legs”):
Location of pain:
|
|
| Chronic limb-threatening ischaemia (critical limb ischaemia – old term) | Characterised by the presence of
|
Characterised by the presence of tissue loss:
Other findings:
|
Key exam presentations:
- Pain with walking that is relieved by rest = intermittent claudication
- Pain at rest +/- ulcer or gangrene = chronic limb-threatening ischaemia (critical limb ischaemia)
Guidelines
Investigation and Diagnosis
Approach:
- 1st line: ABPI (in clinic)
- Then, perform imaging in secondary care if revascularisation is being considered
ABPI (Ankle Brachial Pressure Index)
How to measure:
- Similar to measuring a clinic BP – instead of using a stethoscope, a handheld doppler is used
- BP cuff placed on the arm and ankle
- Use doppler to locate the pulse (DP, PT pulses & brachial pulses)
- Inflate the cuff until the pulse is no longer audible on doppler
- Deflate the cuff slowly and note the pressure (systolic BP) when doppler is audible again
ABPI calculation: highest ankle systolic BP (DP or PT) / highest brachial systolic BP (right or left arm)
Interpretation:
| ABPI | Interpretation |
|---|---|
| >1.4 | May suggest arterial calcification/stiffness (typically diabetes) Unable to rule in or out PAD |
| 1.0 – 1.4 | Normal |
| ≤0.9 | PAD |
| <0.5 | Chronic limb-threatening ischaemia |
Do not exclude a diagnosis of peripheral arterial disease in people with diabetes based on normal or raised ABPI alone.
- Diabetes can cause arterial calcification, which makes arteries more incompressible, thus a falsely high ABPI reading.
Alternative diagnostic test if ABPI is >1.4 (suggesting arterial calcification/stiffness) → toe-brachial index (TBI) [Ref]
- Same as ABPI but using digital artery pulse in the toes.
Imaging
Imaging should be performed if revascularisation is being considered:
- 1st line: duplex ultrasound
- 2nd line: MR angiography with contrast
- 3rd line: CT angiography
Management
Definitive Management
Intermittent Claudication
| Step 1 | Supervised exercise programme |
| Step 2 | Revascularisation (see below for choosing approaches)
|
| Step 3 (considered if surgery is inappropriate for patient) | Naftidrofuryl oxalate |
NICE did not make any specific recommendations on choosing between endovascular vs open revascularisation approaches. Selected points from the 2024 ACC/AHA guidelines: [Ref]
Endovascular revascularisation (angioplasty + stenting) is generally 1st line.
Open revascularisation is preferred as 1st line in
- Multilevel occlusions
- Long-segment (>10cm) occlusions
- Lesions involving the common femoral artery and profunda femoris artery origin
Chronic Limb-Threatening Ischaemia (Critical Limb Ischaemia)
- Refer all patients to vascular specialist
- Offer revascularisation to all patients
- Recent trials suggest that open revascularisation is superior to endovascular in those with chronic limb-threatening ischaemia, especially if there is a suitable autogenous vein (e.g. great saphenous vein)
Secondary Prevention
Offer all the following:
- Lifestyle changes + treat comorbidities
- Atorvastatin 80mg PO OD
- Clopidogrel 75mg PO OD