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Lower limb peripheral arterial disease overview

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Lower limb peripheral arterial disease HAI

About

What is covered

This pathway covers lower limb peripheral arterial disease in adults (18 years and older).
Lower limb peripheral arterial disease (called peripheral arterial disease in this document) is a marker for increased risk of cardiovascular events even when it is asymptomatic. The most common initial symptom of peripheral arterial disease is leg pain while walking, known as intermittent claudication. Critical limb ischaemia is a severe manifestation of peripheral arterial disease, and is characterised by severely diminished circulation, ischaemic pain, ulceration, tissue loss and/or gangrene.
The incidence of peripheral arterial disease increases with age. Population studies have found that about 20% of people aged over 60 years have some degree of peripheral arterial disease. Incidence is also high in people who smoke, people with diabetes and people with coronary artery disease. In most people with intermittent claudication the symptoms remain stable, but approximately 20% will develop increasingly severe symptoms with the development of critical limb ischaemia.
Mild symptoms are generally managed in primary care, with referral to secondary care when symptoms do not resolve or deteriorate. There are several treatment options for people with intermittent claudication. These include advice to exercise, management of cardiovascular risk factors (for example, with aspirin or statins) and vasoactive drug treatment (for example, with naftidrofuryl oxalate).
People with severe symptoms that are inadequately controlled are often referred to secondary care for assessment for endovascular treatment (such as angioplasty or stenting), bypass surgery, pain management and/or amputation.
Rapid changes in diagnostic methods, endovascular treatments and vascular services, associated with the emergence of new sub-specialties in surgery and interventional radiology, has resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation.

Updates

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

4 September 2014 Minor maintenance update.
22 July 2014 Link to cardiovascular disease prevention pathway added.
22 January 2014 Minor maintenance update.
20 January 2014 Quality standard on peripheral arterial disease added to the pathway.
2 January 2014 Minor maintenance update.
22 October 2013 Minor maintenance updates, and links to NICE pathway on obesity added to this pathway.
26 February 2013 Minor maintenance updates.
28 August 2012 Links added to new clinical audit tool on imaging for revascularisation and supervised exercise.

Short Text

Lower limb peripheral arterial disease: diagnosis and management

What is covered

This pathway covers lower limb peripheral arterial disease in adults (18 years and older).
Lower limb peripheral arterial disease (called peripheral arterial disease in this document) is a marker for increased risk of cardiovascular events even when it is asymptomatic. The most common initial symptom of peripheral arterial disease is leg pain while walking, known as intermittent claudication. Critical limb ischaemia is a severe manifestation of peripheral arterial disease, and is characterised by severely diminished circulation, ischaemic pain, ulceration, tissue loss and/or gangrene.
The incidence of peripheral arterial disease increases with age. Population studies have found that about 20% of people aged over 60 years have some degree of peripheral arterial disease. Incidence is also high in people who smoke, people with diabetes and people with coronary artery disease. In most people with intermittent claudication the symptoms remain stable, but approximately 20% will develop increasingly severe symptoms with the development of critical limb ischaemia.
Mild symptoms are generally managed in primary care, with referral to secondary care when symptoms do not resolve or deteriorate. There are several treatment options for people with intermittent claudication. These include advice to exercise, management of cardiovascular risk factors (for example, with aspirin or statins) and vasoactive drug treatment (for example, with naftidrofuryl oxalate).
People with severe symptoms that are inadequately controlled are often referred to secondary care for assessment for endovascular treatment (such as angioplasty or stenting), bypass surgery, pain management and/or amputation.
Rapid changes in diagnostic methods, endovascular treatments and vascular services, associated with the emergence of new sub-specialties in surgery and interventional radiology, has resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation.

Quality standards

Peripheral arterial disease

These quality statements are taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice for peripheral arterial disease and should be read in full.

Quality statements

Identification and assessment of peripheral arterial disease

This quality statement is taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice in peripheral arterial disease and should be read in full.

Quality statement

People who have symptoms of, or who are at risk of developing, peripheral arterial disease (PAD) are offered a clinical assessment and ankle brachial pressure index (ABPI) measurement.

Rationale

Early identification of both asymptomatic and symptomatic PAD means that treatment can begin earlier, potentially slowing disease progression and improving quality of life through better mobility and reduced pain. Early identification and treatment of PAD and its risk factors may also reduce the risk of cardiovascular morbidity and mortality, and the need for lower limb amputation. A comprehensive assessment should include both a clinical assessment with structured history taking, and ABPI measurement with a hand-held doppler ultrasound scan to ensure an accurate diagnosis and quantification of disease severity.

Quality measures

Structure
(a) Evidence of local arrangements to ensure that health and social care practitioners receive training to recognise the symptoms of PAD.
Data source: Local data collection.
(b) Evidence of local arrangements to ensure that people who have symptoms of, or who are at risk of developing, PAD are offered a clinical assessment and ABPI measurement.
Data source: Local data collection.
(c) Evidence of local arrangements to ensure that all healthcare practitioners undertaking hand-held doppler ultrasound assessment of ABPI are appropriately trained.
Data source: Local data collection.
Process
(a) Proportion of people who have symptoms of PAD who receive a clinical assessment and ABPI measurement.
Numerator – the number of people in the denominator receiving a clinical assessment and ABPI measurement.
Denominator – the number of people who have symptoms of PAD.
Data source: Local data collection.
(b) Proportion of people who are at risk of developing PAD who receive a clinical assessment and ABPI measurement.
Numerator – the number of people in the denominator receiving a clinical assessment and ABPI measurement.
Denominator – the number of people at risk of developing PAD.
Data source: Local data collection.
Outcome
Disease severity at diagnosis.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that hand-held doppler ultrasounds are adequately available; that staff are trained to recognise the symptoms of PAD; and that people who have symptoms of PAD or who are at risk of developing it are offered a clinical assessment and ABPI measurement.
Health and social care practitioners ensure that they are aware of the symptoms of PAD and the need to have these symptoms assessed; that they are aware of the risk factors for PAD; and that healthcare practitioners ensure that they offer a clinical assessment and ABPI measurement to people who have symptoms of PAD or who are at risk of developing it.
Commissioners ensure that they commission services that have an adequate supply of hand-held doppler ultrasounds, and have staff trained to carry out clinical assessments and ABPI measurements in people who have symptoms of PAD or who are at risk of developing it.

What the quality statement means for patients, service users and carers

People with possible peripheral arterial disease, and people who are at risk of developing peripheral arterial disease receive a thorough assessment to find out whether or not they have it, in which they are asked about their symptoms, their legs and feet are examined, their pulses are checked, and the blood pressures in their arms and ankles are compared.

Source guidance

Definitions of terms used in this quality statement

Symptoms of PAD include:
  • non-healing wounds on the legs or feet
  • unexplained leg pain
  • pain in the leg when walking that resolves when stopping (intermittent claudication), pain in the foot at rest, often made worse by elevation (for example, in bed at night disturbing sleep and relieved by hanging the foot down)
  • tissue loss (ulceration and/or gangrene).
People at risk of PAD include those who:
  • have diabetes or
  • are being considered for interventions to the leg or foot (for example, podiatric and orthopaedic foot surgery and chiropody) or
  • need to use compression hosiery.
A clinical assessment should include:
  • asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia using a structured questionnaire
  • examining the legs and feet for evidence of critical limb ischaemia, for example, tissue loss (ulceration and/or gangrene)
  • examining the femoral, popliteal and foot pulses.
ABPI measurement:
Recommendation 1.3.3 in NICE clinical guideline 147 provides guidance on how this should be done.

Comorbidity assessment

This quality statement is taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice in peripheral arterial disease and should be read in full.

Quality statement

People with peripheral arterial disease (PAD) are offered an assessment for cardiovascular comorbidities and modifiable risk factors.

Rationale

People with both asymptomatic and symptomatic PAD have an increased risk of mortality from cardiovascular disease, mainly due to heart attack and stroke. It is therefore important to assess people with PAD for other cardiovascular comorbidities and modifiable risk factors, so that appropriate evidence-based treatment, advice and support can be given to reduce this risk.

Quality measures

Structure
Evidence of local arrangements to ensure that people with PAD are offered an assessment of cardiovascular comorbidities and modifiable risk factors.
Data source: Local data collection.
Process
Proportion of people with PAD who receive an assessment of cardiovascular comorbidities and modifiable risk factors.
Numerator – the number of people in the denominator receiving an assessment of cardiovascular comorbidities and modifiable risk factors.
Denominator – the number of people with PAD.
Data source: Local data collection. Data on the percentage of patients with PAD in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, the percentage of patients with PAD in whom the last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less, and the percentage of patients with PAD with a record in the preceding 12 months that aspirin or an alternative antiplatelet is being taken, are available in the Quality and Outcomes Framework (QOF) indicators PAD002, PAD003 and PAD004.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that staff are trained to carry out assessments for cardiovascular comorbidities and modifiable risk factors.
Healthcare practitioners ensure that they offer people with PAD an assessment for cardiovascular comorbidities and modifiable risk factors.
Commissioners ensure that they commission services so that staff are trained on how to assess for cardiovascular comorbidities and modifiable risk factors.

What the quality statement means for patients, service users and carers

People with peripheral arterial disease are offered an assessment to check their risk of having a heart attack or a stroke, and identify any lifestyle factors that they can alter to reduce their risk (for example, eating healthily, reducing alcohol consumption, stopping smoking, maintaining a healthy weight and exercising regularly).

Source guidance

  • Lower limb peripheral arterial disease (NICE clinical guideline 147), recommendation 1.2.1 (key priority for implementation).

Definitions of terms used in this quality statement

The assessment of cardiovascular comorbidities and modifiable risk factors should include a review of:
  • smoking status
  • diet
  • weight
  • cholesterol levels
  • presence of diabetes
  • presence of hypertension
  • current antiplatelet therapy.

Supervised exercise programmes

This quality statement is taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice in peripheral arterial disease and should be read in full.

Quality statement

People with intermittent claudication are offered a supervised exercise programme.

Rationale

Supervised exercise programmes can improve walking distance and quality of life for people with intermittent claudication. However, the provision of services varies across the country and so there is a need for both new provision and improvement in existing care.

Quality measures

Structure
Evidence of local arrangements to ensure the availability of supervised exercise programmes.
Data source: Local data collection.
Process
(a) Proportion of people with intermittent claudication who are offered a supervised exercise programme.
Numerator – the number of people in the denominator offered a supervised exercise programme.
Denominator – the number of people with intermittent claudication.
Data source: Local data collection. Contained within NICE clinical guideline 147 audit support – imaging and supervised exercise programmes: audit standard 3.
(b) Proportion of people with intermittent claudication who start a supervised exercise programme.
Numerator – the number of people in the denominator starting a supervised exercise programme.
Denominator – the number of people with intermittent claudication offered a supervised exercise programme.
Data source: Local data collection.
(c) Proportion of people with intermittent claudication who complete a supervised exercise programme.
Numerator – the number of people in the denominator completing a supervised exercise programme.
Denominator – the number of people with intermittent claudication who start a supervised exercise programme.
Data source: Local data collection.
Outcome
(a) Improvement in pain-free walking distance.
Data source: Local data collection.
(b) Improvement in health-related quality of life.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure the availability of a supervised exercise programme for all people with intermittent claudication.
Healthcare practitioners ensure that they offer supervised exercise programmes to all people with intermittent claudication.
Commissioners ensure that they commission supervised exercise programmes that can be offered to all people with intermittent claudication.

What the quality statement means for patients, service users and carers

People who have pain when walking because of poor circulation are offered a supervised exercise programme to gradually build up their pain-free walking distance and improve their quality of life.

Source guidance

  • Lower limb peripheral arterial disease (NICE clinical guideline 147), recommendation 1.5.1 (key priority for implementation).

Definitions of terms used in this quality statement

Intermittent claudication is defined as a walking- or exercise-induced pain in the lower limbs caused by diminished circulation. [Full NICE clinical guideline 147]
Supervised exercise programmes may involve the following components:
  • 2 hours of supervised exercise a week for a 3 month period
  • encouraging people to exercise to the point of maximal pain.

Imaging

This quality statement is taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice in peripheral arterial disease and should be read in full.

Quality statement

People with peripheral arterial disease (PAD) being considered for revascularisation who need further imaging after a duplex ultrasound are offered magnetic resonance angiography (MRA).

Rationale

Imaging should only be performed in people with PAD if it is likely to provide information that will influence their management. Duplex ultrasound followed by MRA, where clinically appropriate and if needed, offers the most accurate, safe and cost-effective imaging strategy for people with PAD. However, local training and expertise and the availability of imaging equipment may be variable.

Quality measures

Structure
(a) Evidence of local arrangements to ensure that healthcare practitioners undertaking imaging are appropriately trained in the use of duplex ultrasound and MRA for PAD.
Data source: Local data collection.
(b) Evidence of local arrangements to ensure that people with PAD being considered for revascularisation who need further imaging after a duplex ultrasound are offered MRA.
Data source: Local data collection.
Process
Proportion of people with PAD being considered for revascularisation needing further imaging after a duplex ultrasound who receive MRA.
Numerator – the number of people in the denominator receiving MRA.
Denominator – the number of people with PAD being considered for revascularisation who need further imaging after a duplex ultrasound.
Data source: Local data collection. Contained within NICE clinical guideline 147 audit support – imaging and supervised exercise programmes: audit standard 2.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that imaging equipment is adequately available, and that people with PAD who are being considered for revascularisation and need further imaging after a duplex ultrasound are offered MRA.
Healthcare practitioners ensure that they offer MRA to people with PAD who are being considered for revascularisation who need further imaging after a duplex ultrasound imaging.
Commissioners ensure that they commission services with adequate availability of imaging equipment and which offer MRA to people with PAD being considered for revascularisation who need further imaging after a duplex ultrasound.

What the quality statement means for patients, service users and carers

People with peripheral arterial disease whose healthcare practitioner thinks surgery might help to improve their blood flow, are offered imaging tests (for example, an ultrasound) to see whether surgery would be suitable.

Source guidance

Definitions of terms used in this quality statement

Revascularisation is any procedure that is used to restore blood flow to an area of the body that is supplied by narrowed or blocked arteries. This can be done either by making the narrowed arteries wider (angioplasty, stenting), or by using another blood vessel to bypass the blocked or narrowed artery (bypass surgery).
People being considered for revascularisation include those:
  • with intermittent claudication, who should be offered angioplasty only when:
    • advice on the benefits of modifying risk factors has been reinforced (see recommendation 1.2.1) and
    • a supervised exercise programme has not led to a satisfactory improvement in symptoms and
    • imaging has confirmed that angioplasty is suitable for the person
  • being considered for primary stent placement, for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis)
  • with critical limb ischaemia who need revascularisation, who should be offered angioplasty or bypass surgery, taking into account factors including:
    • comorbidities
    • pattern of disease
    • availability of a vein for grafting
    • patient preference
  • being considered for primary stent placement, for treating people with critical limb ischaemia caused by complete aorto-iliac occlusion (rather than stenosis).
[Adapted from NICE clinical guideline 147, recommendations 1.5.3, 1.5.5, 1.6.2 and 1.6.4]

Angioplasty for intermittent claudication

This quality statement is taken from the peripheral arterial disease quality standard. The quality standard defines clinical best practice in peripheral arterial disease and should be read in full.

Quality statement

People with intermittent claudication are offered angioplasty only when imaging has confirmed it is appropriate, after advice on the benefits of modifying risk factors has been given, and after a supervised exercise programme has not improved symptoms.

Rationale

Angioplasty can be used to treat intermittent claudication, but it is an invasive procedure and should only be used after non-invasive options (including reinforcement of the importance of lifestyle changes and participation in supervised exercise programmes) have not improved symptoms, and imaging has confirmed that angioplasty is suitable. Greater use of non-invasive treatments may reduce the need for angioplasty and improve overall outcomes for peripheral arterial disease (PAD).

Quality measures

Structure
Evidence of local arrangements to ensure that people with intermittent claudication are offered angioplasty only when imaging has confirmed it is appropriate, advice on the benefits of modifying risk factors has been given and a supervised exercise programme has not improved symptoms.
Data source: Local data collection.
Process
Proportion of people with intermittent claudication receiving angioplasty who have had imaging to confirm angioplasty is appropriate, received advice on the benefits of modifying risk factors and undergone a supervised exercise programme that did not improve symptoms.
Numerator – the number of people in the denominator who have had imaging to confirm angioplasty is appropriate, received advice on the benefits of modifying risk factors and undergone supervised exercise programme that did not improve symptoms.
Denominator – the number of people with intermittent claudication who receive angioplasty.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that supervised exercise programmes are adequately available and have local protocols in place to ensure healthcare practitioners only offer angioplasty to people with intermittent claudication when imaging has confirmed it is appropriate, advice on the benefits of modifying risk factors has been given and a supervised exercise programme has not improved symptoms.
Healthcare practitioners ensure that they offer angioplasty to people with intermittent claudication only when imaging has confirmed it is appropriate, advice on the benefits of modifying risk factors has been given and a supervised exercise programme has not improved symptoms.
Commissioners ensure that they commission services in which people with intermittent claudication are only offered angioplasty when imaging has confirmed it is appropriate, advice on the benefits of modifying risk factors has been given and a supervised exercise programme has not improved symptoms.

What the quality statement means for patients, service users and carers

People who have pain when walking because of poor circulation are offered angioplasty (a procedure in which a small balloon is inserted into the narrowed artery and inflated to widen the artery) only when an imaging test has confirmed that angioplasty is suitable, and advice on the risk factors of peripheral arterial disease and a supervised exercise programme have not improved symptoms.

Source guidance

Definitions of terms used in this quality statement

Intermittent claudication is defined as a walking- or exercise-induced pain in the lower limbs caused by diminished circulation. [Full NICE clinical guideline 147]

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Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

4 September 2014 Minor maintenance update.
22 July 2014 Link to cardiovascular disease prevention pathway added.
22 January 2014 Minor maintenance update.
20 January 2014 Quality standard on peripheral arterial disease added to the pathway.
2 January 2014 Minor maintenance update.
22 October 2013 Minor maintenance updates, and links to NICE pathway on obesity added to this pathway.
26 February 2013 Minor maintenance updates.
28 August 2012 Links added to new clinical audit tool on imaging for revascularisation and supervised exercise.

Supporting information

Offer duplex ultrasound as first-line imaging to all people with peripheral arterial disease for whom revascularisation is being considered.
Offer contrast-enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.
Offer computed tomography angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) if contrast-enhanced magnetic resonance angiography is contraindicated or not tolerated.

Glossary

Paths in this pathway

Pathway created: August 2012 Last updated: September 2014

© NICE 2014

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