Lower limb peripheral

arterial disease overview

A NICE pathway brings together all NICE guidance, quality
standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/lower-limb-peripheralarterial-disease
Pathway last updated: 28 September 2015. To see details of any updates to this pathway since its
launch, visit: About this Pathway. For information on the NICE guidance used to create this path, see:
Sources.
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Lower limb peripheral arterial disease pathway

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Lower limb peripheral arterial disease overview

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Person with suspected lower limb peripheral arterial disease (with or

without symptoms)

No additional information

Assessment and 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 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.

Quality standards
The following quality statement is relevant to this part of the pathway.
1.

Identification and assessment of peripheral arterial disease

Lower limb peripheral arterial disease pathway

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Resources
The following implementation tools are relevant to this part of the pathway.
Lower limb peripheral arterial disease: clinical audit tool - primary care
Lower limb peripheral arterial disease: online educational tool

Patient information and support

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 information about secondary prevention of
cardiovascular disease in preventing vascular events [See page 5] in this pathway)
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.
NICE has produced guidance on the components of good patient experience in adult NHS
services. Follow the recommendations in the NICE pathway on patient experience in adult NHS
services.
NICE has written information for the public explaining the guidance on peripheral arterial
disease.

Resources
The following implementation tool is relevant to this part of the pathway.

Lower limb peripheral arterial disease pathway

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Lower limb peripheral arterial disease: clinical audit tool - primary care

Preventing vascular events

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 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.
For more information see:
the NICE pathways on cardiovascular disease prevention, smoking, diet, physical activity,
diabetes, preventing type 2 diabetes, hypertension and obesity.
technology appraisal guidance on ezetimibe for the treatment of primary (heterozygousfamilial and non-familial) hypercholesterolaemia and statins for the prevention of
cardiovascular events.
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular
events
This guidance applies to people who have had an occlusive vascular event, or who have
established peripheral arterial disease.
Clopidogrel is recommended as an option to prevent occlusive vascular events:
for people who have had an ischaemic stroke or who have peripheral arterial disease or
multivascular disease
Treatment with clopidogrel to prevent occlusive vascular events should be started with the least
costly licensed preparation.

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These recommendations relating to people who have peripheral arterial disease are an extract
from clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular
events (NICE technology appraisal guidance 210).
NICE has written information for the public explaining the guidance.

Quality standards
The following quality statement is relevant to this part of the pathway.
2.

Comorbidity assessment

Resources
The following implementation tools are relevant to this part of the pathway.
Lower limb peripheral arterial disease: clinical audit tool - primary care
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events:
audit support tool
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events:
costing template

Managing critical limb ischaemia

See Lower limb peripheral arterial disease / Managing critical limb ischaemia in people with
peripheral arterial disease

Managing intermittent claudication

See Lower limb peripheral arterial disease / Managing intermittent claudication in people with
peripheral arterial disease

NICE pathway on patient experience in adult NHS services

See Patient experience in adult NHS services / Patient experience in adult NHS services
overview

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Sources
Lower limb peripheral arterial disease (2012) NICE guideline CG147
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
(2010) NICE technology appraisal guidance 210

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright
Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

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nice@nice.org.uk

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