Peripheral vascular disease (PVD) refers to a range of symptoms usually resulting from atherosclerosis of arteries. In Australia it is estimated that 10% of patients in the primary care setting suffer from PVD and 20% of all patients over the age of 75 have arterial disease.
Vascular Surgeons, Nedlands
Progression from asymptomatic PVD lesions is low with some studies quoting an estimated 5% progressing to symptoms at five years to 21% symptomatic at one year.
Most patients with claudication have stable symptoms at five years (70-80%), while 10-20% develop worsening claudication and 5-10% develop critical limb ischemia (CLI).
The outcomes for patients with CLI remain poor with mortality rates of 25% and amputation rates of up to 30% at one year.
There is also a significant overlap with coronary and cerebrovascular disease, where the mortality rates in patients with PVD are between 13% and 50% at five years. There has traditionally been an underdiagnosis and undertreatment of cardiovascular disease in this group of patients.
Management
The aims of management include decreasing the risk of cardiovascular morbidity and mortality, reducing claudication symptoms, improving quality of life and preventing disability. It includes lifestyle changes, medical therapy and select surgical management in patients with lifestyle limiting claudication and CLI.
Smoking Cessation: 50% of PVD is due to tobacco consumption. Smoking cessation doubles five-year survival improves claudication distance and reduces the risk of postoperative complications.
Antiplatelet agents: These reduce cardiovascular morbidity and mortality in patients with PVD.
Blood pressure control: Hypertension is associated with progression of atherosclerosis and increases rates of cardiovascular mortality.
Lipid lowering agents: Statins reduce major cardiovascular events and major limb adverse events in patients with PVD.
Glycaemic control: Good glycaemic control in patients with diabetes improves the long-term prognosis.
Exercise prescription: An exercise program can reduce symptoms of claudication and increase walking distance. The recent 2024 European Vascular and Endovascular Surgery guidelines ‘recommend at least 150-300 minutes a week of moderate intensity or 75-150 minutes of vigorous exercise a week to reduce all cause cardiovascular morbidity and mortality’.
Revascularisation
Revascularisation is indicated in patients with severe lifestyle limiting claudication (IC) or critical limb ischaemia. Asymptomatic PVD patients do not need treatment, unless the aim of the intervention is to preserve patency of a procedure which has previously been performed (e.g. for in-stent stenosis).
Revascularisation decisions in patients with IC should be individualised as the majority treated conservatively have benign outcomes. Studies show that an early revascularisation procedure for IC increases the rate of subsequent reintervention, development of CLI and in some case limb loss. This is worse in patients who continue smoking.
The choice of surgical intervention depends on numerous factors including the patient’s age, comorbidity and the location and extent of arterial disease. Generally, endovascular surgery is used to treat shorter narrowing or occlusions and those in vessels below the knee. Multiple endovascular surgical techniques are now available to improve patency and go alongside angioplasty techniques such as drug-eluting balloons, stenting, atherectomy and lithotripsy to the vessel walls.
Endovascular techniques allow for treatment of large vessels through small incisions in the skin. Although not without risk, this technique can be done under local anaesthetic and sedation as a day case or overnight stay, reducing some of the risk from larger surgeries.
Open surgery, in the form of a bypass or endarterectomy, uses patients’ veins or prosthetic grafts to reconstitute blood flow. These operations are generally reserved for patients who can tolerate a bigger procedure under general anaesthetic and have longer and multiple level disease that may not be suitable for endovascular surgery.
Both endovascular and open surgery rely on patients adhering to best medical therapy as described above as well as complying with a surveillance program of stents and bypasses allowing early intervention on any stenosis that may occur.
There is an immediate risk of post procedural restenosis and re-thrombosis of peripheral arteries which persists despite single antiplatelet and statin therapy. Recent trials have demonstrated that low-dose rivaroxaban with aspirin reduces the risk of acute limb ischaemia, major amputation, MI, ischaemic stroke and cardiovascular death in post-operative patients.
Ongoing smoking post-revascularisation increases the risk of graft/stent failure threefold as well as delaying wound healing post revascularisation.
Key messages
- Peripheral vascular disease is common
- Most patients can be managed conservatively
- There are revascularisation options for those with more severe disease.
– References on request
Author competing interests – nil