Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

Peripheral Vascular Disease (PVD), also known as Peripheral Arterial Disease (PAD), encompasses a range of conditions caused by the narrowing and hardening of arteries. The severity of PVD can vary widely—from having no symptoms at all, to facing severe complications that may even lead to limb amputation.

For patients who are asymptomatic, the presence of hardened arteries, as a result of atherosclerosis, is generally harmless. However, it is crucial to follow your doctor’s recommendations regarding medication and lifestyle changes to manage the condition effectively and prevent deterioration.

Intermittent Claudication refers to a cramping pain in the calves or thighs during walking or exercising, often worse when walking upstairs or hills. In more severe cases of PVD, individuals may experience pain in the foot at night, often finding relief by dangling the foot over the side of the bed or even sleeping in a chair. This condition, known as Rest Pain or Critical Limb-Threatening Ischaemia, which typically requires medical intervention to improve blood flow to the foot.

It’s also worth noting that some patients experience nocturnal calf cramps unrelated to walking or exercise. These cramps are usually not associated with peripheral vascular disease and do not pose a risk to the legs

Intermittent Claudication

Intermittent claudication is often described as a cramp-like pain in the calf or thigh that occurs during walking or movement and is relieved by resting. The pain typically recurs at similar distances and subsides after a brief period of rest. This discomfort may intensify when walking uphill or carrying heavy loads. Depending on the location of the diseased arteries, the pain can also manifest in the thighs or buttocks.

The site of the pain is determined by the location of the arterial narrowing. The severity of symptoms is influenced by the extent of artery blockage, the number of affected arteries, whether these arteries are partially or fully obstructed, and how well your body compensates for the narrowed arteries through collateralization.

Critical Limb Threating Ischaemia

Critical limb ischemia refers to a severe form of peripheral arterial disease where patients experience pain in the foot or feet when lying flat or sleeping. This pain often wakes them up at night. Many patients find relief by dangling their foot over the side of the bed or sleeping in an armchair or recliner, allowing gravity to assist in blood flow to the foot. This pain can be challenging to manage with painkillers alone. When accompanied by ulceration, this condition can be limb-threatening, and vascular intervention to improve blood flow is typically recommended.

What Causes the Pain?

When you walk, your calf muscles engage and require a temporary increase in oxygen supply. Narrowed or blocked arteries restrict adequate oxygen delivery, leading to a buildup of substances in the muscle that cause pain. Once you stop exercising or walking, the oxygen “debt” is repaid, and the pain subsides.

Pain at night typically occurs when the foot is horizontal in bed. In this position, blood flow is so limited that it relies on gravity to help supply the foot with blood. This condition is known as resting pain or critical limb ischemia.

Can I Get Rid of the Damage in the Arteries?

Blocked or narrowed arteries cannot reopen without surgical intervention. The blockages themselves are not inherently dangerous, and many people live with them without ever experiencing symptoms or complications. However, the best medical therapy focuses on preventing the progression of atherosclerotic disease and reducing the risk of recurrence following treatment.

 

How Can I Make a Difference?

 

Exercise

Claudication can improve through conservative therapy as collateral arteries develop and grow. This approach, along with best medical therapy, is recommended initially. Claudication pain is not limb or life-threatening; therefore, patients are encouraged to walk as much as possible. When the pain sets in, take a rest, and then continue walking to stimulate collateralization. Most patients will see improvement or stabilization of symptoms without needing any surgical intervention.

Studies have shown that adhering to an exercise program can increase walking distance. Start by walking until the pain prevents you from going further—this is your walking distance. You can measure this distance using landmarks such as house lengths, streetlamps, or health apps on your phone or watch. Rest until the pain subsides, then walk again. Over time, this routine can significantly increase your walking distance, but it typically takes about 2-3 months to see the desired results. For success, aim to walk for 30 minutes, 3-4 times a week.

Smoking

Cigarette smoking is the most significant risk factor for developing peripheral arterial disease (PAD). Smoking accelerates the hardening of arteries and hinders the development of new arteries and collateral vessels. Quitting smoking is one of the most effective steps you can take to improve your vascular health.

Statins / Cholesterol Management

Statins are medications used to lower cholesterol, which is a leading risk factor for peripheral vascular disease. By reducing cholesterol levels, statins help prevent the progression of the disease and improve overall cardiovascular health.

Blood Pressure

High blood pressure is a risk factor for atherosclerosis and can exacerbate peripheral vascular disease. Lowering your blood pressure reduces your cardiovascular risk and helps prevent your symptoms from worsening.

Diet / Weight Loss

Your calf muscles are primarily responsible for walking, and if they have to carry extra weight, they will fatigue more quickly. Losing weight through a balanced diet and regular exercise can significantly improve claudication distance and symptoms, as your muscles will not tire as easily.

Aspirin / Clopidogrel

These medications are beneficial in preventing further arterial blockages and promoting general cardiovascular health. They are often recommended as part of the treatment plan for patients with PAD.

Information for GPs

Peripheral Vascular Disease (PVD) affects many individuals, but not all cases require intervention. Typically, surgery is reserved for patients whose claudication significantly limits their daily activities despite optimal medical therapy, those experiencing rest pain, or those with ulceration.

Differentiating Between Vascular and Spinal Claudication

    Distinguishing between vascular and spinal claudication can be challenging. Generally, vascular claudication presents as cramping pain that occurs at a consistent distance on level ground and becomes more pronounced when walking uphill. The pain usually subsides quickly with rest and does not vary throughout the day. Claudication symptoms typically arise from severe stenosis in the aorta-iliac or femoro-popliteal segments. Occlusion of a single tibial artery usually does not cause claudication or rest pain.

    Patients who describe sensations like pins and needles, walking on cotton wool, or shooting pains down the legs are less likely to have vascular claudication. However, leg pain can often be multifactorial. A specialist review can help differentiate between these conditions.

    When Do Patients Need Urgent Treatment?

    Patients with ulceration or rest pain are likely experiencing Critical Limb-Threatening Ischemia (CLTI), requiring urgent intervention for limb salvage, typically within a month of diagnosis. Additionally, patients who experience a sudden deterioration in their leg, accompanied by acute pain, loss of sensation, or movement, need immediate attention from a vascular specialist.

    Information for GPs

    Peripheral Vascular Disease (PVD) affects many individuals, but not all cases require intervention. Typically, surgery is reserved for patients whose claudication significantly limits their daily activities despite optimal medical therapy, those experiencing rest pain, or those with ulceration.

    Managing Patients While They Wait for Their Appointment

    PVD is an independent risk factor for cardiovascular death, making it crucial to address and manage these risks [1].

    Smoking Cessation

    Smoking is the primary cause of arterial calcification and hampers the growth of collateral circulation, making it harder for patients to improve their walking distance. Physicians should strongly advise all patients to quit smoking, offering support through pharmacotherapy, behavior modification, and referrals to smoking cessation programs [2].

    Blood Pressure Control

    Hypertension is a key risk factor for atherosclerosis and is linked to poor long-term outcomes in PVD patients. Lifestyle changes, combined with medication, should aim to lower blood pressure to <120-130/80 mmHg in those under 70, and 130-139/80 mmHg in those over 70, to reduce the likelihood of major cardiovascular events [3].

    Exercise Prescription

    Although claudication pain is uncomfortable, it is not life-threatening. Patients should be encouraged to walk as much as possible, resting as needed, to promote collateral circulation [5]. A structured exercise regimen—30 minutes, three times a week—can significantly improve walking distance and alleviate symptoms within 2-3 months [6][7].

    Cholesterol / Statin / Diet

    Carrying excess weight increases the oxygen demand on leg muscles, worsening PVD symptoms. Weight loss and cholesterol management are crucial. Statins can slow disease progression, even if cholesterol levels aren’t elevated, and should be considered if the patient tolerates them well.

    Antiplatelet Agents

    Starting patients with chronic symptomatic PVD on antiplatelet therapy is recommended. Research shows that antiplatelet agents can decrease the risk of secondary cardiovascular events by 20%, making them a critical component of managing PVD [4].

    Diabetic Control

    Diabetes often affects smaller tibial arteries, leading to poor healing of foot wounds and non-healing ulcers. Effective blood sugar management is essential to prevent complications, improve wound healing, and reduce rest pain in patients with PVD.

    Encourage your patients to track the distance they can walk before pain forces them to stop—this is their “walking distance.” Once the pain subsides, they should resume walking, repeating the process until they’ve completed their walk. Over the next few weeks, most patients will notice an increase in their walking distance. For the best results, patients should aim to walk 3-4 times a week, with significant improvements typically seen within 2-3 months.

    1. Geroulakos, G., & Paraskevas, K. I. (2024). The 2024 ESVS Guidelines on Lower Limb Peripheral Arterial Disease: A Step Forward. European Journal of Vascular and Endovascular Surgery, 67(1), 3-5

     

    2. Lampridou, S., Rawasdheh, M., Saghdaoui, L. B., Wells, M., & Davies, A. H. (2024). Factors affecting adherence to medication, smoking cessation and exercise in patients with peripheral artery disease. JVS-Vascular Insights, 100074.

     

    3. Nordanstig, J., Behrendt, C. A., Baumgartner, I., Belch, J., Bäck, M., Fitridge, R., … & ESVS Guidelines Committee. (2024). Editor’s Choice–European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. European Journal of Vascular and Endovascular Surgery, 67(1), 9-96.

     

    4. Ten Berg, J., Sibbing, D., Rocca, B., Van Belle, E., Chevalier, B., Collet, J. P., … & Mehilli, J. (2021). Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease. European heart journal, 42(23), 2265-2269.

     

    5. Leng, G. C., Fowler, B., & Ernst, E. (2000). Exercise for intermittent claudication. The Cochrane database of systematic reviews, (2), CD000990. https://doi.org/10.1002/14651858.CD000990

     

    6. Harwood, A. E., Pymer, S., Ingle, L., Doherty, P., Chetter, I. C., Parmenter, B., Askew, C. D., & Tew, G. A. (2020). Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ open sport & exercise medicine, 6(1), e000897. https://doi.org/10.1136/bmjsem-2020-000897

     

    7. Guidon, M. (2011). An exercise programme for patients with intermittent claudication: randomised trial of health outcomes and cost analysis (Doctoral dissertation, Royal College of Surgeons in Ireland).