Chronic lower limb ischaemia

Lower limb arterial disease is present in about 20% of the UK population aged over 60 years and is asymptomatic in 75%, causes symptoms of intermittent claudication in 4–5% and critical limb ischaemia in about 1%. All patients should be assessed for their cardiovascular risk factors, have a full vascular examination to assess co-existing carotid disease and aneurysmal disease, ankle:brachial pressure index (ABPI) measurement and imaging using Duplex ultrasound in the first instance and angiography if indicated (intra-arterial digital subtraction angiography, CT angiography, MR angiography).

Intermittent claudication (IC)

This is characterized by the gradual onset of pain in the calf muscles (infra-inguinal artery disease) and/or the thigh and buttocks (supra-inguinal artery disease) after walking a certain distance and disappears quickly with rest. The pain recurs if walking is resumed. Only about 1–2% of claudicants will progress to develop critical limb ischaemia per annum, but about 5% will die from other cardiovascular events such as myocardial infarction or stroke.

All patients with cardiovascular disease (where coronary, cerebrovascular or peripheral) should be commenced on best medical therapy to reduce cardiovascular risk (smoking cessation, exercise and dietary advice, diagnosis and treatment of diabetes, antiplatelets, statins, antihypertensives). In patients with IC, best medical therapy will also increase walking distance and improve their quality of life.