Visual summary PAD: symptoms and signs

Peripheral disease (PAD) is most commonly due to , where an atherosclerotic plaque causes arterial or occlusion. This results in a reduction in blood flow to the affected limb. Most patients are asymptomatic but many experience intermittent claudication (pain on walking). Critical limb ischaemia occurs when the reduction in blood flow is so severe that it causes rest pain or tissue loss (ulceration/gangrene)

Claudication Site of stenosis or occlusion Site of pain Aorta Aching or burning in leg muscles Common iliac artery Buttock Common femoral artery Reliably reproduced at a set distance of walking Superficial Thigh Bilateral buttock, femoral artery thigh and calf Relieved within minutes on rest claudication

Never present at rest Calf The site of pain provides an indication Not exacerbated of the site of disease by position

Critical limb ischaemia Ankle-brachial pressure index (ABPI)

1 or more of: ABPI of 0.9 or less is diagnostic of PAD Ulceration Gangrene ABPI of 0.5 or less suggests Rest pain in foot for more than 2 weeks critical limb ischaemia Incompressible (ABPI >1.2) and falsely elevated values are seen in May be resistant to opiate analgesia ABPI is the ratio of blood patients with arterial calcification, pressure at the ankle to notably people with at the arm and/or chronic kidney disease Difficult to distinguish from neuropathy

Patients frequently hang their leg out of bed PAD to try to relieve their pain Ulceration Critical limb ischaemia or wound + Irrespective of ABPI Urgent referral

Acute limb-threatening ischaemia

Rare but important not to miss One or more of the ‘6 Ps’: P Pain at rest P Paraesthesia Classically presents with sudden onset symptoms P Pallor P Paralysis Also indicated by sudden deterioration of claudication P Pulseless P ‘Perishingly’ cold

© 2018 BMJ Publishing group Ltd. Read the full Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, http://bit.ly/BMJpad conditions, or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of article online treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/

See more visual summaries http://www.bmj.com/infographics