4.1. Key priorities for implementation
From the full set of recommendations, the GDG selected 9 key priorities for implementation. They selected recommendations that would:
Have a high impact on outcomes that are important to patients
Have a high impact on reducing variation in care and outcomes
Lead to a more efficient use of NHS resources
Promote patient choice
Promote equality.
In addition to this, the GDG also considered which recommendations were particularly likely to benefit from implementation support. They considered whether a recommendation:
Relates to an intervention that is not part of routine care
Requires changes in service delivery
Requires retraining of staff of the development of new skills and competencies
Highlights the need for practice change
Affects an needs to be implemented across a number of agencies or settings (complex interactions)
May be viewed as potentially contentious, or difficult to implement for other reasons.
The reasons that each of these recommendations was chosen are shown in the table linking the evidence to the recommendation in the relevant chapter.
4.1.1. The recommendations identified as priorities for implementation are
Information requirement for people with peripheral arterial disease
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.
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 (see
section 2.6) 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.
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 recommendation 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.
Imaging for revascularisation
Management of intermittent claudication
Management of critical limb ischaemia
Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.
Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.
4.2. Full list of recommendations
4.2.1. Information requirements
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 recommendation 3)
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 Patient experience in adult NHS services (NICE clinical guideline 138).
4.2.2. Secondary prevention of cardiovascular disease in people with peripheral arterial disease
- 3.
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 (see ‘Related NICE guidance’; section 2.6) 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.
4.2.3. Diagnosis
- 4.
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.
- 5.
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 recommendation 6).
- 6.
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.
4.2.4. Imaging for revascularisation
- 7.
Offer duplex ultrasound as first-line imaging to all people with peripheral arterial disease for whom revascularisation is being considered.
- 8.
Offer contrast-enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.
- 9.
Offer computed tomography angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) if contrast-enhanced magnetic resonance angiography is contraindicated or not tolerated.
4.2.5. Management of intermittent claudication
4.2.5.1. Supervised exercise programme
- 10.
Offer a supervised exercise programme to all people with intermittent claudication.
- 11.
Consider providing a supervised exercise programme for people with intermittent claudication which involves:
4.2.5.2. Angioplasty and stenting
- 12.
Offer angioplasty for treating people with intermittent claudication only when:
advice on the benefits of modifying risk factors has been reinforced (see recommendation 3) and
a supervised exercise programme has not led to a satisfactory improvement in symptoms and
imaging has confirmed that angioplasty is suitable for the person.
- 13.
Do not offer primary stent placement for treating people with intermittent claudication caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease.
- 14.
Consider primary stent placement for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis).
- 15.
Use bare metal stents when stenting is used for treating people with intermittent claudication.
4.2.5.3. Bypass surgery and graft types
- 16.
Offer bypass surgery for treating people with severe lifestyle-limiting intermittent claudication only when:
- 17.
Use an autologous vein whenever possible for people with intermittent claudication having infra-inguinal bypass surgery.
4.2.5.4. Naftidrofuryl oxalate
- 18.
Consider naftidrofuryl oxalate for treating people with intermittent claudication, starting with the least costly preparation, only when:
Review progress after 3–6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit.
4.2.6. Management of critical limb ischaemia
- 19.
Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.
4.2.6.1. Revascularisation
- 20.
Offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including:
comorbidities
pattern of disease
availability of a vein
patient preference.
- 21.
Do not offer primary stent placement for treating people with critical limb ischaemia caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease.
- 22.
Consider primary stent placement for treating people with critical limb ischaemia caused by complete aorto-iliac occlusion (rather than stenosis).
- 23.
Use bare metal stents when stenting is used for treating people with critical limb ischaemia.
- 24.
Use an autologous vein whenever possible for people with critical limb ischaemia having infra-inguinal bypass surgery.
4.2.6.2. Management of critical limb ischaemic pain
- 25.
Offer paracetamol, and either weak or strong opioids depending on the severity of pain, to people with critical limb ischaemic pain.
- 26.
Offer drugs such as laxatives and anti-emetics to manage the adverse effects of strong opioids, in line with the person’s needs and preferences.
- 27.
Refer people with critical limb ischaemic pain to a specialist pain management service if any of the following apply:
their pain is not adequately controlled and revascularisation is inappropriate or impossible.
ongoing high doses of opioids are required for pain control
pain persists after revascularisation or amputation.
- 28.
Do not offer chemical sympathectomy to people with critical limb ischaemic pain, except in the context of a clinical trial.
4.2.6.3. Major amputation
- 29.
Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.
4.3. Key research recommendations
What is the clinical and cost effectiveness of a ‘bypass surgery first’ strategy compared with an ‘angioplasty first’ strategy for treating people with critical limb ischaemia caused by disease of the infra-geniculate (below the knee) arteries?
What is the clinical and cost effectiveness of supervised exercise programmes compared with unsupervised exercise for treating people with intermittent claudication, taking into account the effects on long-term outcomes and continuing levels of exercise?
What is the effect of people’s attitudes and beliefs about their peripheral arterial disease on the management and outcome of their condition?
What is the clinical and cost effectiveness of selective stent placement compared with angioplasty plus primary stent placement for treating people with critical limb ischaemia caused by disease of the infra-geniculate arteries?
What is the clinical and cost effectiveness of chemical sympathectomy in comparison with other methods of pain control for managing critical limb ischaemic pain?
