Peripheral Arterial Disease & Critical Limb Ischaemia GCC Nursing Guide

Comprehensive clinical reference for DHA · DOH · SCFHS · QCHP examinations and vascular ward practice

🩸Pathophysiology of PAD

Peripheral Arterial Disease (PAD) is caused by atherosclerosis of the lower limb arteries — progressive plaque accumulation leads to luminal narrowing (stenosis) and eventually occlusion. Reduced blood flow causes tissue ischaemia, particularly on exertion. Risk factors mirror those for coronary artery disease: smoking (strongest modifiable), diabetes, hypertension, dyslipidaemia, age, male sex, CKD, and family history.

Atherosclerotic process: Endothelial injury → lipid deposition → foam cell formation → fibrous cap → plaque calcification → stenosis → critical ischaemia or acute thrombosis on plaque rupture.

GCC relevance: Diabetes prevalence 15–20% in Gulf states (among world's highest). Smoking endemic in younger males. Dyslipidaemia underdiagnosed. Combined = accelerated PAD onset, often presenting in 5th–6th decade.

📊Fontaine Classification
StageDescriptionClinical FeaturesManagement Focus
Stage IAsymptomaticABPI <0.9 but no symptoms; detectable by screeningRisk factor modification; exercise; surveillance
Stage IIaMild claudicationClaudication-free walking >200 mSupervised exercise therapy; antiplatelet; statin
Stage IIbModerate–severe claudicationClaudication at <200 m; significant lifestyle limitationAs above + consider revascularisation assessment
Stage IIIRest painIschaemic rest pain; worse at night; relieved hanging legUrgent vascular review; revascularisation planning
Stage IVTissue lossIschaemic ulceration or gangrene; limb-threateningEmergency: CLTI pathway, revascularisation or amputation
📋Rutherford Classification
GradeCategoryClinical Description
00Asymptomatic — no haemodynamic abnormality on stress testing
I1Mild claudication
2Moderate claudication
3Severe claudication
II4Ischaemic rest pain
III5Minor tissue loss — non-healing ulcer, focal gangrene with diffuse pedal ischaemia
6Major tissue loss — extending above transmetatarsal level; functional foot not salvageable

Note: Rutherford categories 4–6 correspond to Critical Limb-Threatening Ischaemia (CLTI) — requires urgent revascularisation or amputation planning.

🦵Symptoms & Signs of PAD

Symptoms

Intermittent Claudication: Reproducible muscle pain (calf most common; also thigh, buttock) precipitated by walking a fixed distance, relieved within minutes of rest. Does NOT occur at rest. Location of pain = level of disease (calf = femoro-popliteal; buttock/thigh = aorto-iliac).

Rest Pain (Fontaine III): Constant burning/aching pain in foot and toes at rest. Worse at night (↓ cardiac output in recumbency ↓ perfusion pressure). Relieved by hanging foot over bed edge or standing (gravity ↑ perfusion). Indicates critical ischaemia.

Clinical Signs

  • Absent or diminished peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibial)
  • Pallor on elevation (Buerger's test — elevate leg 45° for 60s)
  • Dependent rubor (reactive hyperaemia on dependency)
  • Prolonged capillary refill time (>3 seconds)
  • Cool, hairless skin distally
  • Nail dystrophy / thickened nails
  • Muscle wasting (chronic ischaemia)
  • Non-healing ulcers (typically punched-out, painful, distal)
  • Dry or wet gangrene (Fontaine IV)
  • Buerger's angle: angle at which leg blanches <20° = severe ischaemia
📏ABPI — Ankle Brachial Pressure Index
ABPI ValueInterpretation
>1.3Incompressible vessels — calcified (diabetes, CKD); use TBI
0.9–1.3Normal
0.8–0.9Borderline — mild PAD; compression therapy with caution
0.5–0.8Moderate PAD — claudication range
0.4–0.5Severe PAD
<0.4Critical Ischaemia — rest pain/tissue loss likely

ABPI Formula

ABPI = Highest ankle systolic BP ÷ Highest brachial systolic BP

Use the highest of DP/PT pressures for ankle; use highest brachial (L or R). Calculate for each limb separately.

Compression therapy rule: ABPI >0.8 = full compression safe. ABPI 0.5–0.8 = modified compression only (specialist guidance). ABPI <0.5 = compression CONTRAINDICATED.

🔬ABPI Measurement Technique

Equipment Needed

Hand-held Doppler (8MHz) Sphygmomanometer Ultrasound gel Correct cuff size
1

Patient supine, resting for 10–15 min. Room temperature must be warm to prevent vasospasm.

2

Apply cuff above ankle (2–3 cm above malleolus). Apply gel over dorsalis pedis (DP) artery.

3

Inflate cuff above systolic, then slowly deflate. Record pressure at which Doppler signal returns — this is ankle systolic BP for DP.

4

Repeat for posterior tibial (PT) artery. Use the HIGHER of the two ankle values.

5

Measure brachial systolic BP both arms. Use the HIGHER value.

6

ABPI = Highest ankle ÷ Highest brachial. Repeat for other leg.

Common Errors to Avoid

  • Wrong cuff size (too small = falsely elevated reading)
  • Patient not supine / not rested
  • Cold room (vasospasm → falsely low reading)
  • Using venous signal (triphasic Doppler = arterial)
  • Not performing bilateral measurement
  • Forgetting to check both DP and PT

Post-exercise ABPI: If resting ABPI normal but PAD suspected, perform after standardised treadmill walk. A drop of >20% post-exercise is diagnostic of PAD.

Calcified vessels (ABPI >1.3): Common in diabetes and CKD. Vessels incompressible → falsely high ABPI. Use Toe-Brachial Index (TBI) instead. TBI <0.7 = PAD; <0.15 = critical ischaemia.

🩻Investigations Summary
InvestigationPurposeFindings / InterpretationNursing Role
Duplex USSFirst-line imaging; non-invasiveMaps stenosis/occlusion; velocity ratios >2 = 50% stenosisConsent, position, explain — no prep needed
CT Angiography (CTA)Pre-revascularisation planningVisualises aorta to foot; identifies bypass targetsIV contrast — check eGFR, allergy, metformin hold
MR Angiography (MRA)Alternative to CTA; no radiationGood soft tissue; less useful for calcified vesselsScreen for metallic implants, claustrophobia
Digital Subtraction Angio (DSA)Gold standard; also therapeuticReal-time; allows PTA/stenting same sessionCatheter lab prep; post-procedure groin care
TcPO2Wound healing potential>40 mmHg = healing likely; <20 mmHg = unlikely to healApply electrodes; patient warm and still
Toe pressureCalcified vessel assessmentTBI <0.7 = PAD; absolute toe pressure <30 mmHg = CLIDigital cuffs; warm digit first
🦶Diabetic Foot & Neuropathy Assessment

Neuropathy Testing

1

10g Semmes-Weinstein monofilament: Apply perpendicular to skin, buckle the fibre (1 second). Test 10 sites per foot. Loss of sensation = protective sensation absent.

2

128Hz tuning fork: Place on bony prominence (1st MTP, medial malleolus). Absent vibration sense = at risk.

3

Pinprick and temperature: Gross assessment of small fibre function.

Diabetic Foot Risk Classification (IWGDF)

RiskFeaturesReview Frequency
LowNo neuropathy, no PADAnnual
ModerateNeuropathy OR PADEvery 3–6 months
HighNeuropathy + PAD or deformityEvery 1–3 months
ActiveUlcer / gangrene presentMDT — weekly minimum
MDT Referral: All active diabetic foot ulcers should be referred to the Multidisciplinary Foot Team (MDFT) within 24 hours. Team includes: vascular surgeon, orthopaedic/podiatric surgeon, diabetologist, tissue viability nurse, orthotist, microbiologist.

Probing to Bone Test: Sterile probe inserted into ulcer base — if bone is reached, specificity for osteomyelitis >85%. MRI is gold standard for osteomyelitis confirmation. Raised WBC, CRP, ESR support diagnosis.

Wagner Ulcer Classification:
Grade 0: Pre/post-ulcerative lesion
Grade 1: Superficial ulcer
Grade 2: Deep to tendon/capsule/bone
Grade 3: Deep with abscess/osteomyelitis
Grade 4: Partial foot gangrene
Grade 5: Whole foot gangrene

Key principle: Medical management is the backbone of PAD care. Revascularisation without risk factor control yields poor long-term outcomes. Every patient with PAD must receive antiplatelet + statin + antihypertensive + lifestyle intervention.
🚭Smoking Cessation — Single Most Important Intervention

Effect of quitting smoking: Doubles claudication-free walking distance. Reduces amputation risk by 50%. Reduces cardiovascular mortality by 30–50%. Improves outcomes from revascularisation procedures.

Cessation support: Brief advice at every contact (5As: Ask, Advise, Assess, Assist, Arrange). Pharmacotherapy: varenicline (most effective), NRT, bupropion. Refer to smoking cessation clinic. Document smoking status at every admission.

💊Pharmacological Management
Drug ClassAgent / DoseIndicationNursing Points
AntiplateletClopidogrel 75mg OD (preferred)
Aspirin 75mg OD (if clopidogrel not tolerated)
All PAD patients — reduces MI/stroke/CV deathMonitor for bleeding; take with food; GI protection if needed
StatinAtorvastatin 80mg OD (high-intensity)All PAD patients regardless of baseline cholesterol; also stabilises plaqueLDL target <1.4 mmol/L; monitor LFTs, myopathy (CK if muscle pain)
ACE Inhibitor / ARBRamipril 10mg OD / Perindopril / LosartanHypertension in PAD; also cardioprotectiveBP target <130/80; monitor K⁺, creatinine; avoid in bilateral RAS
AntidiabeticIndividualised; SGLT-2i / GLP-1 preferred in high CVD riskDiabetes with PAD — HbA1c <53 mmol/mol (<7%)Monitor BM; SGLT-2i: foot hygiene critical (DKA, amputation risk)
Cilostazol100mg BD (phosphodiesterase inhibitor)Claudication symptom relief (2nd line)Contraindicated in heart failure; headache, palpitations common
AnticoagulationLow-dose rivaroxaban 2.5mg BD + aspirin 100mgCOMPASS trial — high CV risk PAD patientsIncreased bleeding risk; assess benefit vs risk
🏃Supervised Exercise Therapy (SET)

Most effective treatment for claudication. Improves collateral circulation, muscle metabolism, endothelial function, and cardiorespiratory fitness. Preferred over revascularisation for stable claudication (Fontaine IIa/IIb).

Prescription: Minimum 2 hours per week × 3 months (NICE recommendation). Treadmill or track walking to near-maximal claudication pain, then rest, then repeat. Supervised by physiotherapist.

GCC Challenge: Supervised exercise programmes are limited in Gulf region. Heat, cultural barriers, limited physiotherapy access, and patient motivation are obstacles. Nurses should encourage structured home walking programmes as an alternative with documented targets.

Outcome Metrics

  • Claudication-free walking distance (CFWD)
  • Maximum walking distance (MWD)
  • 6-minute walk test
  • Quality of life scores (VascuQoL)
🩹Wound Care for Ischaemic Ulcers

Do NOT debride dry ischaemic gangrene until revascularisation is completed or deemed impossible. Debridement without perfusion = worsening tissue loss.

Non-adherent dressings for ischaemic wounds: Mepitel One, silicone foam. Avoid wet-to-dry dressings (traumatic removal). Keep dry eschar dry and protected.

No compression in PAD (ABPI <0.8). Compression in ischaemic limb → gangrene. Always confirm ABPI before applying any compression bandaging.

Critical Limb-Threatening Ischaemia (CLTI) Criteria: Rest pain >2 weeks AND/OR tissue loss (ulcer/gangrene) AND/OR ABPI <0.4 (or absolute toe pressure <30 mmHg). Requires urgent vascular surgical referral — goal is limb salvage.
🔧Endovascular Revascularisation

Percutaneous Transluminal Angioplasty (PTA) & Stenting

1

Access via common femoral artery (groin) or radial artery. Introducer sheath inserted.

2

Guidewire crossed through stenosis/occlusion under fluoroscopic guidance with contrast.

3

Balloon catheter inflated to dilate stenosis. Drug-coated balloons (DCB) reduce restenosis.

4

Stent deployed if recoil or residual stenosis >30%. Bare metal or drug-eluting stents used.

5

Completion angiogram confirms patency. Sheath removed; haemostasis achieved (manual pressure/closure device).

Post-Procedure Nursing Care

Groin observations: Haematoma/bruising (can expand rapidly — firm pressure if bleeding). Mark haematoma borders to monitor expansion.

Pulse monitoring: Hourly neurovascular obs on treated limb for first 4–6 hours. Document: colour, warmth, sensation, movement, capillary refill, Doppler signal.

Post-procedure checks: ABPI recheck at 24h (expect improvement). Adequate hydration for contrast clearance. Hold metformin 48h post-contrast if eGFR borderline. Dual antiplatelet (aspirin + clopidogrel) post-stenting — typically 4–6 weeks.

🏥Surgical Bypass

Common Bypass Procedures

ProcedureIndicationConduit
Femoral-popliteal bypassSFA occlusion; claudication/CLTIGSV (preferred) or PTFE
Femoral-distal bypassTibial/peroneal vessel disease; CLTIGSV only (prosthetic poor patency below knee)
Aorto-bifemoral bypassAorto-iliac occlusion (Leriche)Dacron prosthetic graft
Femoral endarterectomyCommon femoral diseaseN/A — patch closure

Leriche Syndrome (aorto-iliac): Triad of bilateral buttock/thigh claudication + absent femoral pulses + erectile dysfunction (males).

Post-Bypass Nursing Care

  • Hourly neurovascular observations — graft occlusion peaks at 24–48h
  • Anastomosis leak: sudden haematoma, pain, haemodynamic instability — emergency return to theatre
  • Wound care: leg oedema post-bypass is common (dependent positioning avoided)
  • DVT prophylaxis: TEDS + LMWH; ambulate early
  • Antiplatelet therapy: aspirin lifelong; dual antiplatelet for venous graft not standard

Graft Surveillance: Duplex USS at 6 weeks, 3 months, 6 months, 12 months, then annually. Peak systolic velocity >300 cm/s at anastomosis = significant stenosis → intervention needed before occlusion.

✂️Major Amputation
Amputation is a last resort when revascularisation is not technically feasible, has failed, or limb is unsalvageable. The goal is to restore function and quality of life. Early rehabilitation is essential.

Amputation Levels

LevelIndicationsRehabilitation Potential
Toe/ray amputationLocalised gangrene/osteomyelitisExcellent — shoe modification
Transmetatarsal (TMA)Forefoot gangreneGood — custom footwear
Below-knee (BK / transtibial)Foot/ankle ischaemia; viable kneeGood — prosthetic limb likely
Above-knee (AK / transfemoral)BK not viable; knee joint involvementHarder — higher metabolic demand
Hip disarticulationThigh/hip involvementVery limited prosthetic options

Peri-operative & Post-amputation Nursing

1

Pre-op: Baseline mobility assessment, MDT rehab planning, psychological support, explanation of phantom limb pain.

2

Stump care: Firm bandaging (shaping for prosthesis), wound inspection, haematoma prevention.

3

Phantom limb pain: Reassure — normal phenomenon. Gabapentin, pregabalin, mirror therapy, amitriptyline, TENS.

4

Prosthetic referral: Once stump healed and shaped (6–8 weeks). Physio for gait training.

🩹PAD Ulcer vs Venous Ulcer — Differential
FeatureArterial (Ischaemic) UlcerVenous UlcerNeuropathic (Diabetic) Ulcer
LocationToes, heel, dorsum foot, pressure pointsGaiter area (medial malleolus)Plantar surface, metatarsal heads
Wound edgePunched-out, well-definedIrregular, sloping edgesPunched-out, callus rim
Wound bedPale/necrotic base, minimal granulationSloughy, moist, granulatingVariable — can appear well-granulating
PainSevere, constant; worse at nightDull ache; relieved by elevationPainless (reduced sensation)
Surrounding skinPale, shiny, hairless, coldHaemosiderin staining, lipodermatosclerosisCallus, dry, neuropathic changes
PulsesAbsent / diminishedPresent (unless mixed)May be present (bounding)
ABPI<0.8 (often <0.5)Normal (0.9–1.3)May be >1.3 (calcified)
TreatmentRevascularisation; non-adherent dressing; NO compressionCompression therapy (4-layer); elevationOffloading; debridement; infection management
🔧Wound Bed Preparation — TIME Framework

T — Tissue: Remove non-viable tissue. Sharp/surgical debridement (if perfusion adequate), autolytic (hydrogel), enzymatic, larval therapy. NEVER debride dry eschar in ischaemic limb without revascularisation.

I — Infection/Inflammation: Treat clinical infection with systemic antibiotics. Swab for C&S. Signs: erythema, warmth, purulence, odour, pain, cellulitis. Biofilm: consider antimicrobial dressings (Ag, iodine, PHMB).

M — Moisture Balance: Maintain moist wound environment without maceration. Absorptive dressings for exudate (foam, alginate). Non-adherent for low exudate ischaemic wounds (Mepitel, Adaptic).

E — Edges/Epithelium: Stimulate epithelial migration. Consider NPWT (negative pressure wound therapy) for complex wounds after revascularisation. Skin grafting for large defects once granulation established.

Offloading (diabetic neuropathic ulcer): Total Contact Cast (TCC) = gold standard for plantar neuropathic ulcers. Reduces plantar pressure by 84%. Alternatives: removable cast walker (CROW), forefoot offloading shoes. Essential — patient will continue walking on neuropathic foot without feeling pain.

🚨Acute Limb Ischaemia — The 6 Ps
VASCULAR EMERGENCY. Window for limb salvage: 4–6 hours from symptom onset. Irreversible muscle necrosis (myonecrosis, hyperkalaemia, renal failure) occurs beyond 6 hours. Immediate vascular surgical review required.

Pain — Sudden onset severe limb pain; out of proportion to findings

Pallor — White/mottled limb; loss of normal colour

Pulselessness — Absent distal pulses; absent Doppler signal

Paraesthesia — Pins and needles; numbness — indicates nerve ischaemia (urgent)

Paralysis — Inability to move toes/foot — indicates muscle ischaemia (irreversible damage imminent)

Perishing Cold — Limb cold to touch compared to contralateral side; clear demarcation line


Causes

  • Embolism (most common): AF → cardiac thrombus → embolism to popliteal/femoral
  • Thrombosis in situ: Acute-on-chronic PAD; bypass graft occlusion
  • Aortic dissection
  • Trauma / iatrogenic

Emergency Management

1

Immediate IV heparin bolus (5000 units) — prevents propagation

2

Urgent CTA or DSA for location mapping

3

Embolectomy (Fogarty catheter) for embolic cause

4

Thrombolysis (alteplase/urokinase) if <14 days; no neuro symptoms

5

Fasciotomy if compartment syndrome develops post-reperfusion

⚠️Reperfusion Injury & Compartment Syndrome

Reperfusion injury: Restoration of blood flow releases free radicals, potassium, myoglobin from necrotic muscle. Monitor: hyperkalaemia (ECG changes), myoglobinaemia, acute kidney injury (urine output, creatinine). IV fluids to maintain urine output >0.5 mL/kg/h.

Compartment syndrome: Post-reperfusion oedema within fascial compartments. Signs: severe pain on passive stretch, tense swollen calf, paraesthesia, pain out of proportion. Compartment pressure >30 mmHg = fasciotomy. Nursing: never elevate limb (reduces perfusion).

🌍GCC-Specific Clinical Context

Extremely high PAD burden in GCC: Type 2 diabetes prevalence 15–20% (world's highest). Smoking rates high in males. Dyslipidaemia and obesity epidemic. Combined risk factors accelerate atherosclerosis — PAD often presents a decade earlier than Western populations.

Diabetic foot — leading cause of amputation: In GCC hospitals, diabetic foot complications account for the majority of major lower limb amputations. Late presentation, poor glycaemic control, and neuropathy contribute to high amputation rates.

Barefoot walking on hot sand: Cultural and religious practice (mosques, beaches). In patients with diabetic neuropathy, thermal burns from hot surfaces go undetected → infected wounds → amputation. Patient education on protective footwear is a critical nursing intervention.

Heat and peripheral vascular disease: GCC extreme heat causes peripheral vasodilation. This may mask signs of ischaemia — limbs may feel warm despite critically reduced perfusion. Never exclude PAD on warmth alone. Always perform ABPI in high-risk patients.

Limited supervised exercise rehab: Extreme heat, cultural factors, and lack of structured vascular rehabilitation programmes in GCC limit exercise therapy uptake. Nurses should offer structured home-walking plans with clear targets and diary recording.

Vascular infrastructure: Major vascular surgery units in Saudi Arabia (KFSH&RC Riyadh, KAUH), UAE (Cleveland Clinic Abu Dhabi, SKMC), Qatar (HMC Hamad). Tertiary centres offer full endovascular and open surgical services. District hospitals refer for CTA and revascularisation.

📜Regulatory Standards & Pathways

DHA (Dubai Health Authority): Diabetic Foot Care Pathway mandates ABPI screening for all diabetic patients. Defines referral thresholds to vascular surgery. Wound care documented in electronic health record.

DOH (Abu Dhabi — Malaffi): Standards for diabetic foot management aligned with IWGDF guidelines. All DFU patients registered in Malaffi system. MDT foot clinics mandated in licensed hospitals.

QCHP (Qatar): Diabetic foot standards include annual vascular screening, neuropathy assessment, patient education. HAMAD/HMC limb salvage pathway active for CLTI patients across Qatar.

SCFHS (Saudi Commission): Nursing competency framework includes vascular assessment, ABPI measurement, wound care, and patient education for chronic limb ischaemia. Exam candidates should know Fontaine staging, ABPI interpretation, 6Ps of ALI, and antiplatelet choices.

📚DHA / DOH / SCFHS / QCHP Exam High-Yield Points

Must-Know Facts

  • ABPI <0.9 = PAD; <0.4 = critical ischaemia; >1.3 = calcified (use TBI)
  • Fontaine III = rest pain (hanging leg relieves it); Fontaine IV = tissue loss
  • Clopidogrel 75mg preferred over aspirin in PAD (CAPRIE trial)
  • Statin = atorvastatin 80mg; LDL target <1.4 mmol/L
  • 6Ps of ALI: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold
  • Paralysis = irreversible muscle damage imminent — emergency surgery
  • No compression if ABPI <0.8
  • Supervised exercise = most effective for claudication (2h/week × 3 months)
  • Smoking cessation doubles claudication-free walking distance
  • TcPO2 <20 mmHg = wound unlikely to heal without revascularisation
  • Probing to bone = osteomyelitis until proven otherwise
  • Total contact cast = gold standard for diabetic plantar ulcer offloading

Common Exam Traps

Trap 1: ABPI >1.3 does NOT mean normal vessels — it means calcified, incompressible. Do not reassure patient. Order TBI.

Trap 2: Warm foot does NOT exclude ischaemia in GCC climate. Perform Doppler/ABPI if pulses absent.

Trap 3: Do NOT apply compression to a leg with ABPI <0.8 — this is a patient safety issue.

Trap 4: Painless ulcer does NOT mean it is not serious — neuropathic ulcers feel no pain but can lead to amputation.

Trap 5: Dry gangrene should NOT be debrided until revascularisation status is established.

🧮Interactive ABPI Interpreter & PAD Classifier
Left ABPI
Right ABPI
Left Limb Status
Right Limb Status
Fontaine Classification
Management Pathway