Peripheral Arterial Disease – The biggest killer you’ve probably never heard of

Imagine putting on socks one morning and noticing that your massive toe, which has been hurting for weeks, has started to turn black. A visit to a doctor ends with an urgent referral to a specialist. They say that to save the foot, bypass surgery is needed on the blocked artery in the thigh. This is the reality for too many people. In the UK, vascular surgeons performed over 3,500 amputations in 2023.

Efforts are being made across the NHS to reduce the number of amputations performed for this reason peripheral artery disease. The vascular surgery unit at Glenfield Hospital in Leicester aimed to improve the process from referral to treatment for people at risk of amputation. I was a co-author with my colleagues new study showing that focusing on speed could cut the risk of amputation in half.

Peripheral artery disease is a narrowing and blockage of the arteries in the legs. This process of blood vessel coiling is the same one that causes cardiovascular disease. But while the signs and symptoms of a heart attack or stroke are well known, few have heard of their counterparts in the legs.

Above one in ten people people over the age of 65 in the UK have peripheral arterial disease. As the incidence of diabetes increases and the population continues to age, it is becoming more common. Most people have no symptoms, but still have a higher risk heart attacks, strokes or death. The first symptom is pain in the calf when walking, called intermittent claudication – legs to windows as the Dutch call it.

Early in the disease, blood thinners and cholesterol-lowering medications are prescribed. Lifestyle changes such as quitting smoking, exercising, and treating diabetes or high blood pressure are also crucial parts of treatment. For many people, this is all the treatment for peripheral arterial disease they will ever need.

As the disease progresses, it can cause pain at rest, foot ulcers, and even gangrene, requiring leg-sparing surgery or major amputation. This final stage of the disease is called chronic limb-threatening ischemia. Survival of people with this stage of the disease is worse than in the case of many cancers – less than 50% will survive five years after diagnosis.

People with diabetes also often experience nerve damage that causes numbness in the feet. They may not realize they have peripheral arterial disease until they develop a non-healing foot ulcer. These people often require foot surgery and intensive wound treatment, as well as procedures to improve blood circulation. The cost of this care to the NHS ten years ago was estimated at almost £1 billion and has probably only increased since then.

Unfortunately, awareness of peripheral artery diseases among the public is low or even insignificant non-specialist health care workers. Delays may occur in all stages of the treatment path – recognition of symptoms by the patient, referral for specialist diagnosis, timeliness of limb-sparing surgery. There are also potentially missed opportunities initiate treatment and refer patients leads to unnecessary amputations.

Urgent improvements were needed in the treatment of chronic limb-threatening ischemia. The NHS has quickly adopted newer technologies to enable intricate ‘keyhole’ procedures to unclog arteries.

UK guidelines currently recommend surgery to restore the blood supply within two weeks of referral for those who need it. To support achieve these goals, NHS vascular surgery departments are increasingly using rapid access clinics to see and treat patients quickly – showing promising results.

Speed ​​is key

Our research compared a historical group of patients (from 2013–2015) with a contemporary group (2019–22) before and after changes in treatment paths. These changes included the opening of a newfangled hybrid room (with integrated X-ray diagnostics) and the opening of a specialized, quickly accessible clinic. The focus was on reducing the time from referral to surgery using the latest surgical techniques.

After 1 year, 25% of the historical group had undergone major leg amputation (above the ankle). In comparison, only 11% of the newfangled group had an amputation. Even after taking into account the differences between the two groups of people, this represents a 57% reduction in the risk of major amputation.

The results have some caveats given the differences between how the two groups were recruited into the study. Still, the study confirms that focusing on visiting and treating people suspected of having chronic limb-threatening ischemia quickly prevents a significant number of amputations.

More needs to be done to raise awareness of peripheral arterial disease, given its devastating potential impact. A healthier lifestyle and appropriate treatment of the earlier stages of the disease can reduce the number of cases of progression to the end stage where amputation becomes a possibility.

Most importantly, recognizing the signs of foot risk – persistent toe pain, a foot wound that won’t heal, or dim discoloration of one or more toes – and seeking support quickly may just save someone’s foot.