REMEDY : BNSSG referral pathways

Guidelines for the Management of Intermittent Claudication

Checked: 22-11-2017 by Rob.Adams Next Review: 01-12-2018

Clinical Guidance

Intermittent Claudication is a common presentation of peripheral arterial disease in primary care.  If Intermittent Claudication is suspected, then this should be confirmed by ABPI's either in primary care or by referral to Vascular Studies.  Referrals to Vascular Studies at UBHT or NBT are by direct referral and not available via E-Referral.

Surgical Vascular interventions are often not required or not effective in the long term and conservative management in primary care can be tried initially prior to consideration of referral.

Please also refer to the NICE guidelines (web page) on management of peripheral arterial disease.

Principles of Management

Modification of Vascular Risks - Including smoking cessation, lifestyle modification, statins, anti-platelets and screening and management of diabetes and high blood pressure.

Supervised Exercise - Requires patients to attend the BRI twice weekly for 12 weeks. Referrals can be made to the Vascular Clinical Nurse Specialist team via e-referral.

Unsupervised Exercise -This involves advice to exercise for approximately 30 minutes, three to five times per week, walking until the onset of symptoms, then resting to recover. Further information can be found in this Intermittent Claudication patient leaflet.

Vasodilators - Mr Brooks does not advocate the use of Vasodilators (Naftidrofuryl Oxalate) which probably only have minimal effect)

FAQs

Advice provided by Marcus Brooks (Consultant Vascular Surgeon at NBT)

Question - What is the cut off ABPI for referral of patients with Intermittent Claudication?

There is no cut off value for ABPI's when deciding on referral.  The benefit of an ABPI is that if this is normal then it excludes the diagnosis of PAD.  A level less than 0.9 is diagnostic.  If the ABPI is very low (< 0.3) or the pulses cannot be detected then this should raise the possibility of critical limb ischaemia. 

Referral should be for people with lifestyle limiting symptoms or patients who would benefit from and have agreed to attend (twice weekly at BRI for 12 weeks) intermittent claudication exercise classes.

Question - What is the significance of an elevated APBI and is this ever an indicator of Vascular Disease? 

The normal range for ABPI is up to 1.1.   Ratios above this, suggest arteriosclerosis (hardening of the arteries - i.e. in diabetics) and can be a sign of peripheral vascular disease, more likely when a very high ratio.  The key differentiator is the signal, if this is monophasic it indicates vascular disease.  The truth is in diabetics we often need a Duplex to differentiate calcified from stenotic arteries.

Question - If a patient has claudication type symptoms but normal APBIs, is a vascular referral ever warranted or can the GP safely look elsewhere for a cause of the symptoms?

An arterial cause is only 100% excluded by normal post exercise ABPIs. This is because iliac disease and early SFA disease can cause symptoms of intermittent claudication with normal ABPI at rest.  We use a treadmill and then repeat ABPI.  I advise this in any patient in whom the diagnosis of PAD is considered likely with normal resting ABPI.  In primary care, patient could be asked to walk up and down until they have symptoms, it can be useful in addition to document exactly what the symptoms are, or be referred to their local vascular studies unit.  In the most extreme case, professional cyclists with external iliac endointimal fibrosis, their symptoms only come on with vigorous exercise and they have to bring a bike in to be tested.

Red Flags

If Acute Limb Ischaemia is suspected then arrange emergency admission.

If Critical Limb Ischaemia is suspected then refer URGENTLY to Vasular team (see NICE Guidelines (web page) for further advice or discuss with local vascular team).

Urgent patients can be referred to the Vascular HOT clinic  which is now available via eRS.

The vascular network office can also be contacted via telephone 0117 414 0798 or by discussion with either the General Surgery/Vascular Surgery Registrar on call or the Vascular Consultant on call – both can be contacted via NBT switchboard on 0117 9505050.

Referral Guidance

If symptoms persist or worsen despite modification of risk factors and an exercise program has been ineffective or is inappropriate, refer via E-Referral for consideration of angioplasty or bypass surgery. There is a Nurse Led Clinic held at Southmead Hospital which will treat Intermittent Claudication which is available via e-Referral. Please be aware that referrers must stipulate that they want their patient to be seen in this clinic within the referral letter.

The vascular consultants run outpatient clinics accessed via e-referral in the following locations:

  • Southmead Hospital
  • Bristol Royal Infirmary
  • Royal United Hospital Bath
  • Weston General Hospital
  • Cossham Community Hospital
  • Melksham Community Hospital

There is a ‘hot clinic’ Monday to Friday mornings at the Major Arterial Centre -MAC (Southmead Hospital) for patients requiring urgent review but not necessarily admission. The Hot Clinic is now available via e-referral or please contact the vascular network office directly (see 'Useful Link' section below).

Useful Links

NICE Guidelines for the Management of Peripheral Arterial Disease (web page)

Vascular Services Network - for clinicians

Vascular Network Office contact details:

Telephone: 0117 4140798
Fax: 0117 4149378
Email: Nbn-tr.bbwvascularnetwork@nhs.net