Peripheral artery disease – the biggest killer you’ve probably never heard of

Imagine putting your socks on one morning and noticing your big toe, which has been painful for a few weeks, has started turning black. A trip to your doctor ends in being referred urgently to a specialist. They tell you a bypass operation of a blocked artery in your thigh is needed to save your foot. This is the reality for far too many people. In the UK, vascular surgeons performed more than 3,500 amputations in 2023.

Efforts are being made throughout the NHS to reduce the number of amputations performed due to peripheral artery disease. The vascular surgery unit in Glenfield Hospital, Leicester, aimed to streamline the process from referral to treatment for people at risk of amputation. With colleagues, I co-authored a new study that shows this focus on speed may have reduced the risk of amputation by half.

Peripheral artery disease is the narrowing and blocking of the arteries in the legs. This process of furring up of the blood vessels is the same that causes cardiovascular disease. But while the signs and symptoms of a heart attack or stroke are well known, few have heard of their equivalent in the legs.

More than one in ten people aged over 65 in the UK have peripheral artery disease. With the rise in prevalence of diabetes and a steadily ageing population, it is also becoming even more common. Most people have no symptoms but still have a higher risk of heart attacks, strokes or death. The first symptoms are pain in the calf when walking, termed intermittent claudication – window-shopping legs as the Dutch call it.

Blood thinners and cholesterol-lowering drugs are prescribed for the early stage of the disease. Lifestyle changes such as stopping smoking, exercising and managing diabetes or high blood pressure are also important parts of treatment. For many people, this is all the treatment for peripheral artery disease they will need.

As the disease progresses it can cause pain at rest, foot ulcers and even gangrene, necessitating leg-saving surgery or major amputation. This end-stage of the disease is called chronic limb-threatening ischaemia. The survival of people with this stage of the disease is worse than many cancers – less than 50% will be alive five years from diagnosis.

People with diabetes often also have nerve damage causing numbness in their feet. They may not be aware of having peripheral artery disease until a foot ulcer that doesn’t heal appears. These people often need surgery on their foot and intensive wound management as well as procedures to improve blood supply. The cost of this care to the NHS ten years ago was estimated at nearly £1 billion and has probably only increased since then.

Unfortunately, awareness of peripheral artery disease is poor among the public and even non-specialist healthcare professionals. Delays can happen in all stages of the treatment pathway – recognition of symptoms by patients, referral to specialist assessment, timely limb saving surgery. There are also potentially missed opportunities to start treatment and refer patients leading to unnecessary amputations.

Urgent improvements were required in the treatment of chronic limb-threatening ischaemia. The NHS has rapidly adopted newer technologies to enable complex keyhole procedures to unblock arteries.

UK guidelines now recommend surgery to restore blood supply is performed within two weeks of referral for those that need it. To help achieve these targets, vascular surgery units in the NHS are increasingly using rapid-access clinics to see and treat patients quickly – showing promising results.

Speed is crucial

Our research compared a historical group of patients (from 2013-15) to a contemporary group (2019-22) before and after changes to treatment pathways. These changes included opening a state-of-the-art hybrid theatre (with integrated X-ray imaging) and opening a specialist, rapid-access clinic. The focus was to reduce the time from referral to surgery using the most modern surgical techniques.

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

There are some caveats to the results given differences between how the two groups were recruited to the study. Still, the study provides validation that the focus on seeing and treating people suspected of chronic limb-threatening ischaemia quickly does prevent significant numbers of amputations.

More needs to be done to raise awareness of peripheral artery disease given its devastating potential impact. Healthier lifestyles and appropriate treatment of earlier stages of the disease may reduce the numbers progressing to the end stage where amputation becomes a possibility.

Most importantly, recognising the signs of a foot at risk – constant pain in the toes, a foot wound that won’t heal or dark discolouration to one or more toes – and seeking help quickly, may just save someone’s foot.

John Houghton receives funding from the George Davies Charitable Trust and the National Institute for Health and Care Research. He is the trainee representative for the Vascular Surgery Specialist Advisory Committee and is a member of the UK Labour Party.