NICE issues guidance on lower limb PAD treatment pathways

Industry welcomes direction on standard treatment process for NHS patients

Improvements in diagnostics and major advancements in endovascular treatments and technologies has resulted in variation in the practice of treating lower limb peripheral arterial disease (PAD).

Now, in an effort to resolve this confusion, and lay out a standard treatment process for NHS patients, the National Institute for Health and Clinical Excellence (NICE) has published new guidance.

Rapid changes in diagnostic methods, endovascular treatments and vascular services, associated with the emergence of new sub-specialties in surgery and interventional radiology, has resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation

Lower Limb Peripheral Arterial Disease – Diagnosis and Management aims to give patients across the country equal access to the most-effective care pathways, improve patient outcomes, and reduce amputations.

The guidance states: “Rapid changes in diagnostic methods, endovascular treatments and vascular services, associated with the emergence of new sub-specialties in surgery and interventional radiology, has resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation.”

Lower limb PAD is a marker for increased risk of cardiovascular events, even when it is asymptomatic. The most common initial symptom is leg pain while walking, known as intermittent claudication. Critical limb ischaemia is a severe manifestation of PAD and is characterised by severely-diminished circulation, ischaemic pain, ulceration, tissue loss and gangrene.

The incidence of PAD increases with age and population studies have found that about 20% of people aged over 60 years suffer to some degree. Incidence is also high in people who smoke, those with diabetes, and people with coronary artery disease. In most people with intermittent claudication the symptoms remain stable, but approximately 20% will develop increasingly severe symptoms with the development of critical limb ischaemia.

Mild symptoms are generally managed in primary care, with referral to secondary care when symptoms do not resolve or they deteriorate. There are currently several treatment options for people with intermittent claudication including advice to exercise; management of cardiovascular risk factors, for example, with aspirin or statins; and vasoactive drug treatment, for example, with naftidrofuryl oxalate.

The technology to diagnose and manage these conditions is available, and the medical device industry is ready to support healthcare providers to implement this guidance

People with severe symptoms that are inadequately controlled are often referred to secondary care for assessment for endovascular treatment, such as angioplasty or stenting, bypass surgery, pain management and/or amputation.

The guidance lays out when to use the various technologies such as duplex ultrasound, contrast enhanced magnetic resonance angiography, CT angiography and stenting and it has been welcomed by suppliers.

Peter Ellingworth, chief executive of the Association and British Healthcare Industries, which represents healthcare companies across the UK, said: “This guidance is a significant development for patients with lower limb PAD. It is critical for patients that all treatment options are explored before they consider major amputation. I welcome the call for all options for revascularisation to be considered by a vascular multidisciplinary team, as this should ensure all patients get access to the full range of treatments available.

“Too often we see NICE guidance that is not fully implemented, meaning some patients miss out on vital treatments. The NHS cannot let this happen in this instance, no patient should go through an amputation when other options are available.

“The technology to diagnose and manage these conditions is available, and the medical device industry is ready to support healthcare providers to implement this guidance. I look forward to working with the NHS to ensure that all patients who should are able to get access to treatment.”

To read the guidance in full, click here

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