PVD is a narrowing of the arteries which causes impaired blood supply. It is generally seen as pain on walking (claudication). The five common causes:

• Smoking
• High Blood Pressure
• Diabetes
• High Cholesterol
• Strong family history

A large number of inflammatory diseases etc., can cause similar problems in less common situations.

Natural History
Peripheral Arterial Disease (PAD is the US name; PVD is the UK name) is generally a benign disease i.e. if it affects the lower limb and is associated with a blocked artery in the thigh then when the patient walks there will be diminished blood flow to the calf muscles which ache. Over 5 years, more than 90% of these patients will retain their limb. Statistically about a third will be much the same and a third might even improve. The third that worsen are liable to be non-exercising or diabetic or persistent smokers.

Collateral Circulation
Regular walking has been shown to have an improvement affect that is almost comparable to endovascular treatment or even surgery. This is because blood flow can often go through other arteries into muscles and then back around the blockage into a main artery. This is called collateral circulation. The stimulus to develop collateral circulation is exercise. The best exercise is slow steady continuous walking e.g. around the block, or around the park for 30 to 60 minutes each day. The person may need to stop several times. A rest of a few minutes is all that is required and then they walk onwards. Fast walking or walking up hills or steps causes pain and confers little benefit.

Not surprisingly those addicted to golf who have Peripheral Vascular Disease or have undergone bypass surgery generally have very good long-term outcomes.

First Stage of Management
The first management of Peripheral Vascular Disease then is at the non-specialist level i.e. identification of patients at risk and aggressive treatment of vascular risk factors. The vascular surgery summary of this is “stop smoking and start walking”. Patients without active control of their risk factors should probably not proceed to vascular surgery or endovascular surgery.

First Stage of Identification
Patients with peripheral vascular disease will probably by identified by a general practitioner or physician. Arterial ultrasound would reveal certain arterial narrowing’s or occlusions. The vascular surgeon would then assess whether there is a risk of a catastrophic event or whether, like most patients, conservative management is appropriate. The vascular surgeon’s role then would be to organise specialised imaging such as CT Angiography or even Angiography and infrequent but regular supervision of the patient. Ultrasound imaging reports that recommend CT Angiography or Angiography in the absence of higher vascular surgical opinion should be treated with some caution.

Overview
In summary PVD/PAD covers a wide range of cases and should be generally considered a benign disease whose management is medical but doesn’t preclude a surgical opinion from the vascular surgeon.