Peripheral arterial Disease (PAD)

PERIPHERAL
ARTERIAL DISEASE
(PAD)
T.SUNIL KUMAR

INTRODUCTION
• PAD IS A CLINICAL TERM THAT DENOTES
AN OCCLUSIVE DISEASE ARISING FROM
NARROWING OF THE ARTERIES DISTAL
TO THE ARCH OF THE AORTA.
• PERIPHERAL ARTERY DISEASE (ALSO
CALLED PERIPHERAL ARTERIAL DISEASE)
IS A COMMON CIRCULATORY PROBLEM IN
WHICH NARROWED ARTERIES REDUCES
BLOOD FLOW TO THE LIMBS.

ATHEROSCLEROSIS OBLITERANS
IT IS OCCLUSIVE ARTERIAL DISEASE MOST
COMMONLY AFFECTING ABDOMINAL AORTA
&ARTERIES OF LOWER LIMS
• RISK FACTORS – MAIN FACTORS LEADING
TO PROGRESSIVE NARROWING OF THE
MAJOR ARTERIES OF THE LEGS ARE
SMOKING, HYPERTENSION, DIABETES
MELLITUS AND HYPERLIPIDAEMIA.

SYMPTOMS
1. INTERMITTENT CLAUDICATION – SEVERE
CRAMPING PAINS OR DISCOMFORT ON
WALKING WHICH DISAPPEARS AFTER SHORT
REST AND RECURS WHEN THE WALK IS
RESUMED. THE SYMPTOM IS DUE TO INABILITY
OF NARROW ARTERIES TO PROVIDE
ADDITIONAL BLOOD SUPPLY NECESSARY FOR
THE EXERCISING MUSCLES.

• THE POSITION OF PAIN OF CLAUDICATION DEPENDS
ON THE LEVEL OF ARTERIAL LESION –
(A) CALF CLAUDICATION – USUALLY DUE TO
OBSTRUCTION IN FEMORO-POPLITEAL SEGMENT.
(B) THIGH CLAUDICATION – USUALLY DUE TO ILIAC
OCCLUSION WITH ASSOCIATED BUTTOCK
CLAUDICATIONS.
(C) CLAUDICATION OF BUTTOCKS, THIGHS AND
CALVES WITH IMPOTENCY IN MALES – AORTIC
BIFURCATION LESION.

2. REST PAIN– IS LESS COMMON AND SUGGESTS
MORE ADVANCED DISEASE.
(a) PAIN DUE TO ACUTE ARTERIAL OCCLUSION –
SEVERE PAIN IN TISSUES DISTAL TO THE SITE OF
OBSTRUCTION AGGRAVATED BY LIMB MOVEMENT.
(b) (B) PAIN DUE TO ISCHAEMIC NEUROPATHY –
SEVERE BURNING OR LANCINATING TYPE OF PAIN
OCCURRING USUALLY IN PAROXYSMS AND WORSE
AT NIGHT.
(c) (C) PAIN OF PREGANGRENE – BURNING,
THROBBING TYPE OF PAIN WHICH MAY MAKE THE
PATIENT SIT UP IN BED AND HOLD HIS LEGS. PAIN
AGGRAVATED BY HEAT.

3. OTHER SYMPTOMS– NUMBNESS AND
TINGLING AND FEELING OF COLDNESS IN
THE INVOLVED EXTREMITY. THE
OCCURRENCE OF SEPSIS IN MINOR
ABRASIONS OF THE FEET MAY BE THE
FIRST EVIDENCE OF INCIPIENT ISCHAEMIA
IN THE LIMB.

EXAMINATION
(A) INSPECTION – OF FEET. IN PRESENCE OF
REST PAIN, FEET AND TOES WILL BE COLD WITH
PURPLE OR BLUISH DISCOLOURATION. IN MORE
ADVANCED CASES (PREGANGRENE) ATROPHIC
SKIN, POOR COLOUR AND SLUGGISH CAPILLARY
CIRCULATION.
(B) PALPATION – (I) ABSENCE OF PULSES BELOW
THE FEMORAL PULSE (FEMORAL ARTERY IS
MOST COMMONLY INVOLVED) IN AFFECTED LEG.
IF BUTTOCK OR THIGH CLAUDICATION IS
PRESENT, THE FEMORAL PULSE WILL BE WEAK
OR ABSENT INDICATING AORTOILIAC DISEASE. AT
TIMES PULSATIONS ARE PRESENT AT REST AND
DISAPPEAR ON EXERTION.

(II) ABDOMEN – TO EXCLUDE ANEURYSM
OF ABDOMINAL AORTA.
(III) DISTAL TO OBSTRUCTION LIMBS ARE
COLD TO TOUCH.
(C) AUSCULTATION – OF ABDOMINAL
AORTA, ILIAC ARTERIES AND FEMORAL
ARTERIES DOWN TO THE POPLITEAL
FOSSA MAY REVEAL STENOSIS BY
PRESENCE OF A BRUIT.

INVESTIGATIONS
1. ANKLE BRACHIAL PRESSURE INDEX –
UNDER NORMAL CONDITIONS, SYSTOLIC BP IN
THE LEGS IS SLIGHTLY GREATER THAN THAT IN
THE UPPER LIMB. THE ANKLE BRACHIAL
PRESSURE INDEX CALCULATED FROM THE
RATIO OF ANKLE TO BRACHIAL SYSTOLIC
PRESSURE, IS A SENSITIVE INDEX OF
ARTERIAL INSUFFICIENCY. THE HIGHEST
PRESSURE MEASURED IN ANY ANKLE ARTERY
IS USED AS THE NUMERATORY OF THE INDEX,
A VALUE > 1.0 IS NORMAL, AND A VALUE < 0.9
IS ABNORMAL.

MEASUREMENT WITH DOPPLER PROBE
• A HAND HELD PENCIL DOPPLER PROBE IS
PLACED OVER A PATIENT PEDAL ARTERY
AND THE FOOT RAISED AGAINST A POLE
CALIBRATED IN MM HG. THE POINT AT WHICH
THE PEDAL SIGNAL DISAPPEARS IS TAKEN
AS THE ANKLE PRESSURE.
2. EXERCISE TEST – IS PERFORMED BY
EXERCISING THE PATIENT FOR 5 MINUTES SAY
ON A TREAD MILL. THE ANKLE BRACHIAL
PRESSURE INDEX IS MEASURED BEFORE AND
AFTER EXERCISE. A PRESSURE DROP (DUE
TO PERIPHERAL VASODILATION) OF 25% OR
MORE INDICATES SIGNIFICANT ARTERIAL
DISEASE.

3. ECG – FOR EVIDENCE OF ISCHAEMIA.
4. ANGIOGRAPHY – TO DEFINE EXTENT OF
DISEASE AND POSSIBILITY OF BYPASS
SURGERY OR ENDARTERECTOMY.
5. SPECIALIST DIAGNOSTIC AND
THERAPEUTIC DEVICES:
(A) PRESSURE WIRES WITH BUILT-IN
PRESSURE SENSOR AT TIP TO MEASURE
TRANSLESIONAL PERIPHERAL (AND RENAL
ARTERY) GRADIENTS TO DETERMINE
HEMODYNAMIC IMPORTANCE.

(B) INTRAVASCULAR ULTRASOUND FOR
LESION ASSESSMENT AND FOR
OPTIMIZATION AFTER ANGIOPLASTY OR
STENTING.
(C) SPECIFIC ATHERECTOMY DEVICES TO
DEBULK, SLICE AND REMOVE PLAQUE
THROUGH LONG SEGMENTS OF HEAVILY
CALCIFIED LESIONS.
(D) EXCIMER LASER TECHNOLOGY FOR
ENDOVASCULAR ABLATION FOR TOTAL
OCCLUSIONS.

MANAGEMENT OF CHRONIC PERIPHERAL
ISCHAEMIC DISEASE.
MEDICAL TREATMENT – INDICATIONS:
(A) IF INTERMITTENT CLAUDICATION IS THE ONLY
SYMPTOM AND IT DOES NOT INTERFERE WITH
THE PATIENT’S EMPLOYMENT.
(B) DIABETES MELLITUS IS NOT ASSOCIATED.
(C) PRESENCE OF EXTENSIVE DISEASE
CONTRAINDICATES SURGICAL INTERFERENCE.
(D) FAILURE OF SURGERY TO RELIEVE
SYMPTOMS.

1. MEASURES TO PREVENT PROGRESS OF THE
DISEASE
•• REST IF PRESENCE OF REST PAIN, WOUND OR
GANGRENE.
•• NO SMOKING.
•• REDUCTION OF OBESITY.
•• CARE OF FEET – SKIN SHOULD BE PROTECTED
FROM TRAUMA, SHOES SHOULD BE
COMFORTABLE. AVOID TIGHT GARTERS. TRIM
NAILS CAREFULLY. AVOID SITTING WITH LEGS
CROSSED. NO OPERATIVE REMOVAL OF CORNS.
IF SKIN IS DRY, APPLY OIL AT NIGHT AND DUSTING
POWDER DURING DAY. CONTROL OF FUNGUS
INFECTION.

(A) ANTIPLATELET THERAPY – ASPIRIN 75–
300 MG/DAY, IF ASPIRIN SENSITIVITY,
DIPYRIDAMOLE (200 MG BD) OR
CLOPIDOGREL (75 MG/DAY) OR
PRASUGREL (10 MG/DAY) OR TICAGRELOR
90 MG BD.
(B) CILOSTAZOL 100 MG BD ONE HR.
BEFORE OR TWO HRS. AFTER BREAKFAST
AND DINNER IF EXERCISE ALONE IS
INEFFECTIVE. IT SHOULD NOT BE USED IN
PATIENTS OF CONGESTIVE CARDIAC
FAILURE.

(C) PENTOXIFYLLINE, XANTHINE OXIDASE
INHIBITOR, DECREASES BLOOD VISCOSITY
AND ANTI-PROLIFERATIVE ACTION.
(D) CONTROL OF LIPAEMIA IN
ATHEROSCLEROSIS.
(E) ADEQUATE CONTROL OF DIABETES.
(F) CONTROL OF THROMBOSING TENDENCIES
WITH LONGTERM ANTICOAGULANTS

2. MEASURES TO INCREASE CIRCULATION
• (A) WALKING – THE PATIENT SHOULD BE
INSTRUCTED TO WALK SLOWLY UP TO THE
POINT OF CLAUDICATION SEVERAL TIMES A DAY.
• (B) WARM ENVIRONMENT – HOT BAG TO
ABDOMEN MAY CAUSE VASODILATION IN LOWER
LIMBS. BLOOD FLOW CAN OFTEN BE
STIMULATED BY PLACING A THERMOSTATICALLY
CONTROLLED HEATING UNIT OVER THE LOWER
EXTREMITIES; THE TEMPERATURE WITHIN THE
BOX SHOULD NOT EXCEED 90°F. THE SOURCE
OF HEAT IS USUALLY IN THE FORM OF ELECTRIC
LIGHT BULBS. HEAT MUST NEVER BE APPLIED
DIRECTLY TO ISCHAEMIC EXTREMITIES.

• (C) ACTIVE VASCULAR EXERCISE –
BUERGER’S EXERCISE – LEGS ARE
ELEVATED TO 60° AND KEPT IN THAT
POSITION FOR 2–3 MINUTES UNTIL
BLANCHING OCCURS. THEN DANGLE
LEGS FOR 5 MINUTES TILL MAXIMAL
FLUSHING IS SEEN. THEN KEEP LEGS IN
HORIZONTAL POSITION FOR 5 MINUTES.
CONTRAINDICATED IF INFECTION OR
OPEN WOUND.

• (D) PASSIVE VASCULAR EXERCISE – (I)
“SUCTION PRESSURE TREATMENT” –
ALTERNATE HIGH AND LOW PRESSURE IS
PRODUCED IN A HERMETICALLY SEALED
BOOT (PAVEX BOOT). (II) SAUNDER’S
OSCILLATING BED FOR EXTREMELY OLD AND
DEBILITATED PATIENTS IN PLACE OF
POSTURAL EXERCISE. (III) INTERMITTENT
VENOUS OCCLUSION – WITH A
SPHYGMOMANOMETER, THE PRESSURE IS
RAISED TO ABOUT 60 MM HG. FOR 2
MINUTES AND RELEASED FOR 4 MINUTES,
THE PROCESS BEING REPEATED FOR HALF
AN HOUR.

• (E) OTHER MEASURES – TO ALTER FLOW
PROPERTIES OF BLOOD SUCH AS
HAEMODILUTION, DEFIBRINATION, PLASMA
EXCHANGE AND HAEMORHEOLOGICAL
DRUGS.

B. INTERVENTIONAL TREATMENT
• REVASCULARIZATION - PROCEDURES –
(A) PERCUTANEOUS RE-OPENING PROCEDURES– (I)
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY – IS
WIDELY USED FOR CRITICAL STENOSIS OR
OCCLUSION. (II) LOCAL FIBRINOLYTIC THERAPY – AS
ALTERNATIVE OR ADDITIONAL PROCEDURE TO PTA,
PARTICULARLY IF SUGGESTION OF RECENT
THROMBOSIS AND IT CAN BE COMBINED WITH
THROMBECTOMY. STREPTOKINASE 6000 UNITS/HR
DIRECTLY INTO THE OCCLUSION, WITH REPEAT
ARTERIOGRAPHY AFTER 6–12 HOURS. IF SIGNIFICANT
IMPROVEMENT, TREATMENT MAY BE CONTINUED FOR
12–24 HOURS, WITH REPEAT ARTERIOGRAMS EVERY 12
HOURS.

C. RECONSTRUCTIVE ARTERIAL SURGERY (LIMB
SALVAGE):
–– INDICATIONS – (A) PRESENCE OF SEVERE
CLAUDICATION INTERFERING WITH EVERYDAY
WORK. (B) CRITICAL LEG ISCHAEMIA WITH REST
PAIN OR IMPAIRED SKIN AND TISSUE VIABILITY
AND NON-HEALING ULCERS.
–– PROCEDURE – BYPASSING OF OCCLUDED
SEGMENT – RECONSTRUCTIONS ABOVE GROIN
(AORTO-ILIAC SEGMENT) GIVE BETTER RESULTS
THAN THOSE BELOW THE GROIN (FEMORO-
POPLITEAL SEGMENT). MORE DISTAL BYPASSES
TO CALF ARTERIES ONLY AS ALTERNATIVE TO
MAJOR AMPUTATION

• VASCULOPATHY OF SPECIFIC AETIOLOGY
- NON-ATHEROSCLEROTIC (VSE-NA) IN
YOUNG PATIENT. PAD MAY BE THE FIRST
PRESENTATION OF CONNECTIVE TISSUE
DISEASE (CTD) OR THROMBOPHILIC
STATE, YOUNGER AGE OF ONSET, FEVER,
WT. LOSS, MULTIPLE LIMB INVOLVEMENT,
ANAEMIA, HIGH ESR, PROTEINURIA AND
RBCS IN URINE ALL POINT TO CTD, UPPER
LIMB INVOLVEMENT BEING MORE
COMMON.

THROMBOANGIITIS OBLITERANS
(BUERGER’S DISEASE)
INFLAMMATORY OCCLUSIVE DISORDER
INVOLVING SMALL AND MEDIUM-SIZED
ARTERIES AND VEINS IN DISTAL UPPER
AND LOWER EXTREMITIES, USUALLY IN
MALES IN AGE GROUP 25–40. HEAVY
CIGARETTE SMOKING IS A PREDISPOSING
FACTOR. INCREASED INCIDENCE OF HLAB5
AND A-9 ANTIGENS.

CLINICAL FEATURES
1. MIGRATORY SUPERFICIAL
THROMBOPHLEBITIS – RED PAINFUL
AREAS ON DORSUM OF FOOT
PARTICULARLY IN REGION OF ANKLE OR
LOWER LEG AND OCCASIONALLY
LOWER ARM; OFTEN A VEIN 2 TO 4
INCHES IN LENGTH IS INVOLVED.
SLIGHT MALAISE AND LITTLE RISE OF
TEMPERATURE MAY BE PRESENT.
LASTS FOR 10 TO 12 DAYS AND IS
FOLLOWED BY A BROWNISH
PIGMENTATION.

PAIN – ONE OF THE EARLIEST SYMPTOMS,
VARIES IN INTENSITY FROM MILD TO
EXCRUCIATING PAIN AND OFTEN APPEARS
FOR THE FIRST TIME AFTER EXPOSURE TO
COLD.
(a)INTERMITTENT CLAUDICATION OCCURS
IN ALMOST ALL PATIENTS AND IS
CONFINED NOT ONLY TO CALVES BUT
ALSO OCCURS IN FEET. IT IS CRAMP-
LIKE AND OFTEN OCCURS AFTER
PROGRESSIVELY SHORTER INTERVALS
AND LASTS LONGER AFTER CESSATION
OF ACTIVITY.

(B)REST PAIN MAY BE DUE TO IMPENDING
TROPHIC DISTURBANCES.
(C)INVOLVEMENT OF NERVES CAUSES SHARP,
SHOOTING, LANCINATING PAINS IN THE
WHOLE EXTREMITY. OCCASIONALLY PAIN IS
RELIEVED BY KEEPING THE LEG DOWN.
PATIENT SITS ON EDGE OF BED HOLDING THE
INVOLVED FOOT, WHICH IS CROSSED OVER
THE HEALTHY LEG, IN HIS HAND.

3. RAYNAUD’S PHENOMENON (RP) – RAYNAUD’S
PHENOMENON REFERS TO REVERSIBLE SPASM
OF PERIPHERAL ARTERIOLES IN RESPONSE TO
COLD OR STRESS. RP IS USUALLY SEEN IN DISTAL
DIGITS BUT MAY INVOLVE NOSE, EARS AND
TONGUE. IT IS CHARACTERISED BY TRIPHASIC
RESPONSE:
–– PHASE 1: PALLOR DUE TO VASOCONSTRICTION
OF PRECAPILLARY MUSCULAR ARTERIOLES.
–– PHASE 2: CYANOSIS DUE TO VENOUS POOLING
AND DEOXYGENATION OF VENOUS BLOOD.
–– PHASE 3: ERYTHEMA BECAUSE OF
HYPERAEMIA. IT IS ASSOCIATED WITH
THROBBING.

• RAYNAUD’S PHENOMENON SHOULD BE
DISTINGUISHED FROM RAYNAUD’S
DISEASE WHICH IS OCCURRENCE OF
VASOSPASM PRIMARILY WITH NO
ASSOCIATION WITH ANOTHER ILLNESS
(PRIMARY RAYNAUD’S). RP IS
SECONDARY TO OTHER CONDITIONS,
MOST COMMONLY AN AUTOIMMUNE
DISEASE (SECONDARY RAYNAUD’S).

CLINICAL STAGES
1. PREMONITORY STAGE – OFTEN
UNNOTICED BY THE PATIENT.
CHARACTERISED BY ATTACKS OF
RECURRENT PHLEBITIS, SWELLING OF
FEET, LOSS OF HAIR ON THE LEGS AND
FORMATION OF TENDER NODULES IN SKIN.
THE STAGE MAY LAST FROM 2 TO 7 YEARS.

2. STAGE OF CLAUDICATION – SEVERE, CRAMPING
PAINS ON WALKING WHICH DISAPPEAR AFTER SHORT
REST AND RECUR WHEN THE WALK IS RESUMED.
3. STAGE OF REST PAIN – PAIN COMES IN
PAROXYSMS EVEN AT REST, IS INCREASED BY
ELEVATION AND RELIEVED TEMPORARILY BY
LOWERING OF THE EXTREMITY.
4. STAGE OF TROPHIC CHANGES AND GANGRENE –
PAIN CONSTANT AND EXCRUCIATING, VESICLES ON
GREAT TOE FOLLOWED BY ULCERS OR FISSURES.
GANGRENE DRY OR MOIST SPREADING UPWARDS.

INVESTIGATIONS
• ARTERIOGRAPHY – SMOOTH, TAPERING
DISTAL SEGMENTAL VESSELS AND FINE
NETWORK OF COLLATERAL VESSELS.
• EXCISION BIOPSY – OF INVOLVED
VESSELS CONFIRMS DIAGNOSIS.
MANAGEMENT
NO SPECIFIC TREATMENT. ABSTINENCE
FROM TOBACCO. ARTERIAL BY-PASS OF
LARGER VESSELS IN SELECTED CASES
AND ALSO DEBRIDEMENT DEPENDING ON
SYMPTOMS AND SEVERITY OF ISCHAEMIA.
AMPUTATION IF OTHER MEASURES FAIL.

RAYNAUD’S SYNDROME AND
PHENOMENON
• IT IS CHARACTERIZED BY SEQUENTIAL
DEVELOPMENT OF WHITE, NUMB ‘DEAD
FINGERS’ (DIGITAL ISCHAEMIA), CYANOSIS,
RUBOR OF FINGERS (AND TOES) ON
EXPOSURE TO COLD, AND SUBSEQUENT
FLUSHING PHASE DUE TO REWARMING.

CLASSIFICATION: OF RAYNAUD’S
PHENOMENON
PRIMARY OR IDIOPATHIC (RAYNAUD’S
DISEASE)
• NO UNDERLYING CAUSE. OCCURS
USUALLY IN FEMALES BETWEEN 15 TO 20
YEARS OF AGE. FAMILY HISTORY
COMMON. NEVER PROGRESSES
TO ULCERATION.

MANAGEMENT
(1) WARM CLOTHING AND AVOIDANCE OF EXPOSURE
TO COLD
(2) DRUGS – (A) ADRENERGIC BLOCKING AGENTS.
(B) RESERPINE REDUCES PAIN AND
PROMOTES ULCER HEALING.
(C) CALCIUM ANTAGONISTS NIFEDIPINE OR
DILTIAZEM.
(D) PRAZOSIN.
(3) SURGICAL SYMPATHECTOMY – IF FAILURE TO
RESPOND TO DRUGS, BUT EFFECT TRANSIENT

• PERSISTENT DIGITAL ISCHAEMIA – ISCHAEMIA OF A
DIGIT OR DIGITS MAY LAST FOR DAYS OR WEEKS.
PATIENTS ARE USUALLY MIDDLE AGE OR ELDERLY,
OFTEN HYPERTENSIVE. THE CAUSE IS NOT
OBVIOUS BUT MAY BE DUE TO OCCLUSION OF THE
DIGITAL ARTERY BY ATHEROMA. AT TIMES
POLYCYTHAEMIA VERA OR DYSPROTEINAEMIA IS
THE CAUSE, OR, IN YOUNG SUBJECTS, A CERVICAL
RIB MAY BE RESPONSIBLE. TREATMENT –
SPONTANEOUS RECOVERY IS USUAL BUT FOR
SEVERE ISCHAEMIA REFLEX HEATING, ANALGESICS
AND DEXTRAN INFUSION, AND ANTIBIOTICS FOR
INFECTION. AMPUTATION ALONG LINE OF
DEMARCATION IF GANGRENE OCCURS.

• COLD INJURY – FREEZING OF TISSUES IN HANDS
AND FEET LEADING TO FROST BITE CAN OCCUR
FOLLOWING PROLONGED EXPOSURE TO COLD.
THERE IS USUALLY REDNESS, BLISTERING,
INFECTION AND SUPERFICIAL GANGRENE OF
THE DIGITS OF HANDS AND FEET. TREATMENT –
REFLEX HEATING, ANTIBIOTICS AND
ANALGESICS AND DEXTRAN INFUSION. DEEP
TISSUES ARE USUALLY PRESERVED AND SKIN
GANGRENE SEPARATES OUT LEAVING A
SHRUNKEN DIGIT BENEATH.

• ACROCYANOSIS – REDDISH OR BLUISH
DISCOLOURATION OF HANDS AND FEET
ON EXPOSURE TO COLD OCCURRING
MOSTLY IN YOUNG WOMEN. IT IS
THOUGHT TO BE DUE TO ARTERIOLAR
SPASM WITH DILATATION OF VENULES IN
THE SKIN. IT MAY COEXIST WITH
RAYNAUD’S PHENOMENON.

• WHEN THE HAND OR FOOT IS WARM, THE
SKIN BECOMES BRIGHT PINK.
ACROCYANOSIS MAY ALSO BE SEEN IN
ELDERLY PATIENTS WITH CARDIAC
DISEASE AND IN NEUROLOGICAL
DISORDERS SUCH AS STROKE,
POLIOMYELITIS AND MULTIPLE
SCLEROSIS. TREATMENT – LIMBS MUST
BE KEPT WARM. SYMPATHECTOMY MAY
BE NECESSARY IN PATIENTS WITH
SEVERE COLDNESS AND CHILBLAINS

• LIVEDO RETICULARIS – OCCURS USUALLY IN
YOUNG WOMEN. THERE IS BLOTCHY
MOTTLING AND DISCOLOURATION OF FEET
AND LEGS. IT IS LIKELY TO BE DUE TO
PATCHY ARTERIOLAR VASOSPASM IN THE
SKIN. A SECONDARY FORM MAY OCCUR IN
PATIENTS WITH POLYARTERITIS NODOSA OR
POLYCYTHAEMIA VERA. IT IS AS A RULE
LOCALISED TO DIGITS OR FEET AND THE
CONDITION MAY PROGRESS TO GANGRENE.

Peripheral arterial Disease (PAD)

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