Referral for Peripheral Vascular Disease
Patients with peripheral vascular disease (PVD) and multiple atherosclerotic risk factors should be referred to a vascular specialist—specifically a vascular surgeon, vascular medicine physician, interventional cardiologist, or interventional radiologist with expertise in endovascular and surgical revascularization. 1
When to Refer Immediately
Critical limb ischemia (CLI) requires expedited referral within 24 hours to a vascular specialist competent in revascularization: 1, 2
- Ischemic rest pain in the foot or leg
- Non-healing wounds or ulcerations with skin breakdown 1
- Ankle-brachial index (ABI) <0.4, especially in diabetic patients 1
- Signs of tissue loss, gangrene, or infection 1, 2
- Acute limb ischemia with the "6 Ps": pulselessness, pallor, paresthesias, paralysis, pain, and coolness 3
Patients with diabetes, neuropathy, chronic renal failure, or infection who develop acute limb symptoms represent vascular emergencies and must be assessed immediately by a vascular specialist. 1
When to Refer for Elective Evaluation
Lifestyle-limiting claudication warrants referral to a vascular specialist when: 1, 4, 5
- Supervised exercise therapy (3 times weekly for ≥12 weeks) has failed 1, 3
- Pharmacotherapy with cilostazol has been inadequate 4, 6
- The patient has significant disability affecting work or important activities 1
- Comprehensive risk factor modification (antiplatelet therapy, statins, blood pressure control, smoking cessation) has been optimized but symptoms persist 1
The vascular specialist should confirm that lesion anatomy suggests low-risk revascularization with high probability of success before proceeding. 1
Multidisciplinary Team Composition
The interdisciplinary care team for PVD should include: 1, 7
- Vascular specialists (vascular surgery, vascular medicine, interventional radiology, interventional cardiology) for revascularization decisions 1
- Podiatrists or orthopedic surgeons for foot surgery and wound debridement 1
- Wound care specialists for patients with CLI and skin breakdown 1, 2
- Endocrinologists for diabetic patients requiring intensive glycemic control 1, 7
- Infectious disease specialists when limb infection is present 1
Ongoing Surveillance After Treatment
Patients successfully treated for CLI require follow-up at least twice annually by a vascular specialist due to high recurrence rates (approximately 30% within 1 year). 1, 2 At each visit:
- Remove shoes and socks for direct foot examination 1, 2
- Assess for new ulcerations, color changes, temperature changes, or trophic skin changes 1, 8
- Measure resting ABI and perform duplex ultrasound for bypass graft surveillance 2
- Provide written instructions on self-surveillance for recurrence 1
Critical Pitfalls to Avoid
Do not delay referral for "medical optimization" in patients with CLI—these patients require expedited evaluation and treatment within 24 hours to prevent amputation. 2 The combination of diabetes, hypertension, smoking history, and hyperlipidemia places this patient at extremely high amputation risk without prompt revascularization. 2
Do not assume absence of pain means absence of severe disease in diabetic patients—neuropathy masks ischemic pain, and these patients may present with advanced tissue loss without typical claudication symptoms. 8, 3, 2
Approximately 40% of PAD patients have no leg symptoms, so referral decisions should be based on objective testing (ABI, pulse examination, skin findings) rather than symptoms alone. 8, 5
Recognize that PAD patients have 50% mortality at 5 years due to coexistent coronary and cerebrovascular disease—cardiovascular ischemic events are more frequent than limb events in any PAD cohort. 1, 8, 2 All patients require aggressive cardiovascular risk modification regardless of symptom severity. 8, 2