Peripheral Arterial Disease Treatment in Mumbai

Our approach in managing Peripheral Arterial Disease

Our PAD management programme at Shree Hospitals integrates vascular risk factor modification, accurate arterial imaging, catheter-based revascularisation for appropriate disease patterns, wound care for ischaemic tissue loss, and long-term surveillance to maintain arterial patency. Limb salvage  preventing amputation  is the primary goal in critical limb-threatening ischaemia; improving walking distance and quality of life is the primary goal in claudication.

Step 1 — Ankle-Brachial Index and Non-Invasive Assessment

The ankle-brachial index (ABI)  the ratio of systolic blood pressure measured at the ankle to that measured at the brachial artery  is the primary non-invasive screening test for PAD. An ABI below 0.9 diagnoses PAD with 95% sensitivity and specificity. An ABI of 0.7–0.9 indicates mild-to-moderate PAD. An ABI below 0.4 indicates severe PAD consistent with critical limb ischaemia. ABI above 1.4 in diabetic patients suggests arterial calcification making the vessels non-compressible  toe-brachial index (TBI, below 0.7 is abnormal) or toe pressure measurement is used in this population. Duplex ultrasound of the iliac, femoral, popliteal, and tibial arteries at Shree Hospitals characterises plaque morphology, stenosis severity, and flow velocities  providing the first-line vascular mapping that determines whether CT angiography (CTA) or magnetic resonance angiography (MRA) is required for pre-procedural planning.

Step 2 — CT Angiography and Arterial Disease Mapping

CTA of the aortoiliac, femoral, popliteal, and infrapopliteal tibial arteries provides the complete roadmap for revascularisation planning. At Shree Hospitals, CTA with 3D reconstruction maps the level, length, and morphology of each stenosis or occlusion, identifies collateral pathways, and determines the optimal catheter access site, the appropriate balloon and stent dimensions, and whether the disease pattern is best suited for angioplasty alone, drug-eluting balloon (DEB), primary stenting, or atherectomy. TASC II classification of iliac and femoral artery disease guides the choice between endovascular and surgical revascularisation , TASC A and B lesions are optimally managed endovascularly; TASC C and D complex long-segment occlusions may require surgical bypass in appropriate operative candidates. CTA simultaneously assesses coronary and carotid disease burden , PAD is a powerful predictor of concurrent atherosclerotic cardiovascular disease, and many PAD patients have unrecognised significant CAD.

Step 3 — Peripheral Angioplasty and Stenting

Peripheral angioplasty (percutaneous transluminal angioplasty, PTA) at Shree Hospitals is performed through a 4–6 French sheath inserted via the femoral, popliteal, or radial artery under local anaesthesia. Angiographic roadmap imaging identifies the target lesion; a guidewire is advanced across the stenosis or occlusion, and a balloon catheter is inflated to restore vessel lumen. Drug-eluting balloons (DEB)  coated with paclitaxel that elutes into the vessel wall during balloon inflation, inhibiting neointimal hyperplasia  are used for femoropopliteal lesions to reduce the 30–40% restenosis rate seen with conventional balloon alone. Stenting is used for flow-limiting dissection after balloon dilatation, elastic recoil, aortoiliac occlusive disease (TASC A–B iliac lesions: primary stenting is the standard), and in cases where angioplasty alone is insufficient. Self-expanding nitinol stents are preferred in the femoropopliteal segment due to their ability to conform to the repeated bending forces of the knee.

Step 4 — Below-the-Knee (BTK) Angioplasty for Critical Limb Ischaemia

Critical limb-threatening ischaemia in India most commonly involves the tibial arteries  the peroneal, anterior tibial, and posterior tibial arteries below the knee  particularly in diabetic patients with distal small-vessel disease. BTK angioplasty at Shree Hospitals restores direct arterial flow to the foot through technically demanding interventions on 2–4mm tibial arteries using dedicated coronary-technique equipment: 0.014-inch guidewires, 2–4mm diameter long balloon catheters, and drug-coated balloons for the tibial bed. The angiosome concept guides BTK revascularisation  targeting the specific tibial artery that directly perfuses the tissue area of ischaemia or wound  to maximise wound healing after revascularisation. Successful BTK angioplasty in CLTI achieves limb salvage in 70–80% of patients at 1 year.

Step 5 — Medical Optimisation and Long-Term Vascular Surveillance

Revascularisation without concurrent medical management of the atherosclerotic risk factors that caused PAD produces early restenosis and inadequate limb salvage outcomes. At Shree Hospitals, every PAD patient is discharged on a structured medical regimen: antiplatelet therapy (aspirin 75–100mg daily; clopidogrel 75mg daily after endovascular intervention, typically for 1–6 months depending on device used); high-intensity statin (atorvastatin 40–80mg) targeting LDL below 70 mg/dL — statin therapy independently reduces cardiovascular events and improves walking distance in PAD; smoking cessation support (tobacco smoking is the most powerful PAD risk factor); blood pressure control below 130/80 mmHg; and blood glucose optimisation in diabetics. Post-procedure duplex surveillance at 1, 3, 6, and 12 months identifies restenosis early  when it can be retreated with repeat angioplasty before recurrence of limb-threatening ischaemia. Supervised exercise rehabilitation  structured walking programmes with a physiotherapist  improves claudication walking distance by 100–150% in patients with stable claudication.