Management of peripheral arterial occlusive disease in resource-limited settings: A narrative review

INTRODUCTION

Peripheral arterial occlusive disease (PAOD), also known as peripheral arterial disease (PAD), is characterised by progressive atherosclerotic narrowing of the peripheral arteries, most commonly involving the lower extremities. It is a clinical marker of systemic atherosclerosis and is strongly associated with coronary artery disease and cerebrovascular disease, conferring a high risk of major adverse cardiovascular events.^[1] While advances in pharmacotherapy and revascularisation have improved outcomes in high-resource settings, these benefits are not equitably distributed.

In resource-limited environments, structural and socioeconomic barriers impede early detection and optimal management. Consequently, patients often present with advanced disease such as critical limb ischemia (CLI), which is associated with high rates of amputation and mortality.^[2]Addressing PAOD in these settings requires context-sensitive strategies that prioritise affordability, accessibility, and scalability.

EPIDEMIOLOGY AND GLOBAL BURDEN

The global prevalence of PAOD exceeds 200 million individuals and continues to rise due to population ageing and the increasing prevalence of diabetes mellitus, hypertension, and tobacco use.^[3] Notably, the greatest relative increases have been observed in low- and middle-income countries, where rapid epidemiological transition has outpaced healthcare system capacity.

In resource-limited settings, the true burden of disease is likely underestimated because of inadequate screening and diagnostic capabilities. Many individuals remain asymptomatic or are misdiagnosed until they develop complications such as non-healing ulcers or gangrene. Late presentation is a consistent feature and is associated with worse limb and survival outcomes.^[4]

PATHOPHYSIOLOGY

PAOD results from a complex interplay of endothelial dysfunction, lipid accumulation, inflammation, and thrombosis, leading to atherosclerotic plaque formation and arterial stenosis. Progressive luminal narrowing reduces perfusion to distal tissues, particularly during exertion, resulting in ischemic symptoms. Over time, collateral circulation may develop but is often insufficient to meet metabolic demands.

At advanced stages, critical reductions in blood flow lead to rest pain, tissue necrosis, and gangrene. Inflammatory pathways and prothrombotic states further exacerbate disease progression and increase the risk of acute limb ischemia. These processes are often accelerated in patients with diabetes and chronic kidney disease.^[5]

RISK FACTORS

The principal risk factors for PAOD include diabetes mellitus, tobacco use, hypertension, dyslipidaemia, and advanced age. In resource-limited settings, these risk factors are frequently poorly controlled due to limited access to preventive healthcare services and medications. Tobacco use remains particularly prevalent in many rural communities, and diabetes is often undiagnosed or inadequately managed [Table 1].

Compounding these issues are low levels of health literacy and limited awareness of vascular disease, which contribute to delayed health-seeking behaviour. Socioeconomic constraints and competing health priorities further hinder effective risk factor modification.^[6]

CHALLENGES IN RESOURCE-LIMITED SETTINGS

The management of PAOD in resource-constrained environments is complicated by multiple systemic and patient-level barriers. Diagnostic limitations are a major concern, as simple tools such as the ankle-brachial index (ABI) are not routinely available in many primary care settings. Even when equipment exists, a lack of trained personnel can limit its effective use.

Geographic and financial barriers significantly restrict access to healthcare facilities, particularly specialised vascular services. Patients may need to travel long distances to reach tertiary centres, incurring substantial out-of-pocket expenses. In addition, fragmented referral pathways often result in delays in receiving definitive care.

Cultural beliefs and reliance on traditional remedies can further delay presentation. As a result, many patients present with advanced disease requiring complex interventions that are often unavailable or unaffordable. Limited availability of revascularisation procedures and essential medications compounds the problem, leading to high rates of preventable amputations.^[7]

DIAGNOSIS

Accurate and timely diagnosis of PAOD is critical for preventing disease progression and complications. In resource-limited settings, clinical evaluation remains the cornerstone of diagnosis. A detailed history focusing on exertional leg pain, rest pain, and non-healing wounds, combined with physical examination findings such as diminished pulses and trophic skin changes, can provide valuable diagnostic clues [Table 2].

The ABI is a simple, non-invasive, and cost-effective diagnostic tool that can be implemented even in low-resource settings. An ABI value of less than 0.9 is indicative of PAOD and correlates with disease severity.^[7] Handheld Doppler devices, which are relatively affordable, can facilitate ABI measurement at the primary care level.

Advanced imaging modalities such as duplex ultrasonography, computed tomography angiography, and magnetic resonance angiography provide detailed anatomical information but are often limited to higher-level facilities. Establishing referral linkages for selected patients can optimise the use of these resources.

MANAGEMENT STRATEGIES

COST-EFFECTIVE STRATEGIES

Cost-effective approaches are essential for sustainable PAOD management in low-resource environments. The use of affordable diagnostic tools such as handheld Doppler devices enables early detection at the primary care level. Community screening programs integrated with existing non-communicable disease initiatives can increase case identification.

Training frontline healthcare workers in risk factor management, wound care, and patient education can significantly improve outcomes at minimal cost. Public health interventions targeting smoking cessation and diabetes control are also critical components of a comprehensive strategy.

ROLE OF PRIMARY CARE

Primary care systems play a pivotal role in addressing PAOD in resource-limited settings. Early detection, initiation of medical therapy, and ongoing risk factor management can all be effectively delivered at this level. Strengthening primary healthcare infrastructure, ensuring the availability of essential medications, and enhancing provider training are key priorities.

FUTURE DIRECTIONS

Future efforts should focus on developing low-cost diagnostic technologies and expanding telemedicine networks to improve access to care. Policy initiatives aimed at strengthening health systems and addressing social determinants of health are essential. Increased investment in rural healthcare infrastructure and workforce development will be critical for reducing disparities in PAOD outcomes.

CONCLUSION

Peripheral arterial occlusive disease represents a growing public health challenge in resource-limited settings. A pragmatic approach that emphasises prevention, early diagnosis, and cost-effective management strategies is essential. Strengthening primary care systems, improving access to essential services, and leveraging innovative solutions such as telemedicine can substantially improve patient outcomes and reduce the burden of disease.