Management of Peripheral Arterial Disease in Diabetes-Related Foot Disease Clinical Practice Guidelines (DFA, 2022)

A new Australian guideline for diagnosis and management of peripheral arterial disease (PAD) in diabetes was published in July 2022 by the Australian Diabetes-Related Foot Disease Guidelines working group and an expert panel, with the authorization of Diabetes Feet Australia (DFA), in Journal of Foot and Ankle Research . Guideline recommendations were adopted or adapted from International Working Group on the Diabetic Foot (IWGDF) guidelines.

Diagnosis

Clinically examine (eg, by relevant history and palpation of foot pulses) the feet of all diabetic patients annually for PAD, even in the absence of foot ulceration. Clinically examine all diabetic patients with foot ulceration for PAD.

Because clinical examination does not reliably exclude PAD in most diabetic persons with foot ulceration, evaluate pedal Doppler arterial waveforms, and measure ankle systolic pressure and systolic ankle-brachial index (ABI) or toe systolic pressure and toe-brachial index (TBI).

Prognosis

Perform at least one of the following bedside tests in a patient with a diabetes-related foot ulcer (DFU) and PAD: skin perfusion pressure (≥40 mm Hg), toe pressure (≥30 mm Hg), or transcutaneous oxygen pressure (TcPO₂; ≥25 mm Hg).

Use the WIfI (Wound, Ischemia, foot Infection) classification to stratify amputation risk and revascularization benefit in a patient with a DFU and PAD.

Always consider urgent vascular imaging and revascularization in a patient with a DFU and ankle pressure < 50 mm Hg, ABI < 0.5, toe pressure < 30 mm Hg, or TcPO₂ < 25 mm Hg.

Always consider vascular imaging in patients with a DFU, regardless of bedside test results, when the ulcer is not healing within 4-6 weeks despite good care.

Always consider revascularization in a patient with a DFU and PAD, regardless of bedside test results, when the ulcer is not healing within 4-6 weeks despite optimal management.

Do not assume diabetes-related microangiopathy, when present, to be the cause of poor healing in patients with a DFU; always consider other possible causes.

Treatment

When considering lower-extremity revascularization, obtain anatomic information with color duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or intra-arterial digital subtraction angiography. Evaluate the entire lower-extremity arterial circulation.

When performing revascularization in a patient with a DFU, aim to restore direct blood flow to at least one of the foot arteries (preferably the one supplying the anatomic region of the ulcer). After the procedure, objectively measure perfusion to evaluate its effectiveness.

Because it has not been established whether endovascular, open, or hybrid revascularization technique is superior, base the decision on individual factors (eg, morphologic distribution of PAD or availability of autogenous vein).

Any center treating patients with a DFU should have expertise in and/or rapid access to facilities necessary to diagnose and treat PAD (including both endovascular techniques and bypass surgery).

After revascularization in a patient with a DFU, ensure that the patient is treated by a multidisciplinary team as part of a comprehensive care plan.

Urgently assess and treat patients with signs or symptoms of PAD and a diabetes-related foot infection.

Avoid revascularization if, from the patient’s perspective, the risk-benefit ratio is unfavorable.

Provide intensive cardiovascular risk management for any patient with diabetes and an ischemic foot ulcer.

For more information, please go to Peripheral Arterial Occlusive Disease and Diabetic Foot Ulcers.

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Cite this: Management of Peripheral Arterial Disease in Diabetes-Related Foot Disease Clinical Practice Guidelines (DFA, 2022) - Medscape - Aug 08, 2022.