Management of Diabetic Foot with Peripheral Arterial Disease

Immediate Assessment and Management

The American College of Cardiology recommends that patients with diabetic foot and PAD require immediate vascular assessment, prompt infection management with interdisciplinary team referral, and comprehensive preventive foot care including patient education, biannual clinical foot examinations, and appropriate footwear to prevent amputation 1, 2
Assess pedal pulses (dorsalis pedis and posterior tibial) at every visit, as the presence of both pulses generally excludes significant PAD 3
Obtain ankle-brachial index (ABI) and Doppler arterial waveforms in all patients with foot ulcers, and consider severe ischemia (ABI <0.5 or ankle pressure <50 mmHg) as an indication for urgent vascular imaging and revascularization 3
Maintain high index of suspicion for foot infection, as PAD plus infection confers nearly 3-fold higher amputation risk than either alone, and suspect infection if patient presents with local pain/tenderness, periwound erythema, edema, induration, purulent discharge, foul odor, visible bone, probe-to-bone positive, or systemic inflammatory signs 2, 4

Counsel all patients with PAD and diabetes about self-foot examination and healthy foot behaviors, including daily foot inspection, proper foot hygiene, and avoidance of barefoot walking 1, 2, 5
Perform biannual foot examination for patients with PAD and diabetes, and inspect feet at every visit for patients with evidence of sensory loss, prior ulceration, or amputation 2, 4, 5
Prescribe custom therapeutic footwear for high-risk patients with significant neuropathy, foot deformities, or previous amputation, and recommend loose-fitting shoes with roomy cotton socks and padded slippers to avoid pressure points 6, 7

Refer immediately to interdisciplinary care team for prompt diagnosis and treatment to avoid amputation when infection is present, and consider deep soft-tissue infection as an indication for prompt surgical drainage, followed by vascular imaging and expeditious revascularization 1, 2, 4
Revascularization (endovascular or surgical bypass) is recommended for patients with DFU and PAD, especially those with severe ischemia or non-healing wounds despite optimal management 3

Refer patients who smoke with history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or PAD to foot care specialists for ongoing preventive care and lifelong surveillance, and consider multidisciplinary approach for patients on dialysis, those with Charcot foot, or history of prior ulcers/amputation 5
Avoid attributing poor healing to "diabetic microangiopathy" and always assess for correctable vascular insufficiency, and be aware that patients with PAD and infection are at high risk for major amputation and require emergency treatment 3