Robert Hinchliffe Rachael Forsythe Jan Apelqvist Ed Boyko Robert Fitridge Joon Pio Hong

1. Robert Hinchliffe RachaelForsythe Jan Apelqvist Ed Boyko Robert Fitridge Joon Pio Hong Konstantinos Katsanos Joseph Mills Sigrid Nikol Jim Reekers MaaritVenermo Eugene Zierler Nicolaas Schaper www.iwgdfguidelines.org

2. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Peripheral artery disease Any atherosclerotic arterial occlusive disease below the inguinal ligament, resulting in a reduction in blood flow to the lower extremity Diagnosis Prognosis Treatment

3. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Focus of PAD guidelines • Patients with ulceration (highest risk) • Patient Intervention Comparator Outcome • Recommendation

4. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Do we need specific PAD guidelines in people with diabetes?

5. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org • Common in DFU (50%) • Poor prognosis (wound, limb, patient) • Managed by non-vascular specialists (variation) • PAD is a spectrum of disease • Weak evidence to underpin clinical practice (No RCTs) • PAD vascular guidelines – no diabetes focus

6. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Fundamental questions PAD?

7. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Fundamental questions PAD? Who revascularise?

8. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Fundamental questions PAD? Who revascularise? When?

9. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Fundamental questions PAD? Who revascularise? When? How?

10. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Guidelines for clinical practice Relevant to generalist and specialist • Variation in severity / mode of presentation • Variation in distribution of PAD • Variation in fitness of patients • Revascularisation is beneficial & potentially harmful

11. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Guidelines for clinical practice Diagnosis (1-3) • Clinical exam • Non-invasive tests Prognosis (4-9) • Non-invasive tests • Classification • Decision making Treatment (10-17) • Vascular imaging • Revasc technique • Organisation • General principles

12. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Diagnosis (excluding PAD) • Clinical examination unreliable • Pedal Doppler waveforms + ankle pressure / ABI or toe pressure / TBI measurement. • No single modality / threshold optimal • Triphasic pedal Doppler waveforms • Toe brachial index ≥0.75. • ABI 0.9-1.3 (Strong; Low)

13. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Prognosis (classification) • Use the WIfI classification system - Wound - Ischaemia - foot Infection • stratify amputation risk • revascularisation benefit (Strong; Moderate)

14. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Prognosis (be prepared to change strategy) Despite optimal wound and medical care • Ulcer not healing in 4-6 weeks → vascular imaging (Strong; Low) • PAD + no healing in 4-6 weeks → revascularise(Strong; Low)

15. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Treatment • Aim - direct blood flow to ≥1 foot arteries preferably to anatomical region of ulcer post procedure → objective measurement of perfusion. (Strong; Low) • Revascularisation technique based on individual factors. (Strong; Low) • Patient access to expertise and facilities diagnosis PAD revascularisation (endovascular and bypass surgery). (Strong; Low)

16. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Future research priorities • Improve identificaiton of those who benefit from revascularisation • Role of novel methods of perfusion assessment? • Earlier revascularisation? • Angiosome concept • Venous arterialisation • Novel medical therapies

17. Slides courtesy IWGDF; available at: www.iwgdfguidelines.org Conclusions • Clinical examination is unreliable • Bedside tests helpful – limitations • Optimise other aspects of care • Revascularisation decisions complex (heal spontaneously) • Be prepared to change strategy if no improvement