Diabetic foot ulcers with a mixed arterial and venous component present a specific clinical dilemma. Venous hypertension drives oedema and delays healing, and compression is the best-supported treatment for venous ulceration, yet compression carries a theoretical risk of critical ischemia when arterial inflow is already compromised. Because diabetes independently increases the prevalence of both peripheral arterial disease (PAD) and chronic venous insufficiency, clinicians managing diabetic foot ulcers regularly encounter patients in whom neither “treat the vein” nor “treat the artery” alone is sufficient. Recent guideline updates and reviews have refined how ankle-brachial index (ABI) findings should guide, rather than automatically block, compression therapy in this population.
Why Mixed Disease Complicates the Standard Approach
Compression therapy is supported by strong evidence in isolated venous disease. A 2021 Cochrane systematic review of 14 randomized controlled trials (1,391 participants) found that compression nearly doubled the rate of healing compared with no compression, with a pooled hazard ratio of 2.17 for faster healing and 1.77 for complete healing within 12 months (Shi et al., Cochrane Database of Systematic Reviews, 2021). However, this evidence base is drawn overwhelmingly from patients with normal or near-normal arterial perfusion; trials of this kind routinely exclude people with an ABI below roughly 0.8, leaving a gap for the many diabetic patients whose ulcers arise from combined venous and arterial insufficiency.
Rethinking the Ankle-Brachial Index Threshold
A key source of confusion in practice has been treating the ABI cutoff used to diagnose PAD as if it were also the cutoff for compression safety. A 2026 analysis in Wounds UK makes the case that these are distinct thresholds that should not be conflated: an ABI in the 0.8–1.3 range is generally considered compatible with safe strong compression (up to 40 mmHg), while PAD diagnostic thresholds (≤0.9, with an upper limit of 1.4 under recent NICE guidance) serve a different clinical purpose (Atkin and Irvine, Wounds UK, 2026). The authors caution that applying revised PAD diagnostic thresholds directly to compression decisions can lead to unnecessary withholding of a beneficial therapy and prolonged ulcer duration.
The 2023 intersocietal guideline from the International Working Group on the Diabetic Foot, the European Society for Vascular Surgery, and the Society for Vascular Surgery reinforces the importance of formal vascular assessment — including ABI, toe pressures, and toe-brachial index where ABI is unreliable due to arterial calcification — before deciding on compression, offloading, or revascularization strategy in any diabetic patient with a foot ulcer (Fitridge et al., Journal of Vascular Surgery, 2023).
Modified Compression: What the Evidence Supports
Rather than an all-or-nothing decision between full compression and none, current literature increasingly supports graduated, modified regimens matched to arterial status. A 2021 integrative review in the International Wound Journal summarized available evidence on reduced-pressure compression (typically 20–30 mmHg rather than the 30–40 mmHg used for isolated venous disease) in patients with mixed arterial-venous ulcers and mild-to-moderate arterial compromise, reporting that carefully monitored modified compression can support healing without provoking ischemic complications when patients are followed closely.
A 2025 systematic review and meta-analysis in Phlebology examined outcome data across mixed arterial-venous ulcer studies stratified by arterial severity. In patients with moderate arterial disease (ABI 0.5–0.85) managed with modified compression and reserved for rescue revascularization if needed, pooled healing rates approached 75%, with only about one in four eventually requiring revascularization. By contrast, patients with severe arterial disease (ABI below 0.5) who underwent arterial intervention first had a substantially lower healing rate, around 40%, underscoring that arterial severity — not diabetes status alone — should drive the treatment sequence (Alagha et al., Phlebology, 2025). The authors noted the absence of randomized controlled trials in this specific population and called for better-quality prospective data.
Evidence specific to diabetes, while more limited, is reassuring for carefully selected patients. A small pilot study of diabetic patients with lower-extremity oedema and normal-range ABI values found that four weeks of mild compression (18–25 mmHg) significantly reduced calf and foot swelling without any reduction in ABI or adverse vascular events, and ABI values in fact rose slightly over the study period (Wu et al., Journal of Diabetes Science and Technology, 2012). An international consensus statement on the risks and contraindications of medical compression similarly concluded that most contraindications are relative rather than absolute, and that pressure level, bandage type, and monitoring frequency can be adjusted according to arterial status rather than defaulting to complete avoidance (Rabe et al., Phlebology, 2020).
Clinical Summary
The literature increasingly supports a stratified approach to compression in diabetic patients with mixed arterial-venous foot ulcers: formal vascular assessment with ABI, toe pressure, or toe-brachial index to characterize arterial status; avoidance of full-strength compression when severe arterial disease (ABI <0.5) is present until revascularization is considered; and cautious, closely monitored modified compression (generally 20–30 mmHg) for patients with mild-to-moderate arterial involvement whose venous disease is a significant driver of the ulcer. ABI thresholds used to diagnose PAD should not be applied interchangeably with those used to judge compression safety. Because high-quality randomized trial data in this specific population remain scarce, individualized, vascular-status-guided decision-making — rather than a uniform protocol — currently represents the best-supported approach.
References
- Fitridge R, Chuter V, Mills J, et al. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. Journal of Vascular Surgery. 2023.
- Shi C, Dumville JC, Cullum N, et al. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database of Systematic Reviews. 2021.
- Alagha M, Alagha A, Lowery A, Walsh SR. “Veins first” versus “artery first” approach for management of mixed arterial venous leg ulcers (MAVLU): Systematic review and meta-analysis. Phlebology. 2025;40(3):144-152.
- Rabe E, Partsch H, Morrison N, et al. Risks and contraindications of medical compression treatment — A critical reappraisal. An international consensus statement. Phlebology. 2020.
- Wu SC, Crews RT, Najafi B, Slone-Rivera N, Minder JL, Andersen CA. Safety and efficacy of mild compression (18-25 mmHg) therapy in patients with diabetes and lower extremity edema. Journal of Diabetes Science and Technology. 2012;6(3):641-647.
- Atkin L, Irvine C. Ankle-brachial pressure index thresholds in flux: Untangling peripheral arterial disease diagnosis from compression safety in clinical practice. Wounds UK. 2026;22(1).
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