Peripheral arterial disease (PAD) is one of the most powerful — and most under-recognized — drivers of poor outcomes in the diabetic foot. It is present in roughly half of people with a diabetic foot ulcer, and when ischemia coexists with neuropathy, the calculus of healing, infection control, and limb preservation changes profoundly. The 2023 intersocietal guideline from the International Working Group on the Diabetic Foot (IWGDF), the European Society for Vascular Surgery (ESVS), and the Society for Vascular Surgery (SVS) brought the diagnostic and treatment recommendations for diabetes-related PAD into a single, evidence-graded document for the first time (Fitridge et al., 2024). This article summarizes the key clinical concepts that document advances.
Why PAD Behaves Differently in Diabetes
Atherosclerotic disease in people with diabetes tends to be more distal, more diffuse, and more heavily calcified than in patients without diabetes. The infrapopliteal (below-the-knee) arteries are frequently the dominant site of obstruction, and medial arterial calcification can falsely elevate ankle-brachial index (ABI) measurements, masking significant ischemia. Compounding this, neuropathy blunts the ischemic pain that would otherwise prompt earlier presentation, so many patients first encounter the vascular system only after an ulcer or gangrene has developed. The intersocietal guideline emphasizes that any non-healing foot wound in a person with diabetes warrants a deliberate vascular assessment, regardless of palpable pulses (Fitridge et al., 2024).
Diagnosis: Moving Beyond the Ankle-Brachial Index
The 2023 guideline retains ABI as an initial screen but stresses its limitations in diabetes. When arteries are incompressible (ABI ≥ 1.3) or when clinical suspicion is high despite a normal ABI, additional modalities are recommended. Toe pressures and toe-brachial index (TBI < 0.70 considered abnormal) are less affected by medial calcification and are often more reliable in this population. Transcutaneous oxygen pressure (TcPO₂) and skin perfusion pressure provide quantitative data on tissue-level perfusion that correlate with ulcer healing probability. For patients in whom revascularization is being considered, anatomic imaging — duplex ultrasonography, CT angiography, MR angiography, or digital subtraction angiography — is used to plan the procedure (Fitridge et al., 2024).
Risk Stratification with WIfI
The Society for Vascular Surgery’s Wound, Ischemia, and foot Infection (WIfI) classification has become the dominant risk-stratification tool for the threatened limb. Each of the three domains — wound size and depth, degree of ischemia, and severity of infection — is graded from 0 to 3, and the composite score maps to one of four clinical stages. Pooled data summarized in the intersocietal guideline place the one-year major amputation risk at approximately 0% for stage 1, 8% for stage 2, 11% for stage 3, and 38% for stage 4 following revascularization (Fitridge et al., 2024). WIfI staging also helps identify which patients are most likely to benefit from revascularization and which may achieve healing with optimized medical and wound care alone (Mills et al., 2014; Brahmbhatt et al., 2024).
Revascularization: When, How, and What to Expect
The 2023 guideline advises prompt vascular consultation for any patient with diabetes and a foot ulcer whose objective testing suggests inadequate perfusion to support healing — generally a toe pressure below approximately 30 mmHg, a TcPO₂ below approximately 25 mmHg, or an ABI below 0.5 with corroborating findings. The therapeutic goal is restoration of in-line, pulsatile flow to at least one patent foot artery; whenever feasible, the artery supplying the angiosome of the wound is targeted, although the priority remains achieving any direct flow to the foot.
Both endovascular and open surgical revascularization are supported, with choice individualized by anatomy, conduit availability, comorbidities, and local expertise. The guideline does not endorse one modality as universally superior; instead, it recommends a multidisciplinary, patient-centred decision process. After revascularization, perfusion should be objectively reassessed — a normal post-procedure pulse exam alone is insufficient evidence of adequate tissue-level flow (Fitridge et al., 2024).
Medical Therapy and Risk Factor Modification
Revascularization addresses local perfusion but does not modify the systemic atherosclerotic disease that produced it. Antiplatelet therapy, high-intensity statin therapy, optimized glycemic and blood pressure control, and complete tobacco cessation are recommended for essentially every patient with diabetes and PAD (Fitridge et al., 2024). Supervised exercise therapy improves walking distance and quality of life in patients with intermittent claudication, although its role in patients with active ulceration is more limited. The IWGDF prevention guideline reinforces that PAD is a long-term, progressive condition requiring continued surveillance after the index wound has healed (Bus et al., 2024).
Clinical Summary
PAD is common, frequently silent, and a major determinant of healing and amputation outcomes in the diabetic foot. Any non-healing wound in a person with diabetes should trigger structured vascular assessment that goes beyond pulse palpation and unadjusted ABI. The WIfI classification provides a reproducible framework for estimating amputation risk and for identifying patients most likely to benefit from revascularization. When revascularization is indicated, the goal is restoration of in-line flow to the foot, with objective post-procedure confirmation of adequate perfusion. Underpinning all of this is comprehensive cardiovascular risk-factor modification, because the systemic disease that threatened the limb also threatens the heart and the brain.
References
Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, et al. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. Diabetes/Metabolism Research and Reviews. 2024;40(3):e3686.
Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). Journal of Vascular Surgery. 2014;59(1):220–234.e2.
Bus SA, Sacco ICN, Monteiro-Soares M, Raspovic A, Paton J, Rasmussen A, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
Brahmbhatt R, Brewster LP. A review of WIfI clinical staging to predict outcomes in patients with threatened limbs. Seminars in Vascular Surgery. 2024.
Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
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