The Role of Peripheral Arterial Disease in the Pathogenesis of Diabetic Foot Disease: When to Refer for Vascular Surgery

Robert J. Hinchliffe, MD, MRCS; William Jeffcoate, FRCP


Geriatrics and Aging. 2008;11(5):281-283. 

In This Article

Abstract and Introduction

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.

Ulceration of the foot in diabetes is a source of both considerable suffering to the patient and enormous costs to health care services. There is little formal teaching of health care providers and often no clear pathway for specialist referral.[1] However, it is imperative that newly occurring ulcers be assessed as soon as possible by an expert, with the prime aims of determining the relative contributions made by infection, neuropathy, and peripheral arterial disease (PAD) and instituting appropriate treatment. The need for such early referral is emphasized in the United Kingdom by the National Institute for Health and Clinical Excellence (NICE) guidelines.[2]

Both peripheral neuropathy and PAD predispose to the development of ulcers and to their slow healing. Neuropathy inhibits healing partly by increasing forces on certain parts of the foot while walking (as a result of motor neuropathy and wasting of the small muscles of the foot) and by a loss of protective behaviour (as a result of reduced sensation). Peripheral arterial disease inhibits healing though its impact on local blood flow and a disruption of the processes needed for re-epithelialization. When an ischemic foot becomes infected, gangrene can follow: the local inflammatory reaction leads to thrombosis of arteries that are already narrowed by disease. It follows that the early expert assessment focuses on the assessment of the presence and extent of any PAD that might be present, and on whether the patient should undergo investigations to determine if revascularization (by angioplasty or bypass surgery) should be considered and, if so, how soon. It is vital that the generalist be able to the recognize symptoms and signs of critical limb ischemia and use these to expedite referral to a specialist unit.


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