1. Konstantinos Katsanos Joseph Mills Sigrid Nikol Jim Reekers
Robert Hinchliffe
Rachael Forsythe
Jan Apelqvist
Ed Boyko
Robert Fitridge
Joon Pio Hong
Konstantinos Katsanos
Joseph Mills
Sigrid Nikol
Jim Reekers
Maarit Venermo
Eugene Zierler
Nicolaas Schaper

2. Peripheral artery disease
Slides courtesy IWGDF; available at:
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
Definition of PAD from 2012 guidance

3. Focus of PAD guidelines
Slides courtesy IWGDF; available at:
Focus of PAD guidelines
Patients with ulceration (highest risk)
Patient Intervention Comparator Outcome
Recommendation
What outcomes did we select and why?

4. Do we need specific PAD guidelines in people with diabetes?
Slides courtesy IWGDF; available at:
Do we need specific PAD guidelines in people with diabetes?
Associated with poor outcomes both in terms of wound healing (failure), salvage of the limb and prevention of amputation but also in terms of overall patient prognosis and mortality both all-cause and CV related
There is a real variation in the management – in part because to depends who you ask but also because we have a host of different specialists managing these patients – angiologists, surgeons, radiologists, cardiologists
One of the key problems is that they are often managed by non-vascular specialists at least initially who may not be expert or comfortable either having access to the necessary investigative modalities or interpreting their outcomes
The other fundamental problem is that there really is a lack of evidence with few high quality RCTs to influence clinical practice – and those that do exist are in a mixed population of people wit and without diabetes and hence the guidelines that do exist are really not focussed on people with diabetes but the generality of the population of PAD – and why is that important – principally because this population of patients are quite different to the general PAD population

5. Poor prognosis (wound, limb, patient)
Slides courtesy IWGDF; available at:
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
Associated with poor outcomes both in terms of wound healing (failure), salvage of the limb and prevention of amputation but also in terms of overall patient prognosis and mortality both all-cause and CV related
There is a real variation in the management – in part because to depends who you ask but also because we have a host of different specialists managing these patients – angiologists, surgeons, radiologists, cardiologists
One of the key problems is that they are often managed by non-vascular specialists at least initially who may not be expert or comfortable either having access to the necessary investigative modalities or interpreting their outcomes
The other fundamental problem is that there really is a lack of evidence with few high quality RCTs to influence clinical practice – and those that do exist are in a mixed population of people wit and without diabetes and hence the guidelines that do exist are really not focussed on people with diabetes but the generality of the population of PAD – and why is that important – principally because this population of patients are quite different to the general PAD population

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

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

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

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

10. Guidelines for clinical practice
Slides courtesy IWGDF; available at:
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
Focus is on the generalist – why – they see far more patient with PAD than a so called specialist – and specialist soften carry on and do what they want anyway – even thought it is incorrect
But you are going to need some specialist kit I am afraid to treat these patients effectively – inspection, palpation, percussion and auscultation are not going to be enough………….

11. Guidelines for clinical practice
Slides courtesy IWGDF; available at:
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
1 more than the guidance document published in 2015/6
So – what has changed since 2015/6? There are no new RCTs in the field – so guidance base don solid principles and largely uncontrolled observational data
In essence we have 1 more guideline – we have made some minor adaptations for the sake of clarity or where the evidence has changed as a result of contemporary publications or where we have received feedback requesting change.
The major change is the adoption of WIFI system to help inform the decision to revascularise

12. Diagnosis (excluding PAD)
Slides courtesy IWGDF; available at:
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 (Strong; Low)
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?

13. Prognosis (classification)
Slides courtesy IWGDF; available at:
Prognosis (classification)
Use the WIfI classification system
- Wound
- Ischaemia
- foot Infection
stratify amputation risk
revascularisation benefit
(Strong; Moderate)
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?

14. Prognosis (be prepared to change strategy)
Slides courtesy IWGDF; available at:
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)
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?

15. Treatment Aim - direct blood flow to ≥1 foot arteries
Slides courtesy IWGDF; available at:
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)
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?

16. Future research priorities
Slides courtesy IWGDF; available at:
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
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?

17. Conclusions Clinical examination is unreliable
Slides courtesy IWGDF; available at:
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
Better identify patients who do well or poorly with standard approaches
Is there any evidence that earlier intervention improves outcomes
Do some of the novel approaches and therapies do any better?