Editor's Choice – The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer

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CLINICAL PRACTICE GUIDELINE DOCUMENT
The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease
in People With Diabetes Mellitus and a Foot Ulcer
Robert Fitridge
a,*
, Vivienne Chuter
b
, Joseph Mills
c
, Robert Hinchliffe
d
, Nobuyoshi Azuma
e
, Christian-Alexander Behrendt
f
, Edward J. Boyko
g
,
Michael S. Conte
h
, Misty Humphries
i
, Lee Kirksey
j
, Katharine C. McGinigle
k
, Sigrid Nikol
l
, Joakim Nordanstig
m
, Vincent Rowe
n
, David Russell
o
,
Jos C. van den Berg
p
, Maarit Venermo
q
, Nicolaas Schaper
r
a
Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia
b
School of Health Sciences, Western Sydney University, Campbelltown, Australia
c
Baylor College of Medicine, Houston, TX, USA
d
Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
e
Asahikawa Medical University, Hokkaido, Japan
f
Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
g
University of Washington, Seattle, WA, USA
h
University of California, San Francisco Medical Centre, CA, USA
i
UC Davis Medical Centre, Sacramento, CA, USA
j
The Cleveland Clinic, Cleveland, OH, USA
k
University of North-Carolina, Chapel Hill, NC, USA
l
Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
m
Sahlgrenska University Hospital, Gothenburg, Sweden
n
David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
o
Leeds Teaching Hospitals NHS Trust, Leeds, UK
p
CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie
Inselspital, Universitätsspital Bern Switzerland
q
Helsinki University Hospital, University of Helsinki, Helsinki, Finland
r
Division of Endocrinology, Dept. Internal Medicine, MUMCþ, The Netherlands
Abstract: Diabetes related foot complications have become a major cause of morbidity and are implicated in most
major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral
artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events.
The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the
management and prevention of diabetes related foot complications since 1999. This guideline is an update of the
2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with
diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular
Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of
recommendations relevant to clinicians in all countries.
This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment,
Development and Evaluation framework clinically relevant questions were formulated, and the literature was
systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated
which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability,
equity, resources required, and when available, costs.
Through this process five recommendations were developed for diagnosing PAD in a person with diabetes,
with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to
estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or
gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of
people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing
Committee has highlighted key research questions where current evidence is lacking.
The Writing Committee believes that following these recommendations will help healthcare professionals to
provide better care and will reduce the burden of diabetes related foot complications.
Keywords: Chronic limb threatening ischaemia, Critical limb ischaemia, Diabetes mellitus, Diabetes related foot ulcer, Endovascular intervention,
Peripheral artery disease
Available online XXX
ÓThe Author(s). Published by Elsevier Inc. on behalf of The Society for Vascular Surgery, Elsevier B.V on behalf of European Society for Vascular
Surgery and John Wiley & Sons Ltd.
* Corresponding author.
E-mail address: robert.fitridge@adelaide.edu.au (Robert Fitridge).
1078-5884/ÓThe Author(s). Published by Elsevier Inc. on behalf of The Society for Vascular Surgery, Elsevier B.V on behalf of European Society for Vascular
Surgery and John Wiley & Sons Ltd.
https://doi.org/10.1016/j.ejvs.2023.07.020
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020
Eur J Vasc Endovasc Surg (xxxx) xxx, xxx

TABLE OF CONTENTS
Abstract ................................................................ . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. .1
Abbreviations ............................................................ .. .. . . ... . ... . .. . . .. . . ... . ... . ... . ... . ... . ... . ... . ..2
List of Recommendations ........................................................ ... . ... . ... . ... . ... . ... . ... . ... . . .. . . .. . . .. . ...2
External experts, patient representatives and review process .......................................... .. . .. .. .. . .. .. . .. .. .. . .. .. . .. .. .. .5
Methodology ............................................................ .. .. . . ... . ... . .. . . .. . . ... . ... . ... . ... . ... . ... . ... . ..5
Target population and target audience . ................................................ .... . ... . ... . ... . ... . ... . ... . ... . ... . ... . ..6
Guideline writing group conflict of interest policy ............................................ .. ... . ... . . .. . ... . ... . ... . . .. . . .. . . .. . .7
Definitions and terminology as used in this document . . . ........................................ .. .. . . .. . . .. . . .. . . .. . . .. . . .. . . ... . .. .7
Introduction ............................................................ .. ... .. ... .. ... ... .. ... .. ... .... .. ... ... .. ... .. ... ...7
Diagnosis .............................................................. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. .8
Prognosis .............................................................. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. 11
Treatment .............................................................. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. 14
Future research priorities ...................................................... . ... . ... . ... . ... . . .. . ... . ... . . .. . . .. . . .. . . .. . . .25
Contribution of authors .......................................................... . ... . . .. . . .. . . .. . . .. . . .. . . .. . . .. . . .. . . .. . . .. .25
Acknowledgements . ........................................................ .. ... . ... . ... . ... . ... . ... . ... . . .. . . .. . ... . ... . . ..25
Supplementary data . ........................................................ ... . .. . . .. . . .. . . .. . . .. . . .. . . ... . ... . .. . . ... . ... . .25
References ............................................................. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. . .. . .. .. . .. .. 26
LIST OF RECOMMENDATIONS
ABBREVIATIONS
ABI Ankle brachial index
ADA American Diabetes Association
AP Ankle pressure
CDUS Colour Duplex ultrasound
CI Confidence interval
CLTI Chronic limb threatening ischaemia
COI Conflict of interest
CTA Computed tomography angiography
CWD Continuous wave Doppler
DFU Diabetes related foot ulcer
DSA Digital subtraction angiography
EAS European Atherosclerosis Society
EASD European Association for the Study of
Diabetes
eGRF Estimated glomerular filtration rate
ESC European Society of Cardiology
ESVM European Society of Vascular Medicine
ESVS European Society for Vascular Surgery
GLASS Global Limb Anatomic Staging System
GRADE Grading of Recommendations, Assessment,
Development and Evaluation
GVG Global Vascular Guidelines
HbA1c Haemoglobin A1c
IDSA Infectious Diseases Society of America
IWGDF International Working Group on the Diabetic
Foot
LDL Low density lipoproteins
MAC Medial arterial calcification
MACE Major adverse cardiovascular events
MALE Major adverse limb events
MRA Magnetic resonance angiography
NLR Negative likelihood ratio
PAD Peripheral artery disease
PICO Population, Intervention,Comparison, Outcome
PLR Positive likelihood ratio
SGLT-2 Sodiumeglucose cotransporter 2
SPP Skin perfusion pressure
SVS Society for Vascular Surgery
TBI Toe brachial index
TcPO
2
Transcutaneous oxygen pressure
TP Toe pressure
WIfI Wound/Ischaemia/foot Infection
WFVS World Federation of Vascular Societies
Summary of recommendations
Chapter Recommendation Grade Certainty of
evidence
Diagnosis 1. In a person with diabetes without a foot ulcer, take a relevant history for
peripheral artery disease, examine the foot for signs of ischaemia and
palpate the foot pulses at least annually, or with any change in clinical
status of the feet.
Strong Low
2Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

-continued
Chapter Recommendation Grade Certainty of
evidence
2. In a person with diabetes without a foot ulcer, if peripheral artery
disease (PAD) is suspected, consider performing pedal Doppler
waveforms in combination with ankle brachial index (ABI) and toe
brachial index (TBI). No single modality has been shown to be optimal
for the diagnosis of PAD and there is no value above which PAD can be
excluded. However, PAD is less likely in the presence of ABI 0.9 e1.3;
TBI 0.70; and triphasic or biphasic pedal Doppler waveforms.
Conditional Low
3. In a person with diabetes and a foot ulcer or gangrene, take a relevant
history for peripheral artery disease, examine the person for signs of
ischaemia and palpate the foot pulses.
Strong Low
4. In a person with diabetes and a foot ulcer or gangrene, evaluate pedal
Doppler waveforms in combination with ankle brachial index (ABI)
and toe brachial index (TBI) measurements to identify the presence of
peripheral artery disease (PAD).
No single modality has been shown to be optimal for the diagnosis of
PAD, and there is no value above which PAD can be excluded. However,
PAD is less likely in the presence of ABI 0.9 e1.3; TBI 0.70; and
triphasic or biphasic pedal Doppler waveforms.
Strong Low
5. In a person with diabetes without a foot ulcer in whom a non-
emergency invasive foot procedure is being considered, peripheral
artery disease should be excluded by performing assessment of pedal
Doppler waveforms in combination with ankle brachial index and toe
brachial index.
Best Practice Statement
Prognosis 6. In a person with diabetes and a foot ulcer or gangrene, consider
performing ankle pressures and ankle brachial index (ABI)
measurements to assist in the assessment of likelihood of healing and
amputation.
Ankle pressure and ABI are weak predictors of healing. A low ankle
pressure (e.g., <50 mmHg) or ABI (e.g., <0.5) may be associated with
a greater likelihood of impaired healing and greater likelihood of major
amputation.
Conditional Low
7. In a person with diabetes and a foot ulcer or gangrene, consider
performing a toe pressure measurement to assess likelihood of healing
and amputation.
A toe pressure 30 mmHg increases the pre-test probability of healing
by up to 30% and a value <30 mmHg increases the pre-test probability
of major amputation by approximately 20%.
Conditional Low
8. In a person with diabetes and a foot ulcer or gangrene, if a toe pressure
cannot be performed, consider performing a transcutaneous oxygen
pressure (TcPO
2
) measurement or a skin perfusion pressure (SPP) to
assess likelihood of healing.
A TcPO
2
25 mmHg increases the pre-test probability of healing by up
to 45% and value <25 mmHg increases the pre-test probability of
major amputation by approximately 20%. An SPP 40 mmHg increases
the pre-test probability of healing by up to 30%.
Conditional Low
9. In a person with diabetes and a foot ulcer or gangrene, it is suggested
that the presence of peripheral artery disease and other causes of
poor healing should always be assessed. Diabetes related micro-
angiopathy should not be considered the primary cause of foot
ulceration, gangrene, or poor wound healing without excluding other
causes.
Conditional Low
Continued
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 3
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

-continued
Chapter Recommendation Grade Certainty of
evidence
10. In a person with diabetes, peripheral artery disease and a foot ulcer or
gangrene, consider using the Wound/Ischaemia/foot Infection (WIfI)
classification system to estimate healing likelihood and amputation risk.
Conditional Low
Treatment 11. In a person with diabetes, peripheral artery disease, and a foot ulcer or
gangrene who is being considered for revascularisation, evaluate the
entire lower extremity arterial circulation (from aorta to foot) with
detailed visualisation of the below knee and pedal arteries.
Best Practice Statement
12. In a person with diabetes, peripheral artery disease, a foot ulcer, and
clinical findings of ischaemia, a revascularisation procedure should
be considered. Findings of ischaemia include absent pulses,
monophasic or absent pedal Doppler waveforms, ankle pressure <100
mmHg or toe pressure <60 mmHg. Consult a vascular specialist unless
major amputation is considered medically urgent.
Best Practice Statement
13. In a person with diabetes, peripheral artery disease, a foot ulcer, and
severe ischaemia i.e., an ankle brachial index <0.4, ankle pressure
<50 mmHg, toe pressure <30 mmHg or transcutaneous oxygen
pressure <30 mmHg or monophasic or absent pedal Doppler
waveforms, urgently consult a vascular specialist regarding possible
revascularisation.
Best Practice Statement
14. In a person with diabetes, peripheral artery disease, and a foot ulcer
with infection or gangrene involving any portion of the foot,
urgently consult a vascular specialist in order to determine the timing
of a drainage procedure and a revascularisation procedure.
Best Practice Statement
15. In a person with diabetes and a foot ulcer, when the wound
deteriorates or fails to significantly improve (e.g., a less than 50%
reduction in wound area within four weeks) despite appropriate
infection and glucose control, wound care, and offloading, reassess the
vascular status and consult with a vascular specialist regarding
possible revascularisation.
Best Practice Statement
16. In a person with diabetes, peripheral artery disease, and a foot ulcer or
gangrene, avoid revascularisation when the riskebenefit ratio for the
probability of success of the intervention is clearly unfavourable.
Best Practice Statement
17. In a person with diabetes, peripheral artery disease, and a foot ulcer or
gangrene who has an adequate single segment saphenous vein in
whom infrainguinal revascularisation is indicated and who is suitable
for either approach, consider bypass in preference to endovascular
therapy.
Conditional Moderate
18. A person with diabetes, peripheral artery disease (PAD), and a foot
ulcer or gangrene, should be treated in a centre with expertise in, or
rapid access to, endovascular and surgical bypass revascularisation. In
this setting, consider making treatment decisions based on the risk to
and preference of the individual, limb threat severity, anatomical
distribution of PAD, and the availability of autogenous vein.
Best Practice Statement
19. In a person with diabetes, peripheral artery disease, and a foot ulcer or
gangrene, revascularisation procedures should aim to restore in line
blood flow to at least one of the foot arteries.
Best Practice Statement
20. In a person with diabetes, peripheral artery disease, and a foot ulcer or
gangrene undergoing an endovascular procedure, consider targeting
the artery on angiography that supplies the anatomical region of the
ulcer, when possible or practical.
Conditional Very low
4Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

EXTERNAL EXPERTS, PATIENT REPRESENTATIVES AND
REVIEW PROCESS
The review process had several steps, in which six external
experts, four patient representatives, and guideline reviewers
of the International Working Group on the Diabetic Foot
(IWGDF), European Society for Vascular Surgery (ESVS), and
Society for Vascular Surgery (SVS) were involved. The external
experts and patient representatives were from various coun-
tries and continents (Singapore, Japan, South Africa, China,
Hong Kong, Colombia, Bulgaria, Australia, England, the USA).
The process started with review of the clinical questions that
the Writing Committee proposed to address, which were
subsequently adjusted, and which formed the basis of the
guideline development. The first preliminary version of the
guideline was reviewed by the IWGDF, ESVS, and members of
the SVS Document Oversight Committee. The revised text was
then reviewed by the external experts and patient represen-
tatives, and subsequently a new version was submitted for
review to the three organisations.The Writing Committee met
for the firsttimeinlate2020andthefirst draft of the guideline
was sent out for review in December 2022.
METHODOLOGY
This guideline is also part of a set of guidelines (and their
supporting systematic reviews) of the IWGDF on the man-
agement of diabetes related foot ulcers, which all used the
same Grading of Recommendations, Assessment, Develop-
ment and Evaluation (GRADE) methodology. These guide-
lines address the other aspects of management and are
published separately. The IWGDF editorial board had the
task of ensuring that there would not be too much overlap
between these documents and that they were consistent
with each other. The ESVS and SVS Executive Board agreed
with this approach. The methodology used is described in
detail in a separate IWGDF document (https://doi.org/10.
1002/dmrr.3656); here a summary is provided.
1
In brief, the GRADE system was followed.
2,3
GRADE is
structured by the development of clinical questions and
-continued
Chapter Recommendation Grade Certainty of
evidence
21. In a person with diabetes and either a foot ulcer or gangrene who has
undergone revascularisation, objectively assess adequacy of perfusion
e.g., using non-invasive bedside testing.
Best Practice Statement
22. A person with diabetes, peripheral artery disease, and either a foot
ulcer or gangrene should be treated by a multidisciplinary team as
part of a comprehensive care plan.
Best Practice Statement
23. In a person with diabetes and peripheral artery disease the following
target levels should be:
HbA1c <8% (<64 mmol/mol), but higher target HbA1c value may
be necessary depending on the risk of severe hypoglycaemia.
Blood pressure <140/ 90 mmHg but higher target levels may be
necessary depending on the risk of orthostatic hypotension and other
side effects.
Low density lipoprotein target of <1.8 mmol/L (<70 mg/dL) and
reduced by at least 50% of baseline. If high intensity statin therapy
(with or without ezetimibe) is tolerated, target levels <1.4 mmol/L
(55 mg/dL) are recommended.
Best Practice Statement
24. In a person with diabetes and symptomatic peripheral artery disease:
treatment with single antiplatelet therapy should be used,
treatment with clopidogrel should be considered as first choice in
preference to aspirin,
combination therapy with aspirin (75 mg to 100 mg once daily) plus
low dose rivaroxaban (2.5 mg twice daily) should be considered for
people without a high bleeding risk.
Best Practice Statement
25. In a person with type 2 diabetes and peripheral artery disease:
with an eGFR >30 mL/min/1.73m
2
, a sodium glucose cotransporter-
2 (SGLT-2) inhibitor or a glucagon like peptide 1 receptor agonist
with demonstrated cardiovascular disease benefit should be
considered, irrespective of the blood glucose level.
SGLT-2 inhibitors should not be started in drug naïve people with a
diabetes related foot ulcer or gangrene and temporary
discontinuation should be considered in people already using these
drugs, until the affected foot is healed.
Best Practice Statement
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 5
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

selection of critical outcomes, which are subsequently trans-
lated in the PICO (Population, Intervention, Comparison,
Outcome) format. The Writing Committee developed the
clinical questions to be investigated after consultation with the
external experts and patient representatives. Critically
important outcomes for clinical questions were voted upon by
the Writing Committee members. Subsequently, the PICOs
were created and voted on for inclusion by Writing Committee
members.The PICOs to be included were then reviewed by the
external experts, patient representatives, and the guideline
committee of the societies involved.The systematic reviews of
the literature to address the clinical questions were performed
according to the preferred reporting items for systematic re-
views and meta-analyses (PRISMA) guideline.
4
The process of
identifying and evaluating the available evidence, with its
main conclusions, resulted in three systematic reviews on
Diagnosis, on Prognosis, and on Management of Peripheral
Arterial Disease in Diabetes Mellitus.These systematic reviews
are published separately (https://doi.org/10.1002/dmrr.3683,
https://doi.org/10.1002/dmrr.3701,https://doi.org/10.1002/
dmrr.3700).
5-7
The population of interest was people with
diabetes mellitus (with or without a foot ulcer or gangrene,
depending on the clinical question). For diagnosis, the inter-
vention was any non-invasive bedside testand the comparator
an objective imaging study; for prognosis the intervention was
any non-invasive bedside test and for treatment the in-
terventions were bypass (open) and direct revascularisation
and the comparators endovascular and indirect revascular-
isation, respectively. The primary outcomes were wound
healing, minor and major amputation and adverse events,
limb salvage, and wound healing. After the literature search all
abstracts and subsequently selected articles were reviewed by
two authors, as described in the systematic reviews. Included
studies had at least 80% of participants with diabetes or in
which the results of the participants with diabetes were re-
ported separately. All included studies were assessed for
quality and risk of bias with the following instruments,
depending on the type of study: Quality in Prognosis Studies,
the revised quality appraisal tool for studies of diagnostic
reliability, ROBINS-I (for assessing risk of bias in non-
randomised studies of interventions), the Newcastle-Ottawa
Scale (for non-randomised studies, including observational
and cohort studies where details regarding allocation to
intervention groups was not provided), and the Cochrane risk
of bias 2 tool for randomised controlled trials.
8e13
For each
PICO the quality of evidence was graded for risk of bias,
inconsistency, imprecision, publication bias, and overall qual-
ity. The certainty of the evidence was then rated as high,
moderate, low, or very low.
The GRADE evidence to decision approach was subse-
quently used for the development of the recommendations
during online discussions of the Writing Committee (which
were all recorded and available for later review from the
Secretary). In developing each recommendation and its
strength the following aspects were taken into account:
benefits, harms, effect size, and certainty; balance of benefits
and harms; resource use; acceptability; feasibility; equity.The
strength of each recommendation was graded as Strong or
Conditional. All Writing Committee members voted on each
recommendation. For a Strong Recommendation at least 75%
and for a Conditional Recommendation at least 60% had to
agree. After each recommendation, a rationale is provided for
how each recommendation was determined.
1,14
There were situations where sufficient direct evidence
supporting the formulation of a recommendation could not be
identified, but performing the actions recommended would
very likely result in clear benefit, or not performing the test or
intervention in marked harm. In these situations, an ungraded
Best Practice Statement was formulated with a rationale
explaining how the statement was arrived at and how GRADE
criteria for developing such a statement were considered, as
advised in a recent publication of the GRADE group on this
topic.
15
According to GRADE, such recommendations should
be formulated as actionable statements when they are
deemed necessary for practice and when the desirable effects
of an intervention clearly outweigh its undesirable effects.
Although in these cases direct evidence is lacking, they should
be supported byindirect evidence. For the clinical question on
the use of current medical therapies to reduce cardiovascular
risk or lower limb events in people with diabetes and symp-
tomatic peripheral artery disease (PAD), the authors did not
perform a systematic review or develop graded recommen-
dations, as recent high quality guidelines on these topics
already exist.
16e23
However, to give the reader a complete
overview a summary of these existing guidelines was created,
where relevant for the clinical question, and adapted to the
person with diabetes mellitus and symptomatic PAD. These
recommendations were also formulated as Best Practice State-
ments. It is acknowledged that for certain recommendations
high quality evidence exists, as summarised in other guidelines
of organisations such as ESVS, SVS and American Diabetes As-
sociation, but for others there is only lesser quality evidence. In
order not to repeat all these evidence based guidelines already
developed by other relevant organisations, ungraded Best
Practice Statements were made, with references provided to the
relevant guidelines. Finally, the Writing Committee considered
topics for future research and voted to focus on five key topics,
whicharediscussedattheendoftheguideline.
The recommendations and corresponding rationales
were reviewed by the same international external experts
and committees responsible for guideline development of
the three aforementioned societies. Further details are
provided in the IWGDF guidelines methodology document.
1
The summary of judgements tables that were the basis for
formulating each recommendation and Best Practice
Statement, can be found in the Supplementary material
for this article. These systematic reviews provide the evi-
dence for the graded recommendations made in this
guideline.
TARGET POPULATION AND TARGET AUDIENCE
Poorly healing foot ulcers or gangrene in people with dia-
betes mellitus are frequently caused by several factors
acting in concert. The primary target population of this
guideline is people with diabetes mellitus with a foot ulcer
or gangrene on any portion of the foot (with or without
6Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

neuropathy) in whom the presence of PAD could have
contributed to the development of the ulcer and or its poor
healing potential. The secondary target group is people with
diabetes mellitus in whom the presence of PAD was
considered or needed to be excluded. People with pure
venous ulcers, ulcers above the ankle, acute limb ischaemia,
embolic disease, and non-atherosclerotic chronic vascular
conditions of the lower extremity were excluded.
The primary target audience of this guideline is vascular
specialists and all other healthcare professionals who are
involved in the diagnosis, management, and prevention of
diabetes related foot ulcers and gangrene, who work in
primary, secondary, and tertiary care.
Patient representatives will be approached to discuss
which elements of the guideline should be included in the
Information for Patients. This will result in a list of items that
should be addressed in this information. Given cultural and
language differences, the final text should be produced on a
national or local level.
GUIDELINE WRITING GROUP CONFLICT OF INTEREST
POLICY
The three organisations participating in this guideline are
committed to developing trustworthy clinical practice guide-
lines through transparency and full disclosure by those
participating in the process of guideline development. To
prevent a major Conflict of Interest (COI), members of the
Writing Committee were not allowed to serve as an officer,
board member, trustee, owner, or employee of a company
directly or indirectly involved in the topic of this guideline.
Before the first and last meeting of the Writing Committee,
members were asked to report any COI in writing. In addition,
at the beginning of each meeting this question was also asked
and if answered yes, the members were asked to submit an
updated COI form. These COIs included income received from
biomedical companies, device manufacturers, pharmaceutical
companies, or other companies producing products related to
the field. In addition, industry relationships had to be disclosed
each time and these included: ownerships ofstocks or options
or bonds of a company, any consultancy, scientific advisory
committee membership, or lecturer for a company, research
grants, or income from patents.These incomes could either be
personal or obtained by an institution with which the member
had a relationship. All disclosures were reviewed by the three
organisations, and these can be found at IWGDFguidelines.
org/. No company was involved in the development or re-
view of the guideline. Nobody else involved in the guideline
received any payment or remuneration of any costs.
DEFINITIONS AND TERMINOLOGY AS USED IN THIS
DOCUMENT
The definitions and criteria for diabetes related foot disease
were standardised by the IWGDF and in parallel to this
guideline an update is published.
24
In addition, in this
guideline the following terminology was used:
Bedside testing: any non-invasive test assessing for PAD
in the lower limb using a measure of blood flow that could
be conducted at the bedside.
Chronic limb threatening ischaemia: a clinical syndrome
defined by the presence of peripheral artery disease in
combination with rest pain, gangrene, or foot ulcer of at
least two weeks’duration. Venous, embolic, non-
atherosclerotic, and traumatic aetiologies are excluded.
Diabetes related micro-angiopathy: pathological struc-
tural and functional changes in the microcirculation of
people with diabetes mellitus, which can occur in any part
of the body as a consequence of the disease.
Diabetes related foot ulcer: a break of the skin of the foot
that involves, as a minimum, the epidermis and part of the
dermis in a person with diabetes and usually accompanied
by neuropathy and or PAD in the lower extremity.
Diabetes related foot gangrene: a condition that occurs
when body tissue dies because of insufficient blood supply,
infection, or injury.
Foot perfusion: tissue perfusion strictly means the vol-
ume of blood that flows through a unit of tissue and is often
expressed in mL blood/100 g of tissue. With respect to
clinical assessment of the foot, perfusion is traditionally
measured by the surrogate markers of systolic arterial
pressure at the level of the ankle and toe arteries. Pressure
measurements may be misleading in people with diabetes
due to the frequent presence of medial calcification. This
has led to the development of a number of alternative
clinically used means of assessing tissue perfusion, including
TcPO
2
(transcutaneous pressure of oxygen), SPP (skin
perfusion pressure), PAT (pedal acceleration time), and near
infrared spectrophotometry (NIRS).
Multidisciplinary team: a group of people from relevant
clinical disciplines, whose interactions are guided by specific
team functions and processes to achieve team and person
defined favourable outcomes.
Peripheral artery disease (PAD): obstructive atheroscle-
rotic vascular disease of the arteries from aorta to foot with
clinical symptoms, signs, or abnormalities on non-invasive
or invasive vascular assessment, resulting in disturbed or
impaired circulation in one or more extremities.
INTRODUCTION
The incidence of diabetes continues to increase in all
countries. Recent estimates are that 537 million people are
affected by diabetes (1 in 11 adults worldwide) and that 783
million individuals will be affected by 2045.
25
Diabetes is
associated with significant risk of foot complications
including ulceration, gangrene, and amputation. Develop-
ment of diabetes related foot ulceration (DFU) precedes up
to 85% of non-traumatic amputations, with an annual
incidence of ulceration of approximately 2% and lifetime
incidence of DFU up to 34%.
26
Diabetes related complica-
tions in the lower limb, including peripheral neuropathy and
PAD, typically precede the development of DFU.
27
Collec-
tively, these complications are a leading global cause of
disability, hospitalisation, and amputation, with a high
mortality rate following amputation.
28
Diabetes is a significant risk factor for development of
PAD. In a recent systematic review, Stoberock et al.
29
found
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 7
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

that the prevalence of PAD was 10 e26% in the general
adult population and 20 e28% in those with diabetes. In
those with DFU, the prevalence of PAD was 50%, which is
consistent with the findings of the multicentre Eurodiale
study.
29,30
PAD in people with diabetes is characterised by a
disease pattern that is frequently multisegmental and
bilateral with impaired collateral formation, often long
segment tibial artery occlusions, and is more distally
distributed in the lower limb including frequent presenta-
tion of infragenicular arterial occlusive disease, with an
increased risk of amputation.
31e33
The diagnosis of PAD and
chronic limb threatening ischaemia (CLTI) is frequently
complicated by the absence of classical symptoms of PAD
such as intermittent claudication and rest pain, probably
due to factors such as sedentary lifestyle and loss of pain
sensation due to diabetes related peripheral neuropathy,
which is present in the majority of people with an
(ischaemic) DFU.
30,32
Co-existent medial artery calcification
(MAC), which is also associated with peripheral neuropathy,
is common and can affect the accuracy of non-invasive tests
such as the ankle brachial index (ABI) by causing elevation
of ankle and, to a lesser extent, digital pressures.
34
In people with diabetes early diagnosis of PAD is essen-
tial.
29
The disease process is associated with greater likeli-
hood of delayed or non-healing of DFU, gangrene, and
amputation in addition to increased rates of cardiovascular
morbidity and mortality.
35
The prognosis of a person with
diabetes, PAD, and foot ulceration requiring amputation is
worse than for many common cancers, up to 50% of people
will not survive five years.
26,36
PAD places the person at
very high risk of adverse cardiovascular events and thus
optimal medical management of cardiovascular risk factors
should be ensured.
32
Early and adequate assessment of foot
perfusion is necessary to ensure that elevated risk of
delayed or poor wound healing and amputation is identified
early so this can be addressed without treatment delay.
Despite the severity of the outcomes of PAD in people
with diabetes, and particularly for those with DFU, there are
few practice guidelines that specifically address the diag-
nosis and management of PAD in this population. Formu-
lating recommendations for this specific population should
take into account the multisystem nature of diabetes and
the impact of other diabetes complications on the utility of
diagnostic tests, wound healing, amputation, and survival
outcomes. One of the guidelines that specifically addressed
these topics has been that of the IWGDF, with the last
version produced in 2019.
37
Instead of making a new
updated version, the IWGDF together with the ESVS and the
SVS decided to collaborate in writing this new, intersociety,
practice guideline on PAD in diabetes mellitus, with
emphasis on people with diabetes related foot ulcers or
gangrene. The aim is to provide evidence based recom-
mendations on the diagnosis, prognosis (i.e., the prognostic
value of different non-invasive tests), and treatment of PAD
in people with a foot ulcer and diabetes. Each of these
topics is discussed in the different sections below. It is not
the intention to detail the specific roles, tasks, and re-
sponsibilities of each medical specialty involved as these
vary markedly between and within countries and this
guideline is a multinational initiative. However, emphasis is
given to which expertise should be present, in terms of
knowledge, skills, and competence, to manage people
according to the expected standards of care.
Related guidelines
This guideline is also part of the IWGDF guidelines on the
prevention and management of diabetes related foot disease.
Management of PAD in these people without addressing the
other aspects of DFU treatment will frequently result in sub-
optimal outcomes. The reader is therefore referred to the other
IWGDF guidelines for these aspects. This IWGDF, ESVS, SVS
intersocietal guideline on PAD in people with diabetes mellitus
is also part of the IWGDF guidelines on the management of
diabetes related foot complications with additional chapters on
Classification (https://doi.org/10.1002/dmrr.3648),
38
Preven-
tion (https://doi.org/10.1002/dmrr.3651),
39
Offloading (https://
doi.org/10.1002/dmrr.3647),
40
Infection (https://doi.org/10.
1002/dmrr.3687),
104
Charcot (https://doi.org/10.1002/dmrr.
3646),
41
and Wound healing (https://doi.org/10.1002/dmrr.
3644).
42
These guidelines are summarised for daily clinical
use in the Practical Guidelines on the Prevention and Man-
agement of Diabetes Related Foot Disease (https://doi.org/10.
1002/dmrr.3657).
43
This guideline builds on a previous version
of the IWGDF guideline on peripheral artery disease in patients
with foot ulcers and diabetes, and integrates with the Global
Vascular Guidelines (GVG) on the management of Chronic Limb
Threatening Ischaemia.
20,37
DIAGNOSIS
Clinical question
In a person with diabetes with or without a foot ulcer, does
medical history and clinical examination (including pulse
palpation) compared with a reference test (imaging - digital
subtraction angiography [DSA], magnetic resonance angi-
ography [MRA], computed tomography angiography [CTA],
colour Duplex ultrasound [CDUS]) accurately identify and
reliably diagnose PAD?
Clinical question
In a person with diabetes with or without a foot ulcer, which
non-invasive bedside testing alone or in combination compared
with reference tests (imaging - digital subtraction angiography
[DSA], magnetic resonance angiography [MRA], computed to-
mography angiography [CTA], colour Duplex ultrasound [CDUS])
should be performed to accurately and reliably diagnose PAD?
Recommendation 1
In a person with diabetes without a foot ulcer, take a relevant
history for peripheral artery disease, examine the foot for
signs of ischaemia and palpate the foot pulses at least
annually, or with any change in clinical status of the feet.
Grade Certainty of evidence
Strong Low
8Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

Recommendation 2
In a person with diabetes without a foot ulcer, if peripheral
artery disease (PAD) is suspected, consider performing pedal
Doppler waveforms in combination with ankle brachial index
(ABI) and toe brachial index (TBI). No single modality has
been shown to be optimal for the diagnosis of PAD and there
is no value above which PAD can be excluded. However, PAD
is less likely in the presence of ABI 0.9 e1.3; TBI ‡0.70; and
triphasic or biphasic pedal Doppler waveforms.
Grade Certainty of evidence
Conditional Low
Rationale
Diagnosis and treatment of PAD is critical due to the
increased risk of developing DFU as well as the increased
rate of complications from co-existent cardiovascular
disease including myocardial infarction and stroke.
35
Evi-
dence for the diagnostic accuracy of pulse palpation for
PAD in people with diabetes without DFU is limited with
two studies of low quality demonstrating that although
presence of pulses does not exclude disease, there is a
small increase in ability to rule disease in where a foot
pulse is absent or weak (positive likelihood ratio [PLR]
1.84 e2.46).
44,45
The PLR gives the change in odds of
experiencing an outcome if the test is positive, whereas
the negative likelihood ratio (NLR) expresses a change in
odds of experiencing an outcome if the test is negative. A
PLR or NLR of 1.0 means that the test does not change the
probability of the outcome over and above the pre-test
probability and therefore is not a useful diagnostic test.
However, it is important to recognise that pulse palpation
should be performed, and results considered in the
context of other clinical examinations that may be asso-
ciated with PAD including hair loss, muscle atrophy, and
reduced peripheral skin temperature. It should be noted
that these clinical examinations are highly subjective and
such findings may also be associated with neuropathy.
PAD may also be asymptomatic or have an atypical pre-
sentation in people with diabetes as in other elderly or at
risk populations.
27,46,47
For example, peripheral neuropa-
thy can mask pain symptoms and autonomic neuropathy
can result in a warm foot, meaning that the widely rec-
ognised signs and symptoms of PAD may not be
present.
48
These recommendations are applicable to all people with
diabetes. When DFU is absent, but there are clinical signs
and symptoms of PAD or PAD is suspected, for example due
to long standing diabetes, chronic hyperglycaemia, other
diabetes complications such as peripheral neuropathy, or
the presence of atherosclerotic disease in other vascular
beds, more frequent screening vascular assessment
including additional bedside testing is necessary. These
recommendations are consistent with other (inter)national
guidelines on the management of diabetes, endorsing
annual clinical assessment for PAD (and for other foot
complications) in people with diabetes.
49e52
Although based on low quality evidence, data demon-
strating increased likelihood of PAD in those with weak or
absent pulses and elevated risk of cardiovascular
morbidity and mortality support the preference of a
person with diabetes for clinical examination including
pulse palpation to be performed.
35,5
The non-invasive
nature of clinical examination and pulse palpation sug-
gest that these assessments would be valued by people
with diabetes as initial diagnostic tests. As equipment is
not required, the Writing Committee considered pulse
palpation and other forms of clinical examination as
having low resource requirements, which can be applied
on a broad scale by a range of practitioners, and offer a
method to increase equity of healthcare access that is
both feasible for healthcare providers and acceptable for
people with diabetes. This Strong Recommendation is
therefore made, based on low certainty of evidence and
expert opinion.
Bedside testing techniques that provide objective mea-
surement of peripheral blood flow in the lower extremity
(e.g., ankle brachial index [ABI], toe brachial index [TBI],
and pedal Doppler waveforms) have been shown to be
useful to diagnose and exclude PAD in people with dia-
betes. The systematic review demonstrates that multiple
bedside testing techniques that offer objective measure-
ment of the peripheral circulation in the lower limb are
useful as a means to rule disease in or out for people with
diabetes without a DFU but who are suspected of having
PAD.
5
Forty studies investigating the diagnostic accuracy of
non-invasive bedside tests in populations with diabetes
were identified.
5
Twenty eight of the studies used pro-
spective recruitment and the remainder were retrospec-
tive. Overall, the studies were of low quality and evidence
was judged as being of low certainty. Although it was not
possible to identify the absolute threshold or normal
values of bedside tests, it is suggested that PAD is more
likely to be present in this population with an ABI <0.9 or
>1.3, a TBI <0.70, and presence of one or more
monophasic Doppler waveforms from assessment of pedal
arteries with continuous wave Doppler (CWD).
5
In people
without DFU, an ABI of <0.90 is associated with a mod-
erate to large increase in likelihood of PAD with PLRs
ranging from 4.17 to 17.91; however, the ability to rule
disease out is variable (NLR 0 e0.54) (Supplementary
Table S1). A TBI <0.70 has a moderate ability to di-
agnose and exclude PAD (PLR 2.0 e3.55, NLR 0.25 e0.44),
and the presence of a visual monophasic pedal Doppler
waveform (compared with a biphasic or triphasic Doppler
waveform where the waveform crosses the zero flow
baseline and contains both forward and reverse velocity
components)
53
has a moderate ability to diagnose and
exclude PAD (PLR 7.09, NLR 0.19).
Non-invasive bedside tests are therefore likely to be
beneficial for people without a DFU; however, high quality
studies of diagnostic accuracy are required. A summary of
results is provided in Supplementary Table S1.
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 9
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

When calculating the ABI in the leg of a person with and
without DFU for the purposes of diagnosing PAD, it is
advised to use the lower systolic blood pressure of either
the dorsalis pedis or posterior tibial artery as this improves
the diagnostic accuracy of the test.
5
For PAD affecting ar-
teries below the knee, this calculation method identifies the
most severe disease while using the higher pressure iden-
tifies the least affected artery. Use of three tests (ABI, TBI,
and pedal Doppler waveforms) is recommended. This is
because the accuracy of the tests may be affected by the
presence of other diabetes related complications.
Due to the use of bedside measures to monitor PAD
status over time, reliability (or reproducibility) of the tests
is important in determining their clinical effectiveness. The
systematic review showed that the reliability of both the
ABI and TBI was good to excellent. However, these tests
are limited by wide margins of error, which affect the
amount of change required for this to be considered a true
change rather than related to error in the measurement.
For example, an ABI measured by the same rater requires a
change of 0.15 to be considered a true change.
54
There-
fore, care should be taken in performing the measurement
to control for factors that may introduce error including
incorrect positioning of the person being tested (this
should be horizontal supine) and incorrect testing pro-
cedures (e.g., pre-test exercise, caffeine consumption,
etc.).
The recommendation identifies the need to perform
bedside testing in people with diabetes in whom PAD is
suspected. In people with diabetes without a DFU, the
presence of PAD will increase the risk of a future DFU and
amputation. The presence of PAD will influence the fre-
quency of screening and the measures that can be safely
taken to reduce the risk of amputation, as described in the
Prevention Guidelines of the IWGDF (https://doi.org/10.
1002/dmrr.3651).
39
It is therefore critical that, apart
from the history and foot examination, risk factors for PAD
are also considered such as long standing or poorly
controlled diabetes or diagnosis of atherosclerosis in other
vascular beds. Considering the benefits and harms of this
recommendation it is judged to be essential to diagnose or
exclude PAD in this population given the large impact of
untreated disease, the low burden of the tests to the
person undergoing testing, and the high likelihood that
diagnosis will be valued by them. All aforementioned
bedside tests (ABI, TBI, CWD) should be performed by
trained healthcare professionals in a standardised manner
and these tests can be applied by a wide range of practi-
tioners, after having received adequate training. From the
perspective of middle or high income countries the re-
sources required to undertake bedside testing are rela-
tively low compared with other methods of diagnosing
PAD such as CDUS, CTA, MRA, and angiography. It is likely
that many people will value the knowledge that their feet
need more intensive care to prevent amputation, but this
has not been studied in a sufficiently large cohort. Based
on the uncertainty of the evidence a Conditional Recom-
mendation was made for additional non-invasive testing in
this group of people with asymptomatic disease. The role
of additional testing in those with intermittent claudica-
tion is outside the scope of this guideline.
Recommendation 3
In a person with diabetes and a foot ulcer or gangrene, take a
relevant history for peripheral artery disease, examine the
person for signs of ischaemia and palpate the foot pulses.
Grade Certainty of evidence
Strong Low
Recommendation 4
In a person with diabetes and a foot ulcer or gangrene,
evaluate pedal Doppler waveforms in combination with
ankle brachial index (ABI) and toe brachial index (TBI)
measurements to identify the presence of peripheral artery
disease (PAD).
No single modality has been shown to be optimal for the
diagnosis of PAD, and there is no value above which PAD can
be excluded. However, PAD is less likely in the presence of
ABI 0.9 e1.3; TBI ‡0.70; and triphasic or biphasic pedal
Doppler waveforms.
Grade Certainty of evidence
Strong Low
Rationale
PAD is present in approximately half of the people with a
DFU.
29,30
Therefore, in any person with diabetes and a foot
ulcer or gangrene, PAD should be considered and should be
excluded with the appropriate diagnostic strategies. Sub-
sequently, once diagnosed the second question is whether
the PAD is of sufficient severity to contribute to delayed
wound healing and increased risk of amputation. This will
inform whether further investigation or intervention is
required. In addition, although cardiovascular risk factor
modification is always indicated in people with diabetes,
those with symptomatic PAD (i.e., including those with a
DFU) belong to the very high cardiovascular risk category
and need more intensive risk treatment, as described in the
‘Treatment’section.
Apart from taking a clinical history, all people with a DFU
or gangrene should undergo a complete physical examina-
tion, including palpation of the lower limb pulses which can
help to determine the presence of arterial disease.
55
In the
systematic review on diagnosis, one low quality study that
assessed the diagnostic accuracy of pedal pulse assessment
in a population where all participants had a DFU was
identified.
56
Pulse palpation had a PLR of 1.38 and a NLR
0.75 for PAD in people presenting with a foot ulcer.
56
These
likelihood ratios represent a very small ability of the test to
identify or exclude disease. Pulse palpation should be seen
as the first step in a systematic evaluation of the affected
limb and foot, but when DFU is present further diagnostic
procedures should be performed with non-invasive bedside
testing techniques as clinical examination is not sufficient to
10 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

exclude PAD. Although of limited value it should not be
discarded as in the early phase of management other tests
are sometimes unavailable, or findings may be difficult to
interpret. The evidence base is small with low certainty but
as previously discussed this form of testing has low resource
requirements, can be applied on a broad scale by a range of
practitioners, is feasible, and may increase equity of
healthcare access. This Strong Recommendation is therefore
made, based on low certainty of evidence and expert
opinion. However, a systematic foot examination for signs of
ischaemia should be the starting point of a systematic
evaluation, as failure to diagnose and treat this condition
may have dire consequences in many people. When DFU is
present further diagnostic testing using bedside testing
techniques in the first instance should be performed as
palpation of foot pulses and clinical examination alone are
not sufficient to exclude PAD.
The systematic review identified eight studies
56e63
of
diagnostic accuracy of bedside testing that included partici-
pants with active DFU, with the proportion of the study
population affected ranging from 6.6% to 100%.
56,57
One
study demonstrated a visual pedal Doppler waveform eval-
uation to be diagnostic (PLR 10), with a moderate ability of
the test to exclude PAD. In a second study with z40% of the
participants having a foot ulcer, the PLR was lower (3.04) and
the NLR similar (0.35).
61
In studies in which the majority of
the study population had DFU, an ABI <0.90 increased the
pre-test probability of disease by a small amount (PLR 1.69 e
2.40) with limited ability of the test to exclude disease (NLR
0.53 e0.75).
56,59,62,63
Similarly, data for the TBI were limited
and variable with the PLR in both mixed populations (with
and without DFU) and DFU only, ranging from 1.62 (indicating
limited ability to diagnose disease) to being diagnostic (PLR 
10) and indicating the test has small to moderate ability to
exclude disease (NLR 0.30 e0.47).
56,59,61,62
All the aforementioned non-invasive bedside tests (ABI,
TBI, CWD) can be applied by a wide range of practitioners,
in particular in settings where people are treated in sec-
ondary care or specialised outpatient foot clinics. These
tests have low resource requirements relative to other
methods of diagnosing PAD such as CDUS and angiography.
These factors are likely to increase equity in healthcare
access and make the tests feasible and acceptable for both
the person having the tests and healthcare providers. Given
the large potential beneficial effect and its impact on sub-
sequent treatment a Strong Recommendation for this
population has been made, although the limitations of the
evidence base are acknowledged.
Recommendation 5
In a person with diabetes without a foot ulcer in whom a non-
emergency invasive foot procedure is being considered,
peripheral artery disease should be excluded by performing
assessment of pedal Doppler waveforms in combination with
ankle brachial index and toe brachial index.
Grade Certainty of evidence
Best Practice Statement
Rationale
Except when required as an emergency to control severe
infection, all people with diabetes who require foot surgery
should have vascular testing consisting of pedal Doppler
waveforms in combination with ABI and toe pressure (TP)
or TBI. Non-emergency invasive procedures, such as elective
surgery, may be indicated in people with diabetes without a
DFU with the intent to address painful foot conditions.
Particularly in those with peripheral neuropathy,
64
prophy-
lactic procedures could be considered to address risk factors
for foot ulceration, such as foot deformity and elevated
localised plantar pressures. Prior to any surgical procedure
on the foot in a person with diabetes, PAD status should be
established, and this finding should contribute to determi-
nation of the suitability of an individual for the procedure.
The decision to perform the elective surgery should be
made in a shared decision making process that will be
influenced by balancing the benefit of the operation against
the potential harm, such as the risk of poor wound healing
based on the non-invasive assessments.
As discussed above, bedside testing generally has mod-
erate ability to diagnose PAD or to exclude this disease in
people with diabetes mellitus. Any abnormal test result
should be considered indicative of PAD. Therefore, it is
suggested this recommendation will reduce the risk of un-
diagnosed severe PAD which would potentially negatively
affect post-surgical outcomes and it is likely that people will
value this approach. Feasibility and the impact of these
tests on resource use are discussed in Recommendation 4.
No randomised controlled trials (for ethical reasons) or
observational studies of sufficient quality have been per-
formed on the added value of performing bedside tests
prior to any surgical procedure in the foot. Given the indi-
rect evidence discussed above, the major clinical implica-
tions of missing the diagnosis of PAD and the limited harm
and additional costs, a Best Practice Statement was made.
PROGNOSIS
Clinical question
In a person with diabetes, suspected PAD, and a foot ulcer
or gangrene, which non-invasive bedside tests, alone or in
combination, at any time point (including after revascular-
isation procedures), predict DFU healing, healing after mi-
nor amputation, and major amputation?
Recommendation 6
In a person with diabetes and a foot ulcer or gangrene,
consider performing ankle pressures and ankle brachial
index (ABI) measurements to assist in the assessment of
likelihood of healing and amputation.
Ankle pressure and ABI are weak predictors of healing. A low
ankle pressure (e.g., <50 mmHg) or ABI (e.g., <0.5) may be
associated with greater likelihood of impaired healing and
greater likelihood of major amputation.
Grade Certainty of evidence
Conditional Low
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 11
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

Recommendation 7
In a person with diabetes and a foot ulcer or gangrene,
consider performing a toe pressure measurement to assess
likelihood of healing and amputation.
A toe pressure ‡30 mmHg increases the pre-test probability
of healing by up to 30% and a value <30 mmHg increases the
pre-test probability of major amputation by approximately
20%.
Grade Certainty of evidence
Conditional Low
Recommendation 8
In a person with diabetes and a foot ulcer or gangrene, if a toe
pressure cannot be performed, consider performing a
transcutaneous oxygen pressure (TcPO
2
) measurement or a
skin perfusion pressure (SPP) to assess likelihood of healing.
A TcPO
2
‡25 mmHg increases the pre-test probability of
healing by up to 45% and value <25 mmHg increases the pre-
test probability of major amputation by approximately 20%.
An SPP ‡40 mmHg increases the pre-test probability of
healing by up to 30%.
Grade Certainty of evidence
Conditional Low
Rationale
The presence of PAD constitutes a substantially increased riskof
failure to heal and major lower limb amputation for people with
a diabetes related foot ulcer or gangrene. Bedside testing results
are an integral component of determining the severity of
ischaemia and, to that end, to determine the need for, and ur-
gency of, further investigations. Non-invasive bedside tests
including AP, ABI, and TP should be performed in a person with a
DFU or gangrene to guide further management asthey can help
to predict the chance of healing and or major amputation.TcPO
2
and skin perfusion pressure (SPP) give additional information on
healing potential and are useful for measuring perfusion
following forefoot amputations when TPare no longer possible.
However, in the authors’opinion these are secondary tests due
to greater expense and less availability of the equipment and
thetimeandexpertiserequiredtoapplythem.
Assessment of the pedal arterial Doppler waveforms com-
bined with measurement of the AP and subsequent calculation
of the ABI, are usually the first steps in the assessment of PAD.
Although relevant for its diagnosis, as discussed in the Ratio-
nales of Recommendations 1 and 2, it was not possible to
identify sufficient data on the capacity for Doppler arterial
waveform analysis to predict wound healing in populations
with DFU.
5
Two low quality studies were identified which
concluded that abnormal or absent Doppler waveforms were
associated with a small (15%) increase in the likelihood of
major amputation,
65,66
further limiting its use. Similarly, there
are currently insufficient data to support the use of TBI to
predict healing or amputation outcomes; however, TP (as a
component of TBI) has been more widely investigated and is
therefore included in the recommendation.
The predictive capacity of APs and ABI for wound healing was
inconsistent in the 15 studies included in the systematic re-
view.
5
Thresholds for AP and ABI which were associated with
increased probability of healing could not be identified; how-
ever, a very low ankle pressure(e.g., <50 mmHg) or ABI (e.g.,<
0.5) was associated with a greater likelihood ofdelayed healing.
According to current guidelines revascularisation should be
considered when such values are measured in people with PAD
and an ulcer or gangrene.
20
AP and ABI values >50 mmHg or >
0.5, respectively, should not be used in isolation to predict
likelihood of ulcer healing given their uncertainty, but detailed
clinical examination and further vascular testing is needed, as
stated in Recommendation 6. Regarding amputation risk, the
probability of major amputation was increased by approxi-
mately 45% with an ABI <0.4 based on one study in people
who had undergone transmetatarsal amputation. However, an
ABI threshold <0.9 was not associated with any probability
increase.
5,67
Thresholds used for AP were highly variable in the
literature and it was not possible to determine which threshold
was optimal.
5
Other research has demonstrated that an
elevated ABI (>1.3) is associated with both greater likelihood
of amputation and worse amputation free survival outcomes
and therefore should be recognised as a risk factor for poor DFU
outcomes. The same observations were made in people
without diabetes, and an elevated ABI is therefore seen as a
marker for more severe cardiovascular disease with an elevated
risk of amputation.
68,69
TP and TBI can assess blood flow distal to the forefoot and
in toes, where most DFUs occur.
70
Based on 10 studies of low
quality it was found that with TP 30 mmHg the pre-test
probability of healing was increased by up to 30%.
71
Regarding major amputation, a value <30 mmHg increases
the probability of major amputation by approximately 20%,
which suggests a (somewhat) lower predictive capacity
compared with the ABI. In the three studies identified, there
was inconsistent and insufficient evidence for the use of the
TBI to predict either healing or major amputation.
TcPO
2
and SPP are additional tests that have the advantage
of measuring perfusion at tissue level and therefore reflect
both macrovascular and microvascular function. In the sys-
tematic review the majority of available studies (n¼7) which
were of low quality, reported that TcPO
2
canbeusedtopredict
the likelihood of DFU healing,
71e80
although there is variability
in the thresholds used. With a TcPO
2
25 mmHg the pre-test
probability of healing is increased by up to 45%, which was
higher than reported for the other tests in the included studies.
Regarding amputation, a value <25 mmHg increases the
probability of major amputation by approximately 20%, a
predictive value that seems lower than that of the ABI when
the different studies were compared. An SPP (40 mmHg)
was shown to increase the pre-test probability of healing by up
to 30% in one study of low quality.
81
There are insufficient data
investigating the relationship between SPP and amputation
outcomes to formulate a recommendation.
In summary, when comparing different studies, the ABI
seemed to have the best predictive capacity for major
amputation, while the TP and TcPO
2
seemed to have a
better predictive capacity for wound healing. It was
12 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

noteworthy that there was insufficient evidence for the use
of the TBI to predict either healing or amputation out-
comes. The number of prospective studies and the number
of participants included in the aforementioned studies were
relatively low, the populations studied differed, and results
of the tests performed were frequently not blinded.
Moreover, comparison of studies was hampered by the fact
that different studies used different thresholds for disease
and thus combining data for analysis was not possible.
When bedside testing is not performed the risks of a poor
clinical outcome or unnecessary, more costly, investigations
are large. As discussed earlier, most bedside tests are of low
burden to both the person and the healthcare system,
although training andexpertise are necessary. Ifthese tests are
not performed, the clinician must rely only on clinical judge-
ment and on imaging investigations. Although imaging will
provide details of the arterial anatomy, the non-invasive
bedside tests will inform the clinician about the perfusion in
the foot. However, absolute perfusion thresholds applicable
for all people cannot be provided asthe outcome ofthe DFU is
determined not only by the degree of ischaemia. Other factors
such as infection, extent of tissue loss, and ulcer depth, can
have a major effect on healing potential and amputation risk,
as discussed below. For this reason and the uncertainty of the
evidence, a Conditional Recommendation for use of AP, ABI,
and TP to predict the likelihood of healing and amputation was
made.
TcPO
2
and SPP tests require more expensive equipment and
greater expertise for application than other bedside testing,
which may be a barrier for centres in low or middle income
countries. Although healthcare expenditures may increase
with each of these measurements, incorrectassessment of the
severity ofPAD can result in inadequate treatmentand poorer
outcomes with ultimately an increase in costs. Importantly, all
the aforementioned bedside tests have varying capacity to
predict likelihoodof healing and of amputation, as summarised
in the systematic review.
6
Based on current evidence no test
has convincingly been shown to perform better than other
tests as a prognostic indicator of both healing and amputation.
In the opinion of the Writing Committee multiple tests should
be used. Given the limited available evidence on TcPO
2
and
SPP and their higher costs, a Conditional Recommendation on
these two tests was made.
Recommendation 9
In a person with diabetes and a foot ulcer or gangrene, it is
suggested that the presence of peripheral artery disease and
other causes of poor healing should always be assessed.
Diabetes related micro-angiopathy should not be considered
the primary cause of foot ulceration, gangrene, or poor
wound healing without excluding other causes.
Grade Certainty of evidence
Conditional Low
Rationale
The definition of microvascular disease in DFU and its role
in wound healing are not well understood. Many clinicians
have assumed that microvascular disease is present in a
high proportion of people with DFU and that it is a major
cause of delayed wound healing, often despite a lack of
thorough investigation of large vessel arterial disease. As
discussed elsewhere in this guideline, people with diabetes
and a DFU frequently have distal, lower leg obstructive
atherosclerotic disease, often with involvement of the pedal
arteries, which due to their smaller size can be difficult to
image. However, advances in imaging and technology have
shown that tibial and pedal arteries are potentially treatable
by endovascular and open surgical techniques.
The term microvascular disease describes abnormalities
affecting the arteriolar, capillary and venular vessels. Several
studies have reported microvascular abnormalities in the skin
and subcutaneous tissues in people with diabetes. These
abnormalities can be structural, i.e. occlusive disease and
alterations in the blood vessel wall, and functional, such as
impaired vasodilatory responses to endogenous or noxious
stimuli.
82
However, in the systematic review on this topic it
was not possible to identify studies of sufficient quality
showing that such abnormalities contribute to impaired
wound healing (Supplementary material). One prospective
study did report that microvascular changes observed in skin
biopsies in the feet in people with diabetes and neuro-
ischaemia were associated with poorer wound healing after
revascularisation.
83
However, both these microvascular
changes and poorer wound healing could be due to tissue
damage caused by ischaemia and not by pre-existing diabetes
related micro-angiopathy. If perfusion of the foot ulcer is
adequate but the ulcer fails to heal, other causes of poor
wound healing should be sought and treated, such as infec-
tion, insufficient protection from biomechanical stress,
oedema, poor glycaemic control, poor nutritional state, and
underlying co-morbidities.
43
Based on the lack of studies
showing that diabetes related micro-angiopathy contributes
to poor wound healing in DFU and the potential harm if this is
assumed, a Conditional Recommendation based on low cer-
tainty of evidence was made.
Recommendation 10
In a person with diabetes, peripheral artery disease, and a
foot ulcer or gangrene, consider using the Wound/
Ischaemia/foot Infection (WIfI) classification system to
estimate healing likelihood and amputation risk.
Grade Certainty of evidence
Conditional Low
Rationale
The Wound, Ischaemia and Foot infection (WIfI) classification
system was developed to guide the clinician in estimating the
risk of amputation and potential benefit of revascularisation in
people with a foot ulcer or gangrene, and is recommended by
the Global Vascular Guideline for limb staging (relating to
severity of limb threat) in people with chronic limb threatening
ischaemia (CLTI).
20
This system was developed by an inter-
disciplinary panel of experts and stages the limb based on the
presence of, and severity of, the foot wound, ischaemia, and
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 13
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

infection. A Delphi consensus process was used to allocate
these combinations into four clinical stages based on very low
(stage 1), low (stage 2), moderate (stage 3), and high (stage 4)
predicted one year risk of major amputation. Consistent with
all other commonly used limb staging systems, the individual’s
co-morbidities which are likely to influence wound healing and
amputation risk are not incorporated into WIfI. A second
distinct aspect of the WIfI system is the predicted likelihood of
benefit from revascularisation.
84
A recent systematic review concluded that in people
undergoing a revascularisation procedure, the likelihood of
an amputation after one year increases with higher WIfI
stages. The estimated one year major amputation rates
from four studies comprising 569 participants were 0%, 8%
(95% CI 3 e21%), 11% (95% CI 6 e18%), and 38% (95% CI
21 e58%), for WIfI clinical stages 1e4, respectively.
85
For
the population of people with a DFU, the WIfI system was
evaluated in the IWGDF systematic review on classification
systems, that is published in parallel to this guideline. In
summary, in people with diabetes, PAD, and a foot ulcer,
this systematic review identified seven studies, with
low certainty of evidence, demonstrating that a high WIfI
limb clinical stage is associated with longer time to
healing and increased likelihood of non-healing at six and
12 months.
86e92
Higher WIfI clinical stages are also associ-
ated with increased likelihood of major amputation, with one
study reporting an amputation rate of 64% for stage 4.
93
Similarly, higher WIfI clinical stages have been linked to
high rates of minor amputation and lower rates of amputa-
tion free survival at 12 months.
88,89,92,94e99
For prediction of
revascularisation benefit there are few data available and
inadequate evidence to determine whether WIfI revascular-
isation benefit staging predicts healing or amputation out-
comes in people undergoing revascularisation.
The WIfI tool (Tables 1e5) has demonstrated predictive
capacity for the key outcomes of wound healing and ampu-
tation in people with DFU.
88,89,92,94e99
It uses clinicalgrading of
infection and wound characteristics in combination with non-
invasive bedside testing to determine the severity of ischaemia
and it has wide availability, also as an online tool (https://apps.
apple.com/us/app/svs-ipg/id1014644425). Moreover, it can
be used by a wide range of practitioners making its application
in clinical practice feasible, its costs are relatively limited,and it
is expected to be acceptable to practitioners as well as being of
value to people receiving the care. It is likely to stimulate a
standardised accessto a form of vascular assessment, which is
also relevant for low income countries where invasive testing
may not be widely available. Due to the observational and
often retrospectivenature of most of the currentevidence, this
recommendation was made Conditional.
TREATMENT
Clinical question
In which persons with diabetes, PAD, and a foot ulcer or
gangrene using clinical findings, perfusion test findings, and
or classification systems, should revascularisation be
considered?
Recommendation 11
In a person with diabetes, peripheral artery disease, and a
foot ulcer or gangrene who is being considered for
revascularisation, evaluate the entire lower extremity
arterial circulation (from aorta to foot) with detailed
visualisation of the below knee and pedal arteries.
Grade Certainty of evidence
Best Practice Statement
Rationale
As per Recommendations 1 e4, clinical examination and
bedside testing should be the first line testing undertaken to
diagnose the presence of PAD. When revascularisation is being
considered further anatomical information on the arteries of
the lower limb should be obtained to assess the presence,
severity, and distribution of arterial stenoses or occlusions. In
this process, adequate imaging of the tibial and pedal vessels is
of critical importance, particularly in planning intervention in
people with diabetes and a foot ulcer.
20
Modalities that can be
used to obtain anatomical information include CDUS, CTA,
MRA, or DSA (including anteroposterior and lateral views of the
foot). The Writing Committee considered that each of the im-
aging techniques have their advantages and disadvantages, and
their use will depend heavily on the availability of equipment
and local expertise, preferences of the individual clinician, and
associated costs. For these reasons a Best Practice Statement
was formulated. Regarding their use in people with diabetes,
Table 1. Wound Ischaemia foot Infection Classification System:
Wound clinical category adapted from Millset al.(reference84)
Grade Clinical description
0 Ischaemic rest pain; without ulcer or gangrene
1 Minor tissue loss: small shallow ulceration on foot
or distal leg. No gangrene.
Salvageable with simple skin coverage or 2 toe
amputations
2 Major tissue loss: deeper ulceration(s) with exposed
bone, joint or tendon not involving calcaneus.
Gangrenous changes limited to digits.
Salvageable with extensive forefoot surgery
3 Extensive ulcer or gangrene involving forefoot or
midfoot; full thickness heel ulcer calcaneal
involvement.
Salvageable with complex foot reconstruction and/
or complex wound management
Table 2. Wound Ischaemia foot Infection Classification System:
Ischaemia category adapted from Mills et al. (reference 84)
Grade ABI Ankle SP emmHg TP, TcPO
2
emmHg
00.8 >100 60
1 0.6e0.79 70e100 40e59
2 0.40e0.59 50e69 30e39
3<0.40 <50 <30
ABI ¼ankle brachial index; SP ¼systolic pressure; TP ¼toe pressure;
TcPO
2
¼transcutaneous oxygen pressure.
14 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

the utility of some these techniques, such as CDUS and CTA,
can be affected by (severe) MAC, which is frequently present in
the smaller arteries of the leg in people with DFU. MRA images
are incapable of defining the extent of calcification which may
be important when planning revascularisation.
20
Finally, as
stated in the GVG, catheter DSA, represents the gold standard
imaging technique, especially for the below knee and foot ar-
teries.
20
In many centres DSA is typically used when MRA or
CTA are not available, fail to adequately define the arterial
anatomy, or when an endovascular intervention is planned.
Arterial imaging should allow complete anatomical staging from
aorta to foot using, for example, TASC for aorto-iliac disease and
the Global Anatomic Staging System (GLASS), described in the
GVG, for infrainguinal and pedal disease.
20
Recommendation 12
In a person with diabetes, peripheral artery disease, a foot
ulcer, and clinical findings of ischaemia, a revascularisation
procedure should be considered. Findings of ischaemia
include absent pulses, monophasic or absent pedal Doppler
waveforms, ankle pressure <100 mmHg or toe pressure <60
mmHg. Consult a vascular specialist unless major amputation
is considered medically urgent.
Grade Certainty of evidence
Best Practice Statement
Rationale
The natural history of people with diabetes, PAD, and a DFU
or gangrene remains poorly defined, but in two studies
reporting the outcomes of participants with diabetes and
limb ischaemia who were not revascularised, the limb
salvage rate was around 50% at one year.
73,100
Analysis of the
evidence for revascularisation suggests that revascularisation
in appropriately selected people with diabetes and haemo-
dynamically significant PAD, can improve perfusion, expedite
wound healing, and reduce major limb amputations.
6
After a
revascularisation procedure, most studies report limb salvage
rates of 80 e85% and ulcer healing in >60% at 12
months.
101
On the other hand, performing a revascularisa-
tion is not without risks. As summarised in the systematic
review performed by the IWGDF in 2019,
101
the peri-
operative or 30 day mortality rate was around 2% in peo-
ple with diabetes undergoing either endovascular or surgical
revascularisation.
101
The highest risk group includes people
with end stage renal disease, who have a 5% peri-operative
mortality rate, 40% one year mortality rate, and one year
limb salvage rate of around 70%.
101
People with signs of ischaemia, e.g., as defined by WIfI
and the GVG; absent pulses and monophasic or absent
pedal Doppler waveforms, ankle pressure <100 mmHg or
toe pressure <60 mmHg, are very likely to have significant
PAD that could impact wound healing potential and
amputation risk.
20,84
The certainty of evidence in the sys-
tematic review on the effects of revascularisation on wound
healing and amputation risk was judged to be very low, as
many important factors that can affect outcomes were not
reported, such as the availability of vein conduit, wound
care, offloading, and sufficient anatomical details about the
extent and severity of the lesions treated. Factors that in-
fluence the decision to revascularise include the degree of
limb threat (e.g., WIfI classification), the amount of tissue
loss, presence of infection, co-morbidities, feasibility of the
different revascularisation options, and their risks.
Table 3. Wound Ischaemia foot Infection Classification System: foot Infection category adapted from Mills et al. (reference 84)
Grade Clinical description IDSA IWGDF
Class
0 Wound without purulence or manifestations of infection Uninfected 1
1>2 manifestations of infection, erythema (<2 cm), pain or tenderness, warmth, induration or purulent
discharge
Mild 2
2 Local infection in a patient who is systemically stable as described above with erythema >2cm, or
involving subcutaneous structures e.g., abscess, osteomyelitis, septic arthritis or fasciitis
Moderate 3
3 Infection in patient with systemic or metabolic toxicity (systematic inflammatory response
syndrome/ sepsis)
Severe 4
IDSA ¼The Infectious Diseases Society of America; IWGDF ¼International Working Group on the Diabetic Foot.
Table 4. Wound Ischaemia foot Infection Classification System: estimated risk of amputation at one year adapted from Mills et al.
(reference 84)
Ischaemia e0 Ischaemia e1 Ischaemia e2 Ischaemia e3
W-0 VL VL L M VL L M H L L M H L M M H
W-1 VL VL L M VL L M H L M H H M M H H
W-2L L MHMMHHMHHHHHHH
W-3MMHHHHHHHHHHHHHH
fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3
VL ¼Very Low ¼Class or Clinical Stage 1
L¼Low ¼Class or Clinical Stage 2
M¼Moderate ¼Class or Clinical Stage 3
H¼High ¼Class or Clinical Stage 4
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 15
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

As discussed in other parts of the IWGDF guidelines,
restoration of perfusion in the foot is only part of the
treatment required to optimise wound healing and to
prevent or limit tissue loss, which should be provided by a
multidisciplinary team.
43
Any revascularisation procedure
should be part of a comprehensive care plan that addresses
other important issues including: prompt treatment of
concurrent infection, regular wound debridement, biome-
chanical offloading, control of blood glucose, assessment
and improvement of nutritional status, as well as treatment
of oedema and co-morbidities.
43
The decision to perform a
revascularisation procedure and which procedure is
preferred depends therefore on several factors and in each
individual the balance should be made between expected
benefits, potential risks, harms and costs, in a shared de-
cision making process. For these reasons a Best Practice
Recommendation was made. The care of persons with a
DFU is frequently managed by healthcare professionals who
are not specifically trained in the treatment of PAD. Care for
people with PAD is differently organised in many countries,
with different medical disciplines involved, such as vascular
surgeons, angiologists, interventional radiologists, nephrol-
ogists, cardiac surgeons, and cardiologists. For this reason,
the term vascular specialist consultation is used in the
recommendation, but whatever the organisation of care all
people with diabetes and PAD should have access to both
bypass surgery and endovascular procedures.
Recommendation 13
In a person with diabetes, peripheral artery disease, a foot
ulcer, and severe ischaemia i.e., an ankle brachial index
<0.4, ankle pressure <50 mmHg, toe pressure <30 mmHg or
transcutaneous oxygen pressure <30 mmHg or monophasic
or absent pedal Doppler waveforms, urgently consult a
vascular specialist regarding possible revascularisation.
Grade Certainty of evidence
Best Practice Statement
Rationale
Severe ischaemia is definedintheGVGasanABI<0.4, AP
pressure <50 mmHg, TP <30 mmHg or TcPO
2
<30 mmHg
or monophasic or absent pedal Doppler waveforms.
20,84
Such
perfusion deficits are, as also stated in the GVG, an indication
for revascularisation, unless contraindicated or technically not
possible. There is retrospective evidence demonstrating that a
delay in revascularisation of more than two weeks in people
with diabetes results in increased risk of limb loss.
102
This is
supported by observational research demonstrating that a
shorter time to revascularisation (<8 weeks) is associated
with a higher probability of DFU healing and lower likelihood
of limb loss.
74
As shorter time to revascularisation was
associated with higher probability of DFU healing and lower
likelihood of limb loss, a Best Practice Statement supporting
urgent referral for vascular consultation in people with DFU
and evidence of severe ischaemia was made (Fig. 1).
Recommendation 14
In a person with diabetes, peripheral artery disease, and a
foot ulcer with infection or gangrene involving any portion of
the foot, urgently consult a vascular specialist in order to
determine the timing of a drainage procedure and a
revascularisation procedure.
Grade Certainty of evidence
Best Practice Statement
Rationale
In the presence of PAD and infection or gangrene, an ur-
gent revascularisation should be considered. In the pro-
spective Eurodiale study, participants with the
combination of a foot infection and PAD had a one year
major amputation rate as high as 44%.
103
In addition,
participants with higher WIfI infection grade had higher
risk of amputation in several observational studies, as
summarised in the IWGDF systematic review on Classifi-
cation Systems (https://onlinelibrary.wiley.com/doi/10.
1002/dmrr.3645).
38
Delayintreatmentcanleadtorapid
tissue destruction and life threatening sepsis as described in
the IWGDF/IDSA Guidelines on Management of Diabetic
Foot Infections.
104
In a person with a foot abscess or infection of
a deep foot compartment that needs immediate drainage, or
where there is gangrene that must be removed to control the
infection, immediate surgery should be considered first.
104
This
should be accompanied by broad spectrum antibiotic therapy,
which is subsequently tailored according to tissue culture re-
sults, as “time is tissue”in these people. Once the sepsis is
controlled and the person is stabilised, evaluation of the arterial
Table 5. Wound Ischaemia foot Infection Classification System: estimated likelihood of benefit of or requirement for
revascularisation adapted from Mills et al. (reference 84)
Ischaemia e0 Ischaemia e1 Ischaemia e2 Ischaemia e3
W-0VLVLVLVLVLL L ML L MMMH H H
W-1VLVLVLVLL MMMMHHHHHHH
W-2VLVLVLVLMMHHHHHHHHHH
W-3VLVLVLVLMMHHHHHHHHHH
fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3 fI-0 fI-1 fI-2 fI-3
VL ¼Very Low ¼Class or Clinical Stage 1
L¼Low ¼Class or Clinical Stage 2
M¼Moderate ¼Class or Clinical Stage 3
H¼High ¼Class or Clinical Stage 4
16 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

tree should lead to consideration for prompt revascularisation
(i.e., within a few days) in people with substantial perfusion
deficits. Once blood flow is improved and infection is
controlled, a definitive operation may be required to create a
functional foot, which may require soft tissue and bone
reconstruction.
105
Due to the risk of amputation in this clinical
scenario, the likelihood that the person will value avoidance of
amputation, and the need for appropriate prioritisation of
intervention strategies to achieve this, the Writing Committee
formulated a Best Practice Statement.
Recommendation 15
In a person with diabetes and a foot ulcer, when the wound
deteriorates or fails to significantly improve (e.g., a less than
50% reduction in wound area within four weeks) despite
appropriate infection and glucose control, wound care, and
offloading, reassess the vascular status and consult with a
vascular specialist regarding possible revascularisation.
Grade Certainty of evidence
Best Practice Statement
Rationale
Multiple factors may contribute to delayed or non-healing
of DFU, including presence of infection, wound size and
depth, elevated foot pressures at the wound site, and inad-
equate wound care. A number of studies have demonstrated
that a reduction in percentage of wound area of more than
50% by four weeks after presentation is predictive of healing
at 12 weeks.
106e109
This has been shown to be the case
independent of the ulcer size at baseline and supports review
of treatment protocols where adequate wound reduction is
not being achieved in the four week timeframe. Presence of
suspected CLTI or a DFU that is failing to adequately heal
despite best practice care requires prompt consultation with
a vascular specialist and assessment of whether a revascu-
larisation procedure is indicated. There is no direct evidence
supporting the recommendation which is a pragmatic
statement based on indirect evidence and expert opinion.
Given the risk of poor outcomes when PAD is left untreated
in a person with a poorly healing ulcer, a Best Practice
Statement has been made.
Recommendation 16
In a person with diabetes, peripheral artery disease, and
a foot ulcer or gangrene, avoid revascularisation when the
riskebenefit ratio for the probability of success of the
intervention is clearly unfavourable.
Grade Certainty of evidence
Best Practice Statement
Person with diabetes and an ulcer or gangrene
ABI 0.90–1.3, TBI ≥ 0.70, triphasic
or biphasic pedal Doppler waveforms,
persist with wound care and treatment
of infection as needed
Re-assess perfusion if there is lack of
healing progress at 4 weeks
Palpate pulses and examine for signs of ischaemia
Evaluate pedal Doppler waveforms, perform ABI and TBI
to diagnose or exclude PAD
Use Wifi to stratify healing likelihood and amputation risk
ABI < 0.4, ankle pressure < 50 mm Hg,
TP < 30 mm Hg or TcPO2 < 30 mm Hg
or monophasic or absent pedal Doppler
waveforms
Urgent revascularisation procedure should
be considered, consult vascular specialist
Absent pulses, monophasic or absent
pedal Doppler waveforms or ankle
pressure < 100 mm Hg or
TP < 60 mm Hg
Consult vascular specialist
unless urgent amputation
indicated
PAD, ulcer with infection
or gangrene
Urgent consultation by
vascular specialist
Wound care and offloading as
recommended by IWGDF
Assess for presence of infection and
manage as recommended by IWGDF
Figure 1. Assessment and management pathway for a person with diabetes, peripheral artery disease, and a foot ulcer with findings of
ischaemia, infection, or gangrene. Yellow ¼Conditional Recommendation; green ¼Strong Recommendation; gray ¼Best Practice
Recommendation; ABI ¼ankle brachial index; IWGDF ¼International Working Group on the Diabetic Foot; TBI ¼toe brachial index; TP ¼
toe pressure; PAD ¼peripheral artery disease; WIfI ¼Wound Ischaemia foot Infection classification system
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 17
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

Rationale
Revascularisation should not be performed if there is no
realistic chance of wound healing, when major amputation is
inevitable, a functional foot is unlikely to be achieved, or when
life expectancy is short and there is unlikely to be benefittothe
person. The Writing Committee considered that in such per-
sons any revascularisation procedure is unlikely to be of
benefit to the person and may cause harm. Many affected
individuals pose high peri-procedural risk because of comor-
bidities. In particular, the following people may not be suitable
for revascularisation: those who are very frail, have short life
expectancy, have poor functional status, are bed bound, and or
have a large area of tissue destruction that renders the foot
functionally unsalvageable and those who cannot realistically
be expected to mobilise following revascularisation. There are
occasional situations where an arterial inflow procedure is
performed to improve the likelihoodof healing of a major limb
amputation (below or above knee).
There is evidence from several observational studies of a
50% healing rate for ischaemic DFU in people with diabetes
unsuitable for revascularisation and this should also be
considered in determining choice of care.
74,100
The decision to
proceed to primary amputation, or to adopt a palliative
approach, should be made in conjunction with the person and
the multidisciplinary team
110
including a vascular specialist
unless an emergency procedure is indicated as discussed
earlier. The Writing Committee considered that in these cir-
cumstances where healing is improbable a person is unlikely to
value the outcomes from revascularisation over no revascu-
larisation. Similarly in such circumstances the benefitof
revascularisation will not outweigh the potential harms.
Clinical question
In people with diabetes, PAD, and either a foot ulcer or
gangrene, how does endovascular revascularisation
compare with open or hybrid revascularisation?
Recommendation 17
In a person with diabetes, peripheral artery disease, and a
foot ulcer or gangrene who has an adequate single segment
saphenous vein in whom infrainguinal revascularisation is
indicated and who is suitable for either approach, consider
bypass in preference to endovascular therapy.
Grade Certainty of evidence
Conditional Moderate
Recommendation 18
A person with diabetes, peripheral artery disease (PAD) and a
foot ulcer or gangrene, should be treated in a centre with
expertise in, or rapid access to, endovascular and surgical
bypass revascularisation. In this setting, consider making
treatment decisions based on the risk to and preference of the
individual, limb threat severity, anatomical distribution of
PAD, and the availability of autogenous vein.
Grade Certainty of evidence
Best Practice Statement
Rationale
Once the decision to revascularise has been made, the next
decision is whether an endovascular, an open (i.e., bypass
or endarterectomy) procedure, or a combination of both
(i.e., hybrid procedure) should be performed. Recommen-
dation 18 highlights the complementary role of open and
endovascular techniques in contemporary vascular practice.
In particular, endovascular techniques have largely replaced
open surgery in the management of aorto-iliac disease and
also allow treatment of foot and pedal arch disease.
The majority of studies identified in the systematic re-
view on endovascular and bypass surgical outcomes were
observational and retrospective case series, with a high risk
of bias.
7
The BEST CLI trial was a large randomised clinical
trial with low risk of bias comparing an endovascular first
with a surgical first approach. People with CLTI who were
deemed appropriate for revascularisation for infrainguinal
arterial occlusive disease were included.
111
The primary
outcome was above ankle amputation of the index limb or a
major re-intervention in the index limb (new bypass, vein
graft interposition revision, thrombectomy or thrombolysis)
or death. It was designed in two parallel cohort trials:
Cohort 1 people who had an adequate single segment great
saphenous vein (GSV) available for use as a bypass conduit,
and Cohort 2 people without an adequate single segment
GSV who required an alternate conduit. Treatment with a
GSV bypass first approach was superior to endovascular
therapy first for the primary outcome (hazard ratio [HR],
0.68; 95% confidence interval [CI] 0.59 e0.79; p<.001). In
Cohort 2 the primary outcomes were similar between the
two groups. Subgroup analysis of people in Cohort 1 fav-
oured surgery in people with diabetes (HR 0.72; CI 0.61 e
0.86) with benefit comparable with those without diabetes
(HR 0.57; CI 0.41 e0.78). At the time of writing this
guideline, further results of this study have not been pub-
lished. Of note, whole group data for Cohort 1 demon-
strated a higher rate of major amputation in those
undergoing an endovascular procedure compared with
those having surgery (Surgery: 74/709 [10.4%] Endovas-
cular: 106/711 [14.9%]). Further subanalysis may demon-
strate this is relevant to those with diabetes and therefore
this may affect an individual’s preference for intervention.
From the perspective of the person receiving treatment, the
difference in length of hospital stay should be taken into
account, which in the systematic review was longer in the
bypass publications than in endovascular publications. In
addition, people might prefer to have an endovascular
approach given the more invasive approach of bypass
surgery.
Considering costs, there are probably no major differ-
ences except the length of hospital stay; however, this is yet
to be determined and may be an additional outcome of the
BEST-CLI study. Subsequent analyses are also awaited to
shed more light on the anatomical patterns and extent of
disease treated, as well as which patterns of disease were
not well represented or excluded. As BEST-CLI is currently
the only randomised controlled trial (RCT) in this area, the
18 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

certainty of the evidence for the recommendation was
moderate. Given the important differences in outcomes in
the BEST-CLI trial it is recommended to consider bypass
surgery as the first option in people with a suitable
saphenous vein. It is acknowledged that this recommen-
dation may lead to some major changes in the policy of the
many centres, which currently have an endovascular first
approach for everyone.
The recommendation may not be feasible in the short
term in all countries due to the lack of equipment and
expertise. Finally, it should be noted that in the BEST-CLI
study, endovascular procedures could be performed in the
iliac and common femoral artery to ensure optimal inflow
into the bypass, emphasising that a centre treating PAD in
people with a DFU should have the expertise to perform
both endovascular and bypass procedures. In addition, in
some centres the immediate availability of an endovascular
approach might be a reason to opt for this treatment when
an urgent revascularisation is needed or when the surgical
risk is deemed too high. For these reasons and the mod-
erate certainty of the evidence a Conditional Recommen-
dation was made.
In people with diabetes in whom a revascularisation is
considered but who do not have a suitable single segment
GSV for bypass surgery, the results in BEST-CLI were similar
for endovascular and surgical bypass. This statement is in
line with the results of the systematic review, in which the
non-randomised and observational studies showed that the
evidence was inadequate to establish whether an endo-
vascular, open, or hybrid revascularisation technique is su-
perior. Each of these techniques has its advantages and
disadvantages. A successful distal venous bypass can result
in a marked increase of blood flow to the foot, but general,
spinal, or epidural anaesthesia is usually necessary and a
suitable vein, as a bypass conduit, should be present, as in
the BEST-CLI trial. An endovascular procedure has several
logistical advantages, but sometimes, very complex in-
terventions are necessary to obtain adequate blood flow in
the foot and a failed endovascular intervention may lead to
worse outcomes when an open procedure is performed
subsequently.
112
Over the past few decades, there have
been significant advances in endovascular techniques;
however, parallel to this, there have been improvements in
anaesthesia and peri-operative care that have helped
improve surgical outcomes. As there is no one size fits all
approach to treatment for people with diabetes, PAD, and
foot ulceration or gangrene, it is important that a treating
centre has the expertise and facilities to provide a range of
treatment options with availability of both endovascular
and open techniques. It is recommended that for each
person requiring lower limb revascularisation, all revascu-
larisation techniques should be considered (Fig. 2).
Clinical question
In people with diabetes, PAD, and either a foot ulcer or
gangrene, how does direct angiosome revascularisation
compare with indirect angiosome revascularisation?
Recommendation 19
In a person with diabetes, peripheral artery disease, and a
foot ulcer or gangrene, revascularisation procedures should
aim to restore in line blood flow to at least one of the foot
arteries.
Grade Certainty of evidence
Best Practice Statement
Rationale
In people with diabetes and a foot ulcer or gangrene
in whom revascularisation is required, optimising
blood flow to the foot is important to maximise the chance
of healing the foot and avoiding amputation. Incomplete
revascularisation (including treating inflow disease when
distal disease is present or bypassing into blind segment
arteries with no runoff), can result in delayed or non-wound
healing and a substantial risk of amputation.
Bypass surgery is ideally performed to an outflow
vessel that runs into the foot. However, bypasses per-
formed to the peroneal artery (which rely on collaterali-
sation to the foot) are most effective when there is good
collateralisation to the foot and a patent pedal arch is
present.
99
Pedal arch patency also seems to be associated
with improved wound healing and reduced risk of major
amputation.
113
Recommendation 20
In a person with diabetes, peripheral artery disease, and a
foot ulcer or gangrene undergoing an endovascular
procedure, consider targeting the artery on angiography that
supplies the anatomical region of the ulcer, when possible or
practical.
Grade Certainty of evidence
Conditional Very low
Rationale
Angiosomes are three dimensional regions of tissue and
skin supplied by a source artery. The six angiosomes of the
foot and ankle are supplied by the posterior tibial artery
(n¼3), peroneal artery (n¼2), and anterior tibial artery
(n¼1) (Fig. 3). Communications between angiosomes
include direct arterial to arterial connections, as well as
choke vessels which link adjacent angiosomes.
113e115
The
effect or influence of angiosome based revascularisation on
wound healing and prevention of amputation (major and
minor) in the management of diabetes related foot com-
plications remains controversial.
Direct revascularisation involves revascularisation of the
tibial artery supplying the angiosome in which the tissue
loss has occurred. The alternative to this is indirect revas-
cularisation where the tibial artery treated is the artery in
which successful in line flow to the foot is most likely to be
achieved by endovascular techniques or is deemed the best
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 19
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

tibial outflow vessel for anastomosis in bypass surgery but
does not directly supply the affected area of tissue loss. The
systematic review found that open vascular reconstruction
procedures were equally effective whether direct or indirect
revascularisation to the affected foot angiosome was
performed.
7
In addition, healing and amputation outcomes for direct
and indirect endovascular revascularisation show that if
direct revascularisation is possible, DFU healing time and
major amputation may be reduced compared with indirect
revascularisation. There is inadequate evidence to deter-
mine whether direct revascularisation is superior to indirect
revascularisation to prevent minor amputation.
116
Indirect
revascularisation with collaterals was associated with
wound healing and limb salvage outcomes which were
similar to direct revascularisation outcomes and notably
better than the indirect revascularisation without collateral
cohorts.
117e121
The majority of studies included in the systematic re-
view used endovascular procedures with data probably
favouring direct revascularisation. For bypass procedures
there was little difference in healing and amputation
outcomes at 12 months between direct and indirect
revascularisation.
121e124
These studies had a high risk of
bias, lacked randomisation (and it is unlikely that this will
ever be possible), and were mostly retrospective. Baseline
variables such as wound and foot staging (e.g., by WIfI)
and extent of tissue loss were reported infrequently.
Heterogeneity of the included studies was found to be
high, preventing meta-analysis of data. This is likely to be
due to high variability in participants and wound stage
(extent of tissue loss, severity of ischaemia, presence of
infection). Comparison of primary outcomes (healing and
amputation) or adverse events is therefore problematic.
Based on the available data it appears direct revascular-
isation may have improved outcomes and therefore it was
considered that this procedure is likely to be preferred by
people receiving treatment to improve healing and pre-
vent amputation. However, the Writing Committee
considered there is likely to be important variability in
patient values due to the lack of clear benefitofone
approach over the other.
Factors such as the severity of ischaemia and tissue loss
(e.g., WIfI staging) and patient suitability for the procedure
Assess GSV for suitability for bypass if open bypass
or endovascular intervention likely indicated
Patient deemed unfit for bypass or arterial
lesion considered suitable for straightforward
endovascular procedure
Patient suitable for bypass or endovascular procedure
Person with diabetes, PAD and an ulcer, gangrene
in whom revascularisation is indicated
Image arterial system from aorta to pedal arch using;
Arterial colour duplex ultrasound
CT Angiography
MR Angiography
or DS Angiography
DS angiography ± intervention
Ideally target artery supplying angiosome
associated with ulcer or gangrene
Single segment GSV suitable
for bypass not available
Endovascular procedure or
bypass
Suitable single segment GSV
Consider bypass
Figure 2. Approach to vascular intervention for a person with diabetes and a foot ulcer or gangrene. Yellow ¼
Conditional Recommendation; gray ¼Best Practice Recommendation; PAD ¼peripheral artery disease; CT ¼
computed tomography; GSV ¼great saphenous vein; MR ¼magnetic resonance; DS ¼digital subtraction.
Anterior tibial
artery
Medial plantar
artery
Lateral plantar
artery
Peroneal artery
Posterior tibial
artery
Posterior tibial
artery
Anterior tibial artery
Peroneal artery
Dorsalis pedis artery
Figure 3. Angiosome distribution in the lower leg and foot.
20 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

and presence of comorbidities, as well as the availability of
expertise and costs of the procedures (which may vary
between locations and countries) drives decision making in
relation to the type of procedure considered appropriate
with these factors also impacting. Several studies have
noted that only a minority of foot and ankle wounds in their
series corresponded to one angiosome. Kret et al.
125
found
that only 36% of wounds in their series corresponded to a
single distinct angiosome. Similarly, Aerden et al.
126
found it
difficult to allocate people to direct revascularisation versus
indirect revascularisation due to the presence of multiple
wounds and large wounds that had more than one angio-
some supplying them. In such cases it is the opinion of the
Writing Committee that the best quality artery should
preferentially be targeted. Many clinicians will consider
attempting to treat the second vessel supplying the wound
as well, although there is a lack of evidence to support this
approach.
7
Clinical question
In people with DFU, do revascularisation perfusion out-
comes predict healing, major amputation, or the need for
further revascularisation?
Recommendation 21
In a person with diabetes and either a foot ulcer or gangrene
who has undergone revascularisation, objectively assess
adequacy of perfusion e.g., using non-invasive bedside testing.
Grade Certainty of evidence
Best Practice Statement
Rationale
There are few available data examining the predictive
capacity of post-revascularisation perfusion measures for
healing or amputation outcomes or for the need for
further revascularisation in people with diabetes. How-
ever, adequate perfusion is essential for wound healing
and clinical examination is often too unreliable. Diabetes
related PAD is characterised by atherosclerotic plaque
formation that is long and diffuse in nature and more
likely to involve distal vascular beds. Frequently, long
term patency is not achieved in endovascular treatment
of tibial lesions.
127
Regular assessment of perfusion post-revascularisation
should therefore be undertaken due to the risk of occlu-
sion and restenosis after intervention. This should be con-
ducted in combination with regular assessment of the foot
lesion to determine whether healing is indeed taking place.
It is recommended that revascularisation should aim to
improve perfusion to the foot as much as possible, which
will vary according to the individual. Due to the lack of data
available determining the optimum time frame for follow
up and the likelihood that this may vary depending on the
testing methods being used, a Best Practice Statement
based on indirect evidence and expert opinion has been
made.
Recommendation 22
A person with diabetes, peripheral artery disease, and either
a foot ulcer or gangrene should be treated by a
multidisciplinary team as part of a comprehensive care plan.
Grade Certainty of evidence
Best Practice Statement
Rationale
As discussed in several parts of this guideline and in other
IWGDF guidelines on the diagnosis and management of
DFU, restoration of perfusion in the foot is only part of the
treatment, which should be provided by a multidisciplinary
care team.
43
Lack of access to specialist care is associated
with worse foot outcomes. In rural and remote locations
and areas where specialist access is challenging, referral
pathways that address care access (e.g., through virtual
referral pathways) are essential to establish to provide
multidisciplinary care.
128
Any revascularisation procedure
should therefore be part of a comprehensive care plan that
addresses other important issues including: prompt treat-
ment of concurrent infection, regular wound debridement,
biomechanical offloading, control of blood glucose, cardio-
vascular risk reduction, and treatment of co-morbidities.
128
Moreover, once the ulcer has healed the risk of recurrence
is up to 50% over five years in several studies so preventive
measures need to be taken and many people need long
term follow up by a dedicated foot complication prevention
team.
26
Clinical question
In a person with diabetes, PAD, and a foot ulcer, which
medical treatments should be advised to prevent major
adverse cardiovascular events (MACE), major adverse limb
events (MALE), and death?
MACE is defined as a composite of non-fatal stroke, non-
fatal myocardial infarction, and cardiovascular death.
MALE is defined as the development of severe lower leg
ischaemia leading to a vascular intervention or a major
lower leg amputation.
These definitions vary slightly between studies.
People with diabetes and PAD (with or without a foot
ulcer) are at a very high cardiovascular risk. Cardiovascular
risk factor goals should always be individualised, taking life
expectancy, expected benefit, treatment burden, potential
drug interactions, and undesirable treatment effects into
account. While taking these considerations into account,
the Writing Committee suggests the following treatment
targets to reduce the risk of future major adverse limb and
cardiovascular events.
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 21
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

Recommendation 23
In a person with diabetes and peripheral artery disease, the
following target levels should be:
HbA1c <8% (<64 mmol/mol), but higher target HbA1c
value may be necessary depending on the risk of severe
hypoglycaemia.
Blood pressure <140/90 mmHg but higher target levels
may be necessary depending on the risk of orthostatic
hypotension and other side effects.
Low density lipoprotein target of <1.8 mmol/L (<70 mg/dL)
and reduced by at least 50% of baseline. If high intensity
statin therapy (with or without ezetimibe) is tolerated,
target levels <1.4 mmol/L (55 mg/dL) are recommended.
Grade Certainty of evidence
Best Practice Statement
Recommendation 24
In a person with diabetes and symptomatic peripheral artery
disease:
treatment with single antiplatelet therapy should be used,
treatment with clopidogrel should be considered as first
choice in preference to aspirin,
combination therapy with aspirin (75 mg to 100 mg once
daily) plus low dose rivaroxaban (2.5 mg twice daily)
should be considered for people without a high bleeding
risk.
Grade Certainty of evidence
Best Practice Statement
Recommendation 25
In a person with type 2 diabetes and peripheral artery
disease:
with an eGFR >30 mL/min/1.73m
2
, a sodium glucose
cotransporter-2 (SGLT-2) inhibitor or a glucagon like
peptide 1 receptor agonist with demonstrated
cardiovascular disease benefit should be considered,
irrespective of the blood glucose level.
SGLT-2 inhibitors should not be started in drug naïve
people with a diabetes related foot ulcer or gangrene and
temporary discontinuation should be considered in people
already using these drugs, until the affected foot is healed.
Grade Certainty of evidence
Best Practice Statement
Rationale
The Writing Committee decided to not write their own
guidelines on pharmacological interventions in people with
diabetes, PAD, and a foot ulcer or gangrene in order to
reduce cardiovascular risk or to prevent major limb events
as defined above. There are already a number of guidelines
on cardiovascular risk prevention in people with diabetes
and cardiovascular disease, and thus another guideline
would have little added value. It was decided to base the
Best Practice Statements on the GVG for CLTI produced by
the ESVS, SVS, and World Federation of Vascular Societies
(WFVS),
20
as these address the specific population of peo-
ple with CLTI. However, it was also felt that some of the
recommendations of the CLTI guidelines should be adapted
to the specific population of people with diabetes. When it
was felt applicable, the guidelines of the American Diabetes
Association (ADA), the European Association for the Study
of Diabetes (EASD) and other guidelines on peripheral ar-
tery disease (European Society of Cardiology [ESC]-ESVS,
European Society of Vascular Medicine [ESVM], and ESC-
EASD, ESC- European Atherosclerosis Society [EAS]) were
used.
16e19,22,23,129
PAD runs a more aggressive course in those with diabetes
mellitus compared with those without diabetes, with an
elevated risk of lower leg amputation. In addition, the
combination of diabetes and PAD is associated with a high
risk of developing complications in other vascular beds. As
discussed previously, persons with an ischaemic diabetes
related foot ulcer have an overall five year cardiovascular
mortality of around 50%.
130
Therefore, according to the
international guidelines of several major vascular and dia-
betes associations, these individuals should be considered
as having a very high cardiovascular risk and should be
treated as such. On the other hand, they usually have, in
addition to peripheral neuropathy, other diabetes related
complications as well as several co-morbidities, resulting in
a high burden of diseases and multiple medications.
30
Many
affected persons are elderly, frail, and are living in vulner-
able socio-economic circumstances with a low quality of
life.
131,132
It is therefore essential that cardiovascular risk
factor management in these people should be individu-
alised, tailored, and should be part of a shared decision
making process, taking life expectancy, diabetes related
complications and co-morbidities, expected benefit, treat-
ment burden, drug interactions, and undesirable treatment
effects into account. This care should be provided by
healthcare worker(s) with sufficient expertise in treating
cardiovascular risk factors and glycaemia, preferably by
person(s) who are part of the multidisciplinary team for
diabetes related foot care.
Glycaemic goals. As stated in the ADA and ESC-EASD
guidelines, near normal glycaemia with HbA1c level below
7.0% (53 mmol/mol) will decrease microvascular compli-
cations.
18,22
Tighter glucose control initiated early in the
course of diabetes in younger individuals leads to a reduc-
tion in macrovascular complications, i.e., cardiovascular
outcomes, over a 20 year timescale. Such glucose control
can have beneficial effects on microvascular complications
in a shorter period of time. However, when blood glucose
lowering agents are used that have the risk of severe
hypoglycaemia, this can increase the risk of cardiovascular
events and death, as detailed in the ADA and ESC-EASD
guidelines.
18,129
As many people with a DFU and PAD also
have atherosclerotic disease in other vascular beds, tight
glucose control can be harmful. The risk of hypoglycaemia is
markedly lower when people are only treated with met-
formin, a sodium glucose cotransporter-2 inhibitor or a
glucagon like peptide 1 receptor agonist. Tight glucose
control is often not indicated in people with PAD and a DFU
due to the risk of hypoglycaemia outweighing the potential
22 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

benefit. The ADA recommends in the 2022 Standards of
Care to aim for an HbA1c <8% (<64 mmol/mol) in such
persons and the ESC-EASD 2019 guideline for levels below
8e9% (<64 e75 mmol/l).
18,129
However, the target chosen
will depend on factors such as age, duration of diabetes,
complications, co-morbidities, and risk of hypoglycaemia.
These target HbA1c levels are higher than the level formu-
lated in the GVG for CLTI (<7.0%, 53 mmol/mol), but as
discussed above it is concluded that the risk of such tight
blood glucose control is too high in this specific population.
Blood pressure goals. The ESC-EASD guidelines state that
RCTs have demonstrated the benefit (reduction of stroke,
coronary events, and kidney disease) of lowering systolic BP
to <140 mmHg and diastolic BP to <90 mmHg.
18
Usually,
multiple drugs are necessary to reach these levels in people
with diabetes. In younger people (e.g., younger than 65
years) levels below 130/80 mmHg can be considered if
there are no contraindications for such tight blood pressure
control and the risk of orthostatic hypotension is low. Both
the ADA and ESC-EASD stress the importance of individu-
alised treatment as overly aggressive blood pressure
lowering is not without risk in the usually elderly with a DFU
and those with multiple diabetes related complications and
co-morbidities. Therefore, in these people blood pressures
<140/90 mmHg are recommended, but in younger in-
dividuals (e.g., <65 years) and with a small risk of adverse
effects of the treatment, lower target levels might be
considered.
Lipid goals. The ADA and EASD guidelines recommend in
persons with diabetes and atherosclerotic cardiovascular
disease an LDL target of <1.8 mmol/L (70 mmol/L).
21
In
line with the lower the better approach, recent trials sug-
gest that lower levels of LDL of <1.4 mmol/L (55 mg/dL)
can be beneficial in persons with a very high cardiovascular
risk. Therefore, the recent ESC-EASD and ESC-EAS guidelines
recommend that such very low LDL levels should be the
target in these individuals.
18,19
In those with recurrent
events within two years, even LDL levels <1.0 mmol/L (40
mg/dL) are suggested as target in ESC-EAS guidelines.
19
With statin therapy such as rosuvastatin 20 e40 mg or
atorvastatin 40 e80 mg, marked reductions of LDL
cholesterol can be achieved if these relatively simple
treatments are tolerated. When the target is not reached
ezetimibe can be added, which is available in combination
tablets with both statins. These treatments have limited
side effects in most (but not all) people and are relatively
inexpensive. According to the recent ESC-EASD and ESC-EAS
guidelines, an LDL level below 1.0 mmol/L (40 mg/dL) can
be the target in people with recurrent cardiovascular events
(within two years), based on a limited number of RCTs in
which relatively few participants with CLTI and diabetes
were included. To reach the aforementioned very low LDL
levels, additional treatment with a PCSK9 inhibitor will be
necessary in a proportion of people. PCSK9 inhibitors are
monoclonal antibodies that have limited side effects but
have the drawback of high costs, parenteral administration,
and at present there is very limited evidence of the cost
effectiveness of PCSK9 inhibitors in people with diabetes,
PAD, and a foot ulcer or gangrene. In addition, the use of
these expensive drugs is a problem for many countries in
the world, and for these reasons a recommendation on LDL
level below 1.0 mmol/L (40 mg/dL) for this specific popu-
lation was not included, but it is acknowledged that in
several countries PCSK9 inhibitors are used to reach these
goals in those with recurrent cardiovascular events.
In line with the other cardiovascular risk reduction in-
terventions in these usually frail, multimorbid individuals,
treatment and its goals should be based on shared decision
making and should be individualised after careful weighting
of the benefits, harms, and costs. The LDL (and other)
treatment targets in the recommendation should not be
interpreted as absolute goals but more as desired goals.
Even if the goal is only partially met, it can result in a
marked reduction in cardiovascular events in these very
high risk people. Although very low LDL levels are perhaps
not achievable in all, LDL reductions of up to 50% can be
achieved in many with the aforementioned potent statins
(and ezetimibe), with marked reduction in cardiovascular
risk.
16
Additional therapies
Antithrombotic therapy. The subsequent advice on anti-
platelet therapy is in line with the recent ESVS antith-
rombotic guidelines.
137
All guidelines strongly recommend
treatment with a single antiplatelet agent in persons with
symptomatic cardiovascular disease, or more specifically
chronic limb threatening ischaemia (CLTI). These drugs
reduce the risk of cardiovascular events; for the increased
risk of gastric bleeding in aspirin treated individuals, a
proton pump inhibitor as additional treatment should be
considered. There is less consensus regarding which drug to
choose, clopidogrel or aspirin. The ADA and ESC-EASD
guideline advises aspirin as first choice in persons with
diabetes and a cardiovascular event but did not specify for
the presence of PAD.
18,21
In the recent ESVM, ESC-ESVS,
and GVG guidelines, clopidogrel is considered as the anti-
platelet agent of choice in those with PAD. This recom-
mendation is in particular based on The Clopidogrel versus
Aspirin in Patients at Risk for Ischaemic Events (CAPRIE)
trial, in which clopidogrel was more effective in reducing
cardiovascular risk without an increased risk of bleeding.
133
It should be noted that only a subset of participants in this
trial had PAD, of which only 21% had diabetes. Also, a meta-
analysis did not show any benefit from aspirin for those
with PAD.
134
A post hoc subanalysis of the CAPRIE trial
showed that clopidogrel was superior to aspirin in reducing
recurrent ischaemic events in those with diabetes.
135
The
relative risk reduction was comparable with those without
diabetes, but due to the greater number of events among
people with diabetes, the absolute risk reduction was even
larger. Given the potential benefit, it is suggested in a
Conditional Recommendation that clopidogrel should be
considered as first choice, in line with the aforementioned
guidelines.
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 23
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

As an additional alternative to single antiplatelet therapy,
combination therapy with aspirin (100 mg once daily) plus
low dose rivaroxaban (2.5 mg twice daily) should be
considered for those with low bleeding risk to prevent car-
diovascular events as well as reduce extremity ischaemic
events in those with CLTI, as suggested by the GVG, ESVM,
and ESC-EASD guidelines and the 2023 ADA Standards of
Care.
16,20,23,129
This suggestion is based on the COMPASS
trial in which this combination therapy was more effective
than aspirin but was also associated with an increased risk of
clinically relevant bleeding, mostly gastrointestinal.
136
In this
trial approximately 38% had diabetes mellitus and the
benefit of the combination therapy seemed similar in those
with and without diabetes. Given this limited evidence base
and the added treatment burden for this frequently vulner-
able cohort, a Best Practice Statement in line with the ESVS
and ADA recommendations was made.
129,137
It should be
noted that in the COMPASS trial in addition to a high
bleeding risk of rivaroxaban, other exclusion criteria included
end stage renal disease, severe heart failure, recent stroke,
history of haemorrhagic or lacunar stroke, and poor life ex-
pectancy.
138
A network meta-analysis showed no superiority
for aspirin with rivaroxaban over clopidogrel alone for the
primary composite endpoint in the chronic PAD subgroups of
CAPRIE and COMPASS.
139
Therefore in the absence of a RCT
directly comparing the two, both clopidogrel alone and
aspirin with rivaroxaban are reasonable choices for second-
ary cardiovascular prevention for patients with chronic
symptomatic PAD, but the risk of bleeding and contraindi-
cations should be taken into account when discussing the
options with the patient.
137
The ESVS antithrombotic
guidelines recommend that those not at high risk of bleeding
who undergo an endovascular intervention for lower ex-
tremity PAD may be considered for a one to six month
course of dual antiplatelet therapy (aspirin plus clopidogrel)
to reduce the risk of MACE and MALE followed by single
antiplatelet therapy.
137
Similarly, those undergoing endovas-
cular intervention who are not at high risk of bleeding should
be considered for aspirin (75 e100 mg daily) and low dose
rivaroxaban (2.5 mg twice daily) to reduce the risk of MACE
and MALE.
137,140
If the bleeding risk is considered to be high,
single antiplatelet therapy should be used post-intervention.
If clopidogrel is used in addition to aspirin and low dose
rivaroxaban after endovascular intervention, clopidogrel
should only be used for <30 days as with longer term use
the bleeding risk is likely to outweigh the benefit.
137,141
The ESVS antithrombotic guidelines recommend that
those undergoing infrainguinal endarterectomy or bypass
surgery who are not at high risk of bleeding should be
considered for aspirin (75 e100 mg daily) and low dose
rivaroxaban (2.5 mg twice daily) to reduce the risk of MACE
and MALE. Those persons undergoing infrainguinal bypass
surgery with autogenous vein who are not at high bleeding
risk may be considered for treatment with vitamin K
antagonist to improve graft patency.
137,142
Those undergoing infrainguinal bypass with a prosthetic
graft may be considered for single antiplatelet therapy.
Persons at high risk of bleeding undergoing lower extremity
bypass surgery using an autogenous or prosthetic conduit
may be considered for single antiplatelet therapy to
improve graft patency.
137
Arterial duplex scanning post-autologous vein bypass
surgery is generally advised post-procedure to detect graft
stenoses. The benefits of post-procedure surveillance
following endovascular intervention remain uncertain;
following local protocols is suggested.
Glucose lowering therapies. In recent years it has become
increasingly clear that several sodium glucose
cotransporter-2 (SGLT-2) inhibitors and glucagon like pep-
tide 1 receptor (GLP-1) agonists, which were originally
developed to lower blood glucose levels, can also have
beneficial cardiovascular effects in persons with type 2
diabetes.
21
These effects are independent of their blood
glucose lowering effect. To what extent this benefit can also
be observed in those with type 1 diabetes mellitus, in
whom glucose management with these drugs only has a
limited (SGLT-2 inhibitors) or no (GLP-1 agonists) role to
play, remains to be established. In individuals with an eGFR
<30 mL/min/1.73m
2
, these drugs are contraindicated.
Therefore, it is advised to consider these drugs in type 2
diabetes mellitus and peripheral artery disease with an
eGFR >30 mL/min/1.73m
2
after careful review and
possibly adjustment of other blood glucose lowering
medication to prevent hypoglycaemia, but for SGLT-2 in-
hibitors there are additional caveats.
The SGLT-2 inhibitor canagliflozin was associated with an
increased risk of amputation in an RCT. This was not a pre-
specified endpoint and was not observed in the other SGLT-
2 inhibitor trials
143
or in long term prospective studies, as
concluded in the ADA-EASD 2022 consensus report.
144
In
addition, in post hoc analyses, these drugs had beneficial
cardiovascular and renal effects in people with peripheral
artery disease.
145
However, individuals with foot ulcers
were frequently excluded in SGLT-2 inhibitor trials and there
is a second caveat to be considered. Diabetes related
ketoacidosis is a rare but serious side effect of SGLT-2 in-
hibitors and prolonged fasting, acute illness and the peri-
operative period predispose to developing ketoacidosis. In
these situations, the ADA-EASD recommend temporary
discontinuation of the medication, i.e., three days prior to
surgery.
144
Like those with PAD, a diabetes related foot
ulcer or gangrene have a high risk of developing a foot
infection or to undergo one or more (urgent) surgical pro-
cedures, it is suggested for pragmatic reasons that SGLT-2
inhibitors should not be started in drug naïve individuals
and that temporary discontinuation should be considered in
those already using these drugs, until the affected foot is
healed.
Postscript
The targets discussed in this text are based on reduction of
cardiovascular events, but it should be noted that this is a
composite endpoint and the definition between trials dif-
fers. MALE is also sometimes differently defined and the
24 Robert Fitridge et al.
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

evidence for reducing lower limb events in persons with
diabetes, PAD, and a foot ulcer by pharmacological treat-
ment is scarce. For this reason, a specific recommendation
on this topic could not be made.
FUTURE RESEARCH PRIORITIES
One of the main limitations of this guideline is the lack of
prospective randomised trials, inconsistency of classification
and outcomes reported, and lack of separation of outcome
for people with CLTI with and without diabetes. Data
reporting on PAD in relation to diagnosis, prognosis, and
management overwhelmingly relate to the general popu-
lation. There is a paucity of high level evidence for diagnosis
and management of those with DFU or gangrene, with
studies frequently including only persons with intact feet or
inadequately detailing (or controlling for) confounding fac-
tors including presences of neuropathy, ulcer, infection, or
other contributors to poor outcomes. Moreover, few studies
in CLTI cohorts provide subanalysis for those with diabetes,
although they are likely to make up the majority of the
included population. As such, there is clearly a need for
further research into this unique subgroup of individuals
with diabetes, so that outcomes around the world can be
improved. The Writing Committee considers there are a
number of priority areas for future research. The systematic
review of the prognostic capacity of bedside vascular testing
to predict DFU healing and amputation outcomes demon-
strated a lack of investigations of sufficient quality for
several widely available tests including TBI and TcPO
2
, with
inconsistent use of measurement thresholds and a lack of
data examining the effect of combining test outcomes. New
technologies to develop optimal tools and measures of foot
perfusion for people with DFU and PAD to guide revascu-
larisation therapies would be invaluable in guiding revas-
cularisation strategies for individuals and for determining
when more aggressive strategies are indicated.
Further questions
Which group of people with diabetes and a DFU, tissue loss,
or gangrene most benefit from urgent revascularisation, and
who may benefit from an initial expectant management?
The Writing Committee has made a Best Practice State-
ment attempting to define which people are likely to
benefit most from urgent vascular assessment and revas-
cularisation. Further studies to clarify person and limb
related factors are needed and such predictions may be
facilitated by new prediction methods such as machine
learning.
146
Do newer endovascular revascularisation adjuncts and
techniques developed for infrapopliteal revascularisation
positively impact on patency rates and person centred
endpoints (amputation free survival, improved wound
healing, and health related quality of life) in those with
diabetes, PAD, and a foot ulcer?
A number of new technologies have been developed to
enhance patency of endovascular interventions, including
drug eluting balloons and stents, and bioresorbable vascular
scaffolds and stents. Atherectomy and lithotripsy devices
have been developed to deal with heavily calcified lesions.
Venous arterialisation has also been introduced to attempt
to revascularise those with no option for revascularisa-
tion.
147,148
The role and indications for these interventions
in the general population with CLTI, and in particular those
with diabetes, remains to be clarified.
Identify effective regenerative therapies (e.g., cell or gene
based) to improve foot perfusion in persons with DFU and
PAD who are not candidates for standard revascularisation.
Angiogenesis (formation of new blood vessels from
existing ones) is important for the development of arterial
collateral formation in response to arterial occlusion and
also for wound healing. Diabetes and hyperglycaemia are
associated with impaired angiogenesis. A number of cell,
gene, and protein based therapeutic approaches have, and
are, being trialled for both no option CLTI and wound
healing in diabetes. There are currently no therapies that
have proven beneficial and trials are ongoing.
149
CONTRIBUTION OF AUTHORS
The Writing Committee was chaired by R.F. (on behalf of
the IWGDF), with R.H. (on behalf of the ESVS) and J.L.M (on
behalf of the SVS) as co-chairs and supported by N.S. (on
behalf of the IWGDF). V.C. acted as scientific secretary. The
three organisations involved were each tasked to select six
well recognised experts to create an international, multi-
disciplinary, writing committee of 18 members in total. Care
was taken to have a global, multidisciplinary group that
included disciplines such as vascular surgery, angiology,
interventional radiology, vascular medicine, endocrinology,
epidemiology, and podiatry.
All members of the Writing Committee were involved in
summarising the available evidence in the supporting sys-
tematic reviews, that are published separately, and in
writing this guideline. Several members (the chairs, scien-
tific secretary, N.S, and M.S.C.) were assigned to write in-
dividual sections of the guideline, and all authors reviewed
and discussed the evidence obtained, the evidence to de-
cision items according to GRADE, and each recommenda-
tion during group meetings. All authors reviewed and
agreed with the final document before societal review and
subsequent submission for endorsement. All members of
the working group undertook Level 1 GRADE training, and
the several working group members undertook Guideline
Methodology training (McMaster University).
ACKNOWLEDGEMENTS
We would like to thank the following external experts for
their review of our PICOs for clinical relevance and the
guideline document: Sriram Narayanan (Singapore), Rica
Tanaka (Japan), Ismail Cassimjee (South Africa), Xu Jun
(China), Heidi Corcoran (Hong Kong), Yamile Jubiz
(Colombia), Tsvetalina Tankova (Bulgaria), and our patient
representatives. Production of the 2023 IWGDF Guidelines
was supported by unrestricted grants from: Advanced Ox-
ygen Therapy Inc., Essity, Mölnlycke, Reapplix, and Urgo
Medical. These sponsors did not have any communication
Intersocietal Guidelines on PAD in People with DM and Foot Ulcer 25
Please cite this article as: Fitridge R et al., The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot
Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020

related to the systematic reviews of the literature or related
to the guidelines with working group members during the
writing of the guidelines and have not seen any guideline or
guideline-related document before publication.
APPENDIX A. SUPPLEMENTARY DATA
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ejvs.2023.07.020
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Ulcer, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2023.07.020