8–10 The pathological processes of atherosclerosis Selleckchem Inhibitor Library in those with and without diabetes are broadly similar, as are the main risk factors which include smoking, diabetes, increasing age, abnormal lipid profile, hypertension, and renal disease. Increasing HbA1c is associated with an increasing risk of PAD.11 All patients with PAD should therefore have their diabetes and hypertension well controlled, receive appropriate statin and antiplatelet therapy

unless contraindicated, and smoking should be discouraged. In diabetes patients with PAD there is a greater tendency for the below knee (‘tibial’ or ‘crural’) vessels to be diseased than in the non-diabetic population.12 This propensity for more distal disease influences the types of endovascular and surgical treatment required to revascularise a compromised limb. PAD can result in increased morbidity and impair quality of life through intermittent claudication, rest pain, lower limb ulceration,13 or amputation. The overall incidence Pirfenidone mw of amputations (minor or major) is significantly higher in those with diabetes (2.51 per 1000 person-years) than in those

without (0.11 per 1000 person-years).1 The term ‘critical limb ischaemia’ (CLI) is reserved for the most advanced form of PAD where limb viability is becoming threatened. The prevalence of CLI has been reported as 0.24% in an unselected population of 40–69 year olds, with diabetes increasing the risk.14 Survival in patients with CLI is poor, with one-year mortality rates being over 30% and approximately 25% of patients undergo major amputation within one year.15–17 There are a number of definitions and classifications of PAD available to define the presence and severity of disease5,18,19 but they are not used consistently in clinical practice.10 Formalising a precise and workable definition for CLI has been problematic. In simple terms, CLI is characterised by ‘chronic rest pain (over two weeks), tuclazepam or ulceration, and/or gangrene due to objectively proven arterial occlusive disease’.5 In an

attempt to identify those patients with true limb threatening ischaemia more precisely, ankle or toe arterial occlusion pressures were added to the diagnostic criteria for CLI. Examples of these are an occlusion pressure of 50mmHg at the ankle or 30mmHg at the toe, or in the presence of tissue loss higher levels of 70mmHg and 50mmHg respectively.5 Unfortunately, the problem with arterial occlusion pressure measurements is that not all patients with low ankle and/or toe pressures will end up with tissue loss, and some patients with higher pressures than these may develop tissue loss. The diabetes population may have artifactually elevated ankle pressures due to calcification of the vessel walls. This makes them incompressible for accurate arterial pressure measurement and hence the ankle brachial pressure index (ABPI) may be falsely elevated.