Clinical Features and Diagnosis of Peripheral Arterial Disease

Diabetes mellitus is a well-established risk factor for the development of peripheral arterial disease (PAD). The spectrum of disease in PAD ranges from asymptomatic to rest pain and tissue loss. Patients with diabetes frequently are asymptomatic until they develop a foot wound and subsequently experience poor wound healing due to the lack of perfusion. PAD is broadly defined as an ankle-brachial index (ABI) of less than 0.9. The evaluation of PAD in patients with diabetes begins with a good physical exam, including an inspection of the feet and a thorough pulse exam. The American Diabetes Association recommends that all patients with diabetes undergo screening ABI every 5 years. If the ABI is decreased or there is a concern for ischemia upon examination, further noninvasive arterial testing should be performed. Duplex ultrasound and computed tomography (CT) angiography are important adjuncts to this workup, providing information on the anatomy of atherosclerotic disease. The gold standard in the evaluation of lower extremity PAD remains to be digital subtraction angiography, which allows for a detailed assessment of the arterial anatomy, especially of the smaller tibial and pedal arteries, and allows for endovascular revascularization if warranted or if planning for open revascularization.