Position Paper on the Diagnosis and Treatment of Peripheral ArterialDisease (PAD) in People with Diabetes Mellitus

This position paper is based on the current German and international guideline recommendations [ 1 ] [ 2 ] [ 3 ] and serves as a short, clinically-oriented guideline for the diagnosis and treatment of patients with diabetes mellitus and peripheral arterial disease (PAD). Peripheral circulatory disorders of the pelvic and leg arteries are one of the complications patients with diabetic mellitus suffer from. The term covers stenoses, occlusions and - to a lesser extent - aneurysmal vascular changes of the pelvic leg arteries. Arterial vascular lesions mostly occur in later life, however, people with diabetes mellitus are often affected prematurely. In these patients, the time of the initial manifestation also depends on the duration of the disease and the quality of metabolic control. Only 25% of affected patients have symptoms. Especially in patients with diabetes mellitus, atheroma of the peripheral vessels is aggravated by chronic inflammatory vessel wall processes and hypercoagulability. Second to nicotine abuse, diabetes is the most important risk factor for the occurrence of PAD [ 4 ]. Patients with diabetes have a 2 to 4-time higher risk of developing PAD than patients without diabetes. Up to 30% of all patients with claudication and 50% of all patients with critical limb ischemia (CLI) are people with diabetes mellitus [ 5 ]. PAD patients with diabetes have specific anatomical-morphological and clinical characteristics which must be considered in the diagnostic and therapeutic approach. Compared to people without diabetes mellitus, PAD in people with diabetes mellitus develops earlier, progresses more rapidly and more frequently changes over to critical limb ischemia (CLI). Anatomically-morphologically, a multi-segmental manifestation with long, calcified stenoses/occlusions of the lower leg arteries with insufficient collateral formation is typical. Clinically, people with diabetes mellitus often first consult their doctors because of a critical ischemia, in part because the intermittent claudication preceding a critical ischemia and the pain at rest can remain masked for a long time by the diabetic sensory polyneuropathy. The prognosis regarding a life without amputations is poor for people with diabetes mellitus. This is due, on the one hand, to the high ischemia and ulcer recurrence rates and the associated minor and major amputations, on the other hand it results from the high rate of comorbidities and co-prevalence of terminal organ damage such as cardiac and renal insufficiency, each of which on its own increases mortality. The most significant consequences of diabetic peripheral circulatory disorders are foot lesions (ulcers and gangrene) and minor and major amputations as a result of ischemic or neuro-ischemic diabetic foot syndrome (DFS) ([ Table 1 ]).