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Exp Clin Endocrinol Diabetes 2022; 130(S 01): S127-S136
DOI: 10.1055/a-1624-3631
German Diabetes Association: Clinical Practice Guidelines

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

Joint Statement of the German Diabetes Society (DDG), The German Angiology Society (DGA) and The German Society for Interventional Radiology and Minimally-Invasive Therapy (DeGIR) German Society for Vascular Surgery and Vascular Medicine (DGG)
Bernd Balletshofer   *
1   Angiology Centre, Tübingen, Germany
,
Dittmar Böckler   *
2   Department of Vascular Surgery and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
,
Holger Diener   *
3   Department of Vascular Surgery and Endovascular Surgery, Buchholz Hospital, Buchholz, Germany
,
Jörg Heckenkamp   *
4   Department of Vascular Surgery, Niels Stensen Hospitals, Marienhospital Osnabrück, Osnabrück, Germany
,
Wulf Ito   *
5   Heart and Vascular Center Oberallgäu, Kempten, Germany
,
Marcos Katoh   *
12   Department of Diagnostic and Interventional Radiology, Helios Hospital, Krefeld, Germany
,
Holger Lawall   *
6   Joint practice Prof. Dr. C. Diehm/Dr. H. Lawall, Max Grundig Clinic Bühlerhöhe, Ettlingen, Germany
,
Nasser Malyar   *
7   Department of Cardiology I – Coronary Heart Disease, Heart Failure and Angiology, University Hospital, Münster, Germany
,
Yves Oberländer   *
8   Department of Internal Medicine 1 for Diabetology, Endocrinology, Cardiology and Angiology, Marienhospital, Stuttgart, Germany
,
Peter Reimer   *
9   Institute for Diagnostic and Interventional Radiology, Städtisches Krankenhaus, Karlsruhe, Germany
,
Kilian Rittig   *
10   Department of Internal Medicine IV, Angiology and Diabetology, Klinikum Frankfurt (Oder), Germany
,
Markus Zähringer   *
11   Department of Diagnostic and Interventional Radiology, Marienhospital, Stuttgart, Germany
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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 ischaemia (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 changes over more frequently to critical limb ischaemia (CLI). Anatomically-morphologically, a multi-segmental manifestation is typical with long, calcified stenoses/occlusions of the lower leg arteries with insufficient collateral formation. Clinically, people with diabetes mellitus often first consult their doctors because of a critical ischaemia, in part because the intermittent claudication preceding a critical ischaemia 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 ischaemia 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 ischaemic or neuro-ischaemic diabetic foot syndrome (DFS) ([Tab. 1]).

Tab. 1 Classification of PAD according to Fontaine and Rutherford.

Fontaine

Rutherford

Stage

Clinical picture

Degree

Category

Clinical picture

I

Asymptomatic

0

0

Asymptomatic

IIa

Walking distance>200 m

I

1

Mild IC

IIb

Walking distance<200 m

I

2

Moderate IC

I

3

Severe IC

III

Ischaemic pain at rest

II

4

Ischaemic pain at rest

IV

Ulcer, gangrene

III

5

Small patches necrosis

III

6

Large patches necrosis

IC=Intermittent claudication.

WHAT DOES IT MEAN?

  • The number of patients with PAD and diabetes is constantly increasing.

  • The risk of amputation in people with diabetes mellitus is significantly increased in the presence of PAD.

  • Timely detection of PAD reduces the amputation and cardiovascular event rates if treatment is in accordance with guidelines.

  • Interdisciplinary cooperation and rapid revascularisation are crucial in critical limb ischaemia.

* Authors in alphabetical order




Publication History

Article published online:
22 April 2022

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