Acta Scientific Orthopaedics (ISSN: 2581-8635)

Review Article Volume 4 Issue 11

Screening and Diagnosis of Peripheral Arterial Disease in Patients with Diabetes: Current Perspectives

Alfred Gatt*, Corene Gatt and Cynthia Formosa

Faculty of Health Sciences, University of Malta, Malta

*Corresponding Author: Alfred Gatt, Faculty of Health Sciences, University of Malta, Malta.

Received: September 23, 2021; Published: October 18, 2021



Peripheral Arterial Disease (PAD) is a world-wide concern, especially in persons living with diabetes. This is a challenging condition since often it is asymptomatic and when symptoms do set in, they could be indicative of advanced disease. The early detection of PAD is important as this enables its early management through lifestyle changes and other non-invasive medical modalities. However, there are various issues related to diagnosing PAD especially at primary care level since there are significant issues relating to diagnostic accuracy that could affect the timely diagnosis of this condition.

A clinical assessment tool is only of value if the interpretation of the results is correct and repeatable, which is the main issue relating to the clinical tests outlined in this paper. Although literature highlights the importance of accurate screening, diagnosis and management of PAD, this paper provides evidence from studies on the importance of using different non-invasive modalities when assessing patients with PAD. The authors suggest that when results do not concur, further extensive evaluations should be performed. Such information will alleviate the burden related to PAD and its complications. This paper compares the application of different physiological tests used for the early identification of PAD.

Keywords: Peripheral Arterial Disease; Diabetes Mellitus; Diagnosis; Screening



  1. Hinchliffe RJ., et al. “International Working Group on the Diabetic Foot, (IWGDF). Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)”. Diabetes/Metabolism Research and Reviews 1 (2020): e3276.
  2. Baker N., et al. “A user's guide to foot screening. Part 2: peripheral arterial disease (2005).
  3. Smith-Strøm H., et al. “Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: A retrospective cohort study”. PLoS One5 (2017): e0177176.
  4. Jude EB., et al. “Peripheral arterial disease in diabetic and nondiabetic patients: A comparison of severity and outcome”. Diabetes Care8 (2001): 1433-1437.
  5. Shu J and Santulli G. “Update on peripheral artery disease: Epidemiology and evidence-based facts”. Atherosclerosis 275 (2018): 379-381.
  6. Khanolkar MP., et al. “The diabetic foot”. QJM: An International Journal of Medicine 9 (2008): 685-695.
  7. Norgren L., et al. “Inter-society consensus for the management of peripheral arterial disease”. International Angiology 2 (2007): 81-157.
  8. Thiruvoipati T., et al. “Peripheral artery disease in patients with diabetes: Epidemiology, mechanisms, and outcomes”. World Journal of Diabetes 7 (2015): 961-969.
  9. Thukkani AK and Kinlay S. “Endovascular intervention for peripheral artery disease”. Circulation Research 9 (2015): 1599-1613.
  10. Steffen LM., et al. “Management of peripheral arterial disease”. Diabetes Spectrum3 (2008): 171-177.
  11. Aboyans V., et al. “Epidemiology of lower extremity artery disease”. Presse Med1 (2018): 38-46.
  12. Marso SP and Hiatt WR. “Peripheral arterial disease in patients with diabetes”. Journal of the American College of Cardiology 5 (2006): 921-929.
  13. Morbach S., et al. “Long-term prognosis of diabetic foot patients and their limbs: Amputation and death over the course of a decade”. Diabetes Care10 (2012): 2021-2027.
  14. Olin JW., et al. “ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery disease. A report of the american college of cardiology foundation/american heart association task force on performance measures, the american college of radiology, the society for cardiac angiography and interventions, the society for interventional radiology, the society for vascular medicine, the society for vascular nursing, and the society for vascular surgery (writing committee to develop clinical performance measures for peripheral artery disease)”. Vascular Medicine6 (2010): 481-512.
  15. Rantner B., et al. “The fate of patients with intermittent claudication in the 21st century revisited - results from the CAVASIC study”. Scientific Reports 8 (2017): 45833.
  16. Hirsch AT., et al. “Peripheral arterial disease detection, awareness, and treatment in primary care”. JAMA: The Journal of the American Medical Association11 (2001): 1317-1324.
  17. Sartipy F., et al. “Ten year mortality in different peripheral arterial disease stages: A population based observational study on outcome”. European Journal of Vascular and Endovascular Surgery4 (2018): 529-536.
  18. Nordanstig J., et al. “Improved quality of life after 1 year with an invasive versus a noninvasive treatment strategy in claudicants: One-year results of the invasive revascularization or not in intermittent claudication (IRONIC) trial”. Circulation 12 (2014): 939-947.
  19. Conte SM and Vale PR. “Peripheral arterial disease”. Heart, Lung and Circulation 4 (2018): 427-432.
  20. Williams DT., et al. “An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes”. Diabetes Care 9 (2005): 2206-2210.
  21. Gibbons J and Jude E. “Identifying and treating intermittent claudication in people with diabetes”. Diabetic Foot Journal (2005).
  22. Azzopardi YM., et al. “Agreement of clinical tests for the diagnosis of peripheral arterial disease”. Prim Care Diabetes 1 (2019): 82-86.
  23. Forsythe RO., et al. “Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review”. Diabetes/Metabolism Research and Reviews 1 (2020): e3277.
  24. Gornik HL., et al. “Validation of a method for determination of the ankle-brachial index in the seated position”. Journal of Vascular Surgery5 (2008): 1204-12210.
  25. Stein R., et al. “Limitation of the resting ankle-brachial index in symptomatic patients with peripheral arterial disease”. Vascular Medicine1 (2006): 29-33.
  26. Ix JH., et al. “Test characteristics of the ankle-brachial index and ankle-brachial difference for medial arterial calcification on X-ray in type 1 diabetes”. Journal of Vascular Surgery3 (2012): 721-727.
  27. Leskinen Y., et al. “The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: Requirements for diagnostics”. The American Journal of Kidney Diseases 3 (2002): 472-479.
  28. Suominen V., et al. “PAD as a risk factor for mortality among patients with elevated ABI--a clinical study”. European Journal of Vascular and Endovascular Surgery 3 (2010): 316-322.
  29. Tehan PE., et al. “Diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: A cross-sectional retrospective case-control study”. Journal of Foot and Ankle Research 10 (2017): 58.
  30. Suzuki K. “How to diagnose peripheral arterial disease”. Podiatry Today 4 (2007): 54-65.
  31. Høyer C., et al. “The toe-brachial index in the diagnosis of peripheral arterial disease”. Journal of Vascular Surgery1 (2013): 231-238.
  32. Tehan PE., et al. “How sensitive and specific is continuous-wave doppler for detecting peripheral arterial disease in people with and without diabetes? A cross-sectional study”. Diabetes and Vascular Disease Research 5 (2018): 396-401.
  33. Formosa C., et al. “Interrater reliability of spectral doppler waveform analysis among podiatric clinicians”. Journal of the American Podiatric Medical Association 4 (2018): 280-284.
  34. Romanos MT., et al. “The reliability of toe systolic pressure and the toe brachial index in patients with diabetes”. Journal of Foot and Ankle Research 3 (2010): 31.
  35. Zubair M and Ahmad J. “Transcutaneous oxygen pressure (TcPO2) and ulcer outcome in diabetic patients: Is there any correlation?” Diabetes and Metabolic Syndrome 2 (2019): 953-958.
  36. Fife CE., et al. “Transcutaneous oximetry in clinical practice: Consensus statements from an expert panel based on evidence”. The Undersea and Hyperbaric Medical 1 (2009): 43-53.
  37. Apelqvist J. “Diagnostics and treatment of the diabetic foot”. Endocrine3 (2012): 384-397.
  38. Gazzaruso C., et al. “Transcutaneous oxygen tension as a potential predictor of cardiovascular events in type 2 diabetes: Comparison with ankle-brachial index”. Diabetes Care6 (2013): 1720-1725.
  39. Hirsch AT., et al. “The minnesota regional peripheral arterial disease screening program: Toward a definition of community standards of care”. Vascular Medicine2 (2001): 87-96.
  40. Stephens J., et al. “Got PAD? hidden dangers revealed with ABI”. Journal of Vascular Nursing4 (2011).
  41. Formosa C., et al. “Screening for peripheral vascular disease in patients with type 2 diabetes in malta in a primary care setting”. Qual Prim Care6 (2012): 409-414.
  42. Formosa C., et al. “Diabetes foot screening: Current practice and the future”. Foot 34 (2018): 17.
  43. Mukherjee D and Eagle K. “The importance of early diagnosis and treatment in peripheral arterial disease: Insights from the PARTNERS and REACH registries”. Current Vascular Pharmacology 3 (2010): 293-300.
  44. Gauci J., et al. “Automated region extraction from thermal images for peripheral vascular disease monitoring”. Journal of Healthcare Engineering (2018): 5092064.
  45. Gatt A., et al. “The identification of higher forefoot temperatures associated with peripheral arterial disease in type 2 diabetes mellitus as detected by thermography”. Prim Care Diabetes4 (2018): 312-328.
  46. Ma KF., et al. “A systematic review of diagnostic techniques to determine tissue perfusion in patients with peripheral arterial disease”. Null8 (2019): 697-710.
  47. Pollak AW., et al. “Multimodality imaging of lower extremity peripheral arterial disease: Current role and future directions”. Cardiovascular Imaging 5.6 (2012): 797-807.
  48. Formosa C and Gatt A. “Mportance of Accurate Identification of Arterial Perfusion in the Lower Limb using Different Non- Invasive Physiological Tests”. In: Atherosclerotic Cardiovascular Disease. SM Group, (2016).
  49. Ellul C., et al. “The effectiveness of calf muscle electrostimulation on vascular perfusion and walking capacity in patients living with type 2 diabetes mellitus and peripheral artery disease”. The International Journal of Lower Extremity Wounds 2 (2017): 122-128.
  50. American Heart Association. Prevention and treatment of PAD (2021).
  51. Song P., et al. “Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: An updated systematic review and analysis”. Lancet Glob Health 8 (2019): e1020-30.
  52. Fowkes FG., et al. “Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: A systematic review and analysis”. Lancet 382.9901 (2013): 1329-1340.
  53. AlHamzah M., et al. “Knowledge gap of peripheral artery disease starts in medical school”. Journal of Vascular Surgery 1 (2019): 241-245.


Citation: Alfred Gatt., et al. “Screening and Diagnosis of Peripheral Arterial Disease in Patients with Diabetes: Current Perspectives".Acta Scientific Orthopaedics 4.11 (2021): 28-36.


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