Peripheral arterial disease: the forgotten complication

Abstract

Peripheral arterial disease (PAD) is a very high-risk atherosclerotic manifestation that, in people with diabetes, is associated with major adverse cardiovascular events, adverse limb events, functional decline, ulceration, infection, amputation, and poorer quality of life. Nevertheless, it remains underdiagnosed. The absence of typical claudication, coexistence of peripheral neuropathy, reduced physical activity due to musculoskeletal comorbidities, and frequent medial arterial calcification all contribute to delayed recognition.

To review why PAD remains an overlooked complication in diabetes and to propose a practical approach for screening, diagnosis, stratification, and treatment within a global cardiorenal risk framework. Development: Recent evidence supports viewing PAD not merely as ‘leg disease’ but as a marker of systemic atherosclerosis. Clinicians should actively inquire about reduced walking capacity, rest pain, non-healing wounds, skin colour or temperature changes, and diminished pulses. Systematic foot examination and pulse palpation remain essential. Resting ankle-brachial index is the recommended initial test when PAD is suspected, and screening is reasonable in individuals at increased risk. In patients with non-compressible arteries or persistent suspicion despite a non-diagnostic result, toe-brachial index improves detection. Stratification should distinguish asymptomatic PAD, chronic symptomatic PAD, chronic limb-threatening ischaemia, and acute limb ischaemia; when wounds or ulcers are present, the WIfI system adds prognostic value for healing, amputation risk, and revascularization need. Treatment requires smoking cessation, supervised exercise, high-intensity statins, blood pressure control, antiplatelet therapy, and individualized use of vascular-dose rivaroxaban plus aspirin. In type 2 diabetes, GLP-1 receptor agonists and SGLT2 inhibitors are integrated into broader cardiorenal management; STRIDE provides direct evidence of functional benefit in symptomatic PAD, whereas SUSTAIN 6 and FLOW support a wider macrovascular and cardiorenal perspective.

In diabetes, PAD should be actively sought before it manifests as ulceration, infection, or threatened amputation. Early recognition allows timely intervention on systemic vascular risk while preserving function and limb outcomes.