Peripheral arterial disease: clinical assessment and indications for revascularization in the patient with diabetes.

Peripheral arterial disease (PAD) is an under-recognized complication of diabetes. Recently, prevalence estimates in patients with diabetes over 50 years of age have been placed at 25% to 30%. The main reason for under-reporting is the largely asymptomatic nature of PAD in diabetes. Nonetheless, it is important to diagnose PAD because it is a marker of systemic atherosclerosis with excess cardiovascular risk, and it may identify a patient who may develop progressive disability and risk of limb loss. The most sensitive and specific diagnostic tool is an ankle-brachial index. Imaging studies are performed in patients who are candidates for revascularization. The most durable and effective revascularization procedure for PAD in diabetes is surgical bypass with saphenous vein as the conduit. Endovascular interventions are best used in patients with proximal disease with short-segment stenoses. The indications for revascularization have been immutable for decades, namely rest pain, ischemic ulceration, or gangrene. Presently, clinicians would include "selected" patients with intermittent claudication who have disabling symptoms and proximal disease above the inguinal ligament.