Peripheral vascular disease

Peripheral vascular disease is an important risk factor for diabetic foot disease which still leads to the loss of 5,000 lower limbs every year in the UK. It should be detected early by examining pedal pulses at the annual review and managed actively with lipid modification, smoking cessation, antiplatelet agents and surgical referral for revascularisation.

How long has the patient had diabetes?

Peripheral vascular disease (PVD) is typically a relatively late complication of T1DM but in T2DM it can even be a presenting feature or can antedate the onset of diabetes.

Is there any claudication?

Typical claudication pain presents as a pain in the calf that comes on after walking and remits relatively quickly upon resting. The 'claudication distance' is usually quite consistent. Sometimes the thigh and buttock muscles are involved.

Does the patient have rest pain?

'Rest pain' is pain in the foot due to critical ischaemia which often comes on at night and is relieved by hanging the affected limb out of bed.

Are there additional risk factors?

The presence of smoking, hypercholesterolaemia, hypertension and a strong family history of premature ischaemic heart disease should all be enquired about.

Does the patient have other manifestations of macrovascular disease?

MI, angina pectoris and previous CVA/TIA should all be enquired about as atherosclerosis elsewhere increases the odds of the patient having peripheral vascular disease.

Is there any history of previous episodes of pedal ulceration or digital gangrene?

Foot ulceration and gangrene of toes can be symptoms of advanced lower limb vascular insufficiency.

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