Forsythe Jan Apelqvist Ed Boyko Robert Fitridge Joon Pio Hong Konstantinos Katsanos Joseph Mills Sigrid Nikol Jim Reekers Maarit Venermo Eugene Zierler Nicolaas Schaper ID: 1010705
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1. Robert HinchliffeRachael ForsytheJan ApelqvistEd BoykoRobert FitridgeJoon Pio HongKonstantinos KatsanosJoseph MillsSigrid NikolJim ReekersMaarit VenermoEugene ZierlerNicolaas Schaperwww.iwgdfguidelines.org
2. Peripheral artery diseaseAny atherosclerotic arterial occlusive disease below the inguinal ligament, resulting in a reduction in blood flow to the lower extremityDiagnosisPrognosisTreatmentSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
3. Focus of PAD guidelinesPatients with ulceration (highest risk)Patient Intervention Comparator Outcome RecommendationSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
4. Do we need specific PAD guidelines in people with diabetes?Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
5. Common in DFU (50%)Poor prognosis (wound, limb, patient)Managed by non-vascular specialists (variation)PAD is a spectrum of diseaseWeak evidence to underpin clinical practice (No RCTs)PAD vascular guidelines – no diabetes focusSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
6. Fundamental questions PAD?Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
7. Fundamental questions PAD? Who revascularise?Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
8. Fundamental questions PAD? Who revascularise? When?Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
9. Fundamental questions PAD? Who revascularise? When? How?Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
10. Guidelines for clinical practiceRelevant to generalist and specialistVariation in severity / mode of presentationVariation in distribution of PADVariation in fitness of patientsRevascularisation is beneficial & potentially harmfulSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
11. Guidelines for clinical practiceDiagnosis (1-3)Clinical examNon-invasive tests Prognosis (4-9)Non-invasive testsClassificationDecision making Treatment (10-17)Vascular imagingRevasc techniqueOrganisationGeneral principlesSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
12. Diagnosis (excluding PAD)Clinical examination unreliablePedal Doppler waveforms + ankle pressure / ABI or toe pressure / TBI measurement. No single modality / threshold optimal Triphasic pedal Doppler waveforms Toe brachial index ≥0.75. ABI 0.9-1.3 (Strong; Low) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
13. Prognosis (classification)Use the WIfI classification system- Wound- Ischaemia- foot Infectionstratify amputation risk revascularisation benefit (Strong; Moderate)Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
14. Prognosis (be prepared to change strategy)Despite optimal wound and medical careUlcer not healing in 4-6 weeks → vascular imaging (Strong; Low)PAD + no healing in 4-6 weeks → revascularise (Strong; Low)Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
15. TreatmentAim - direct blood flow to ≥1 foot arteries preferably to anatomical region of ulcer post procedure → objective measurement of perfusion. (Strong; Low)Revascularisation technique based on individual factors. (Strong; Low)Patient access to expertise and facilities diagnosis PAD revascularisation (endovascular and bypass surgery). (Strong; Low) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org
16. Future research prioritiesImprove identificaiton of those who benefit from revascularisation Role of novel methods of perfusion assessment?Earlier revascularisation?Angiosome concept Venous arterialisationNovel medical therapiesSlides courtesy IWGDF; available at: www.iwgdfguidelines.org
17. ConclusionsClinical examination is unreliableBedside tests helpful – limitationsOptimise other aspects of careRevascularisation decisions complex (heal spontaneously)Be prepared to change strategy if no improvementSlides courtesy IWGDF; available at: www.iwgdfguidelines.org