Peripheral artery disease (PAD) impacts approximately 6.5 million individuals in the United States and 237 million people worldwide.¹ It is estimated that 11% of patients with PAD develop the most severe phenotype, chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain, ulcerations, and/or gangrene.² Among the CLTI population, the 1-year amputation rate is 15-20%, and the 1-year mortality rate is 15-40%.² The 2024 American College of Cardiology (ACC)/American Heart Association (AHA)/Multisociety Guideline for the Management of Lower Extremity PAD emphasizes the importance of preventive foot care "across all clinical subsets" of patients with PAD in order to identify those at risk for tissue loss, initiate risk-modification strategies to prevent disease progression, and begin wound care as quickly as possible.³

Patients with PAD, particularly those with diabetes mellitus, are at heightened risk of developing foot ulcerations. Comprehensive management of patients with foot ulceration should involve a coordinated multidisciplinary team of podiatrists, vascular medicine specialists, primary care physicians, wound care specialists, vascular surgeons, interventional cardiologists, and interventional radiologists.³ These patients should have a foot inspection performed at each clinic visit and undergo a complete foot evaluation annually by a member of the health care team.³ The complete evaluation consists of a focused history to identify claudication symptoms, risk factors for tissue loss, and modifiable PAD risk factors to guide medical therapy. The patient's footwear and foot-covering habits should be assessed to ensure that their shoes fit appropriately, socks are clean, and feet are adequately protected. On examination, skin integrity of the entire foot is evaluated, including between the toes, and any deformities should be identified. Focused neurologic and vascular examinations are performed to assess sensation and pulses in the legs and the feet. Foot hygiene is evaluated, ensuring nails are properly trimmed, feet are washed, and no infection is present.

Importantly, patients should be educated on routine foot self-care. This includes routine nail and skin care, daily foot washing and drying, performing foot exercises, wearing clean socks and properly fitting shoes, and avoiding walking barefoot. Limitations against these tasks should also be noted and addressed and may include visual impairment, difficulty reaching their feet, or socioeconomic barriers in acquiring appropriately fitting footwear.

Most foot ulcers happen because of persistent high plantar tissue stress, poor circulation, and loss of sensation in the foot. Pressure offloading is a crucial component of wound healing, which limits weight bearing on the affected limb, reduces plantar pressure, and facilitates tissue growth and wound healing. Furthermore, it prevents the development and recurrence of foot ulceration among those at risk.⁴ Patients with PAD superimposed on foot deformities (bunions, Charcot foot, hammertoes, etc.) are at increased risk of developing foot ulcerations. More complex strategies are used to assemble therapeutic offloading footwear and devices for these patients. If conservative management fails, surgical correction is considered.³ Podiatrists and orthopedic surgeons are best suited to prescribe individualized footwear, orthotics, or braces tailored toward each patient's characteristics and comfort.

Additionally, wound debridement, removal of the necrotic or infected tissue, and removal of the surrounding callus are essential aspects of wound healing. Topical antibiotics are used for localized infection and prevention of osteomyelitis. For wounds that fail to heal with standard treatments, more advanced therapies are employed. Negative pressure wound therapy promotes tissue growth through a vacuum-assisted system closure that reduces edema and removes the wound exudate. Topical biological therapies are used to enhance healing of chronic wounds by using growth factors, skin substitutes, or cellular-based products. Hyperbaric oxygen therapy is another advanced therapy, which improves oxygen delivery to tissues, leading to expedited wound healing.⁴

The 2024 ACC/AHA/multisociety PAD guideline emphasizes the use of objective risk classification tools to assess risk of amputation, identify patients who would benefit from revascularization, and track patient outcomes. One such tool is the WIfI (Wound, Ischemia, and foot Infection) classification system.⁵ The WIfI classification is based on three criteria with scores ranging from 0 to 3:

• Wound extent (W): ranging from no ulceration to extensive gangrene involving the forefoot and/or midfoot.
• Ischemia (I): assessed by ankle-brachial index, ankle systolic pressure, toe pressure (primary determinant of ischemia grade), or transcutaneous oxygen pressure.
• Foot infection (fI): graded based on the degree of localized and/or systemic extension.

Using the combination of these three criteria, patients can be grouped into one of four categories—ranging from very low (clinical stage 1) to high (clinical stage 4) risk—to predict amputation, poor wound healing, and likely benefit from urgent revascularization.⁵ Since its conception, this score system has been validated by observational and registry data, which have demonstrated the reliability of this risk schema irrespective of revascularization strategy or patient comorbidities.⁵ The WIfI classification system has been extended and shown to predict both 1-year overall survival and 1-year amputation-free survival.⁵ In light of this growing body of evidence, the 2024 ACC/AHA/multisociety PAD guideline recommends broader application of risk schema such as WIfI in clinical care. Importantly, while the WIfI score provides guidance as to risk and potential benefit of revascularization, patients with CLTI who undergo revascularization have lower amputation rates and improved wound healing compared with conservative management, and multispecialty evaluation for revascularization carries a Class 1 recommendation, irrespective of WIfI stage.

In conclusion, foot care is an essential component of PAD management. A collegial multidisciplinary care team should follow these patients to prevent the development and progression of foot ulcers and further complications.

References

1. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart disease and stroke statistics: a report of US and global data from the American Heart Association [published correction appears in Circulation. 2024 May 7;149(19):e1164. doi: 10.1161/CIR.0000000000001247.]. Circulation. 2024;149(8):e347-e913. doi:10.1161/CIR.0000000000001209
2. Nehler MR, Duval S, Diao L, et al. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg. 2014;60(3):686-95.e2. doi:10.1016/j.jvs.2014.03.290
3. Writing Committee Members, Gornik HL, Aronow HD, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(24):2497-2604. doi:10.1016/j.jacc.2024.02.013
4. Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36 Suppl 1:e3266. doi:10.1002/dmrr.3266
5. Alameddine D, Satam K, Slade MD, et al. Validation of the WIfI classification in the Vascular Quality Initiative database. J Vasc Surg. Published online March 6, 2025. doi:10.1016/j.jvs.2025.03.001