Recommendations for Minimizing Tissue Loss in Patients With PAD
COR	LOE	Recommendations
I	C-LD	Patients with PAD and diabetes mellitus should be counseled about self–foot examination and healthy foot behaviors.222,223
See Online Data Supplement 34.		Some RCTs have suggested that patient education may help reduce the incidence of serious foot ulcers and lower extremity amputations, but the quality of evidence supporting patient education is low.222 Educational efforts generally include teaching patients about healthy foot behaviors (eg, daily inspection of feet, wearing of shoes and socks; avoidance of barefoot walking), the selection of proper footwear, and the importance of seeking medical attention for new foot problems.223 Educational efforts are especially important for patients with PAD who have diabetes mellitus with peripheral neuropathy.
I	C-LD	In patients with PAD, prompt diagnosis and treatment of foot infection are recommended to avoid amputation.224–228
See Online Data Supplement 34.		Foot infections (infection of any of the structures distal to the malleoli) may include cellulitis, abscess, fasciitis, tenosynovitis, septic joint space infection, and osteomyelitis. Studies have investigated the accuracy of physical findings for identification of infection and determining infection severity and risk of amputation.224–226 Because of the consequences associated with untreated foot infection—especially in the presence of PAD—clinicians should maintain a high index of suspicion.228 It is also recognized that the presence of diabetes mellitus with peripheral neuropathy and PAD may make the presentation of foot infection more subtle than in patients without these problems. Foot infection should be suspected if the patient presents with local pain or tenderness; periwound erythema; periwound edema, induration or fluctuance; pretibial edema; any discharge (especially purulent); foul odor; visible bone or a wound that probes-to-bone; or signs of a systemic inflammatory response (including temperature >38°C or <36°C, heart rate >90/min, respiratory rate >20/min or Paco2 <32 mm Hg, white blood cell count >12 000 or <4000/mcL or >10% immature forms).226 Probe-to-bone test is moderately predictive for osteomyelitis but is not pathognomonic.227
IIa	C-LD	In patients with PAD and signs of foot infection, prompt referral to an interdisciplinary care team (Table 9) can be beneficial.228–230
See Online Data Supplement 34.		The EuroDIALE (European Study Group on Diabetes and the Lower Extremity) study demonstrated that the presence of both PAD and foot infection conferred a nearly 3-fold higher risk of leg amputation than either infection or PAD alone.228 The treatment of deep soft-tissue infection typically requires prompt surgical drainage; vascular imaging and expeditious revascularization generally follow. Experienced clinical teams have reported very good outcomes when this is performed in a coordinated and timely fashion.229,230 Previous groups have described various combinations of functions of interdisciplinary care teams (See Online Data Supplement 34a for a complete list of functions). See Section 9.2 for recommendations related to the role of the interdisciplinary care team in wound healing therapies for CLI.
IIa	C-EO	It is reasonable to counsel patients with PAD without diabetes mellitus about self–foot examination and healthy foot behaviors.
N/A		Although there are limited data to support patient education about self–foot examination and foot care for patients with diabetes mellitus, there are no data that have evaluated this practice in a population of patients with PAD but without diabetes mellitus. Nonetheless, this is a very low-risk intervention with potential for benefit. Educational efforts generally include teaching patients about healthy foot behaviors (eg, daily inspection of feet; foot care and hygiene, including appropriate toenail cutting strategies; avoidance of barefoot walking), the selection of appropriately fitting shoes, and the importance of seeking medical attention for new foot problems.223
IIa	C-EO	Biannual foot examination by a clinician is reasonable for patients with PAD and diabetes mellitus.
N/A		A history of foot ulcers, foot infections, or amputation identifies patients with a very high (>10%) yearly incidence of recurrent ulcers.231 Examination includes a visual inspection for foot ulcers (full-thickness epithelial defects) and structural (bony) deformities, monofilament testing for sensory neuropathy, and palpation for pedal pulses.