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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1347

was observed in study design and results between individual studies, and therefore the assessment of effectiveness was uncertain.11 Pentoxifylline was shown to be generally well tolerated.11 5.	 In a Cochrane review of chelation therapy (eg,

EDTA) that included 2 clinical trials with walking endpoints in patients with PAD, chelation therapy showed no significant improvement in claudication symptoms (maximal and pain-free walking distance) compared with placebo.13

5.8 Preventive Foot Care for PAD

Recommendations for Preventive Foot Care for PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 C-LD 1 In patients with PAD, providing general preventive

foot self-care education to patients and their family members and support persons is recommended.1–7

1 C-EO 2.	 In patients with PAD, foot inspection by a clinician at

every visit is recommended.

1 C-LD 3 In patients with PAD at high risk for ulcers and

amputation (Table 12), therapeutic footwear is recommended.8,9

1 C-EO 4 In patients with PAD, a comprehensive foot

evaluation (Table 13) should be performed at least annually to identify risk factors for ulcers and amputation.

2a B-NR 5.	 In patients with PAD, referral to a footcare specialist,

when available, is reasonable for ongoing preventive care and longitudinal surveillance.10–16

Synopsis PAD increases the risk of foot ulcers, infection, and amputation, and carries a 40% rate of death at 5 years after a foot ulcer has developed.6,17 The presence of foot ulcers is also associated with anxiety, depression, and reduced QOL.4,5 Risk factors for developing foot ulcers is presented in Table 12. Diabetes is a particularly important risk factor for development of ulcers; between 19% and 34% of patients with diabetes are estimated to develop foot ulcers in their lifetime.6 Foot care is an im- portant component of care for patients with PAD (Figure 4), and patients should have their bare feet routinely inspected by clinicians during office visits. When available, referral to a footcare specialist is reasonable for ongoing foot examinations and surveillance. Vascular specialists can help provide patients with PAD with ongoing preventive care and lifelong surveillance and perform an annual comprehensive foot evaluation (Table 13). Wearing therapeutic footwear can reduce the risk of foot ulcers in patients with PAD and severe neuropathy, foot deformities, ulcer or Charcot history, callus formation, or history of amputation. Self-foot care can prevent foot ulcers and consists of nail and skin care, washing and drying the feet daily, doing foot exercises, protecting feet from heat and cold, avoid walking barefoot, and wearing socks and appropriately fitting shoes.1

Recommendation-Specific Supportive Text

1 Education on foot self-care for patients with PAD

and their family members and other support persons is important. Dry, cracked skin and corn or

Table 12.  Risk Factors for Development of Foot Ulcers or Amputation Among Patients With PAD17,21 History of previous foot ulcer(s) or amputation (minor or major) Charcot or other foot deformities Diabetes with poor glycemic control CKD (especially if ESKD) Peripheral neuropathy (especially with loss of protective sensation) Corns or calluses on the feet (considered preulcerous lesions in patients with PAD) Ongoing smoking CKD indicates chronic kidney disease; ESKD, end-stage kidney disease; and PAD, peripheral artery disease. Table 13.  Components of a Comprehensive Foot Evaluation for Patients With PAD17,21

History Previous foot ulcer(s) or CLTI, amputation, Charcot deformity, calluses Current symptoms of PAD or CLTI: claudication or other leg fatigue with walking, rest pain, foot ulcers Lower extremity revascularization (endovascular or surgical procedures) Cigarette or other tobacco use (current, past) Diabetes Retinopathy or visual impairment CKD Symptoms of neuropathy (eg, pain, burning, numbness in feet) History of other CVD (eg, CAD, heart failure, cerebrovascular disease) Physical examination Evaluate skin integrity, including presence of any ulcers, calluses, or corns. Visual inspection includes the whole foot and in between all toes Examine for foot deformity (eg, bunion, hammertoe or claw toe, abnormal foot arch, Charcot deformity) Perform neurological assessment: 10-g monofilament testing with at least 1 other measurement: pinprick, temperature, or vibration Evaluate (palpate) pulses in the legs and feet Other assessments Footwear: Is it ill-fitting, inadequate, or is there lack of footwear? Does patient have poor foot hygiene (eg, improperly cut toenails, unwashed feet, superficial fungal infection, or unclean socks)? Does the patient have physical limitations that may hinder foot self-care (eg, visual impairment, obesity, inability to reach feet)? Does the patient know the components of and perform self-foot care? Modified with permission from Armstrong et al17 and Schaper et al.21 CAD indicates coronary artery disease; CKD, chronic kidney disease; CLTI, chronic limb-threatening ischemia; CVD, cardiovascular disease, and PAD, peripheral artery disease.

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