European Journal of Cardiovascular Medicine

Hyperglycemia due to insulin secretion or action abnormalities, or both, characterizes diabetes mellitus, a chronic metabolic condition. Vision, kidney function, nerves, and blood vessel health are among the organs that might be negatively impacted by its long-term consequences. Diabetic foot is one of the most disabling consequences of the disease. It includes a range of pathological problems, including infection, ulceration, and damage to deep tissues linked to peripheral vascular disease and neurological abnormalities [1-3].
The most common reason for non-traumatic lower limb amputations, extended hospital stays, and morbidity globally is diabetic foot ulcers (DFUs). A higher incidence of diabetic foot ulcers is seen in poorer nations when healthcare facilities are weak, glycemic control is poor, and identification is delayed. The worldwide prevalence of diabetic foot ulcers is estimated to be 4% to 10% among diabetes individuals [4, 5].
The formation and poor healing of diabetic foot ulcers are both exacerbated by peripheral arterial disease (PAD), a sign of systemic atherosclerosis. Reduced blood flow, ischemia, and decreased wound healing are the outcomes of peripheral artery progressive constriction and blockage. Patients with diabetes are at a much higher risk of infection, gangrene, and amputation when PAD is present. The lack of symptoms or the fact that they coincide with diabetic neuropathy mean that PAD is frequently misdiagnosed [6, 7].
For a quick, painless, and accurate diagnosis of PAD, try the Ankle-Brachial Index (ABI). By routinely testing diabetic patients with ABI for PAD, serious problems can be detected early and treated promptly, lowering the risk of complications [8, 9].
In order to emphasize the significance of early vascular evaluation in diabetic foot care, this study set out to assess the frequency of peripheral artery disease in diabetic foot patients and to find out how it related to different biochemical and clinical variables, including length of diabetes, glycemic control, and neuropathy.

This cross-sectional observational study was conducted in the Department of General Surgery, Dr. Patnam Mahender Reddy Institute of Medical Sciences (PIMS), Chevella, Rangareddy, Telangana between February 2024 to January 2025.  A total of 50 diabetic patients presenting with foot ulcers, infections, or gangrene were included after obtaining informed consent. Ethical clearance was obtained from the institutional ethics committee prior to the commencement of the study.

Inclusion Criteria:

• Patients aged 40 years and above with a confirmed diagnosis of type 2 diabetes mellitus.
• Patients presenting with diabetic foot ulcers, infections, or gangrene.
• Patients willing to provide informed written consent.

Exclusion Criteria:

• Patients with type 1 diabetes mellitus.
• Patients with non-diabetic foot ulcers
• Patients with a history of lower limb amputation.
• Patients with acute limb ischemia or critical illness precluding vascular assessment.
• Patients on anticoagulant therapy or with severe renal or hepatic impairment.

In this investigation, 50 patients with diabetic foot were enrolled. They included 32 men (64% of the total) and 18 women (36% of the total). In this study, the average age was 58.2 years with a standard deviation of 8.6. With an average of 10.4 ± 4.7 years, the duration of diabetes varied between 4 and 18 years.

Table 1. Baseline Characteristics of the Study Population

Table 1 displays the demographic and clinical information about the study's participants at the beginning. The bulk of the participants were middle-aged men with moderately long histories of diabetes. Dyslipidemia affected almost 50% of patients, and 42% of those patients also had hypertension.

Table 2. Distribution of Diabetic Foot Ulcers According to Wagner’s Classification

Based on Wagner's grading, Table 2 shows the distribution of diabetic foot ulcers. Ulcers of grade III affected 28% of patients, while those of grade I and IV affected 20% each. There was a substantial burden of severe ulceration, as advanced grades (III-V) were more prevalent (62%).

Table 3. Biochemical Parameters in the Study Population

Table 3 displays the subjects' biochemical profiles. Dyslipidemia, defined as increased levels of triglycerides and low-density lipoprotein (LDL), is present in a large percentage of patients, and the results show that glycemic management is inadequate (mean HbA1c = 8.7%).

Table 4. Prevalence of Peripheral Artery Disease (PAD) and Its Association with Clinical Parameters

Patients with PAD and those without it were compared on a number of clinical indicators in Table 4. The prevalence of neuropathy was higher, the duration of diabetes was longer, and HbA1c levels were higher in patients with PAD. The two groups had significantly different mean ABI values (p < 0.001).

Table 5. Association Between Peripheral Artery Disease and Ulcer Grade

Patients with PAD were more prone to have advanced ulcers (grade III-V) than those without PAD (78.6% vs. 40.9%), as seen in Table 5. The correlation between PAD and ulcer severity and poor healing outcomes was shown to be statistically significant (p = 0.004).

This cohort has a significant frequency of vascular insufficiency, as 56% of patients with diabetic foot had peripheral artery disease (PAD) in the current study. Consistent with earlier research showing a prevalence of PAD between 40 and 60% in individuals with diabetes and foot complications, our study highlights the substantial role of vascular impairment in the development of ulcers and the postponement of wound healing [10, 11].
In this study, patients with PAD were found to be older and to have had diabetes for a longer duration than those without PAD. The increased prevalence of PAD in individuals with long-term diabetes can be attributed to the fact that chronic hyperglycemia leads to endothelial dysfunction, atherosclerosis, and microvascular damage. Jude et al. and Prompers et al. found similar relationships, with age and duration of diabetes being important risk factors for lower extremity arterial disease [12-14].
In this study, elevated HbA1c levels, which indicate poor glycemic control, were also strongly associated with PAD (p = 0.008). Peripheral atherosclerosis is accelerated by hyperglycemia-induced oxidative stress, inflammation, and lipid abnormalities. The significance of avoiding vascular problems by keeping blood sugar levels at optimal levels is highlighted by this correlation [15-17].
In this study, diabetic neuropathy was significantly associated with PAD (p = 0.01). Nerve damage, infection, and gangrene can all go undetected when ischemia and neuropathy are present. Patients with PAD had a significantly higher incidence of advanced (grade III-V) ulcers (78.6% vs. 40.9%, p = 0.004), likely due to a combination of decreased perfusion and sensory loss. Research by Boulton et al. and Armstrong et al. supports this finding, as they also found that neuropathy and ischemia are the main causes of diabetic foot ulcers [18-20].
In previous study, confirming ABI's diagnostic value as a straightforward, non-invasive method for early identification of vascular disease, the average ABI among PAD-positive patients was 0.72 ± 0.10. Patients with diabetes, particularly those with lengthy illness duration or poor glycemic control, can benefit from routine ABI screening by being identified as high-risk and able to get preventative foot care or revascularization treatments sooner rather than later [21-23].
In conclusion, the study highlights the importance of PAD in determining the severity and outcome of diabetic foot ulcers. Improve patient prognosis, decrease complications, and avoid amputations by aggressively managing risk factors such as hypertension, dyslipidemia, and diabetic control. Early detection is crucial through vascular examination [24-26].

Peripheral artery disease affects almost 50% of the people with diabetes who have foot complications, according to one study. Serious foot ulcers can develop and worsen when peripheral artery disease  is present together with neuropathy, a protracted duration of diabetes, and inadequate glucose management. Ischemia is a key factor in delayed wound healing and an increased risk of amputation; patients with PAD had a larger proportion of advanced-grade ulcers, suggesting this. It is essential to include routine PAD screening with the Ankle-Brachial Index in the evaluation of all diabetic patients, especially those who have chronic or non-healing foot ulcers. Diabetic foot patients can greatly benefit from early detection and proper therapy of PAD, along with rigorous glucose control and thorough foot care, in order to greatly decrease morbidity, avoid complications, and improve overall results.

Funding: None

Conflict of Interest:  None.

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