Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Ischaemic tissue loss
Ulceration with limb ischaemia is limb-threatening under NICE, while infection, gangrene or severe haemodynamic deficits further increase amputation and sepsis risk.
Action: Refer immediately when limb-threatening features are present, involve vascular and multidisciplinary foot services, treat infection and sepsis in parallel, and do not postpone escalation for a falsely reassuring ABPI.
Synopsis
Identify perfusion-limited healing, determine vascular urgency, map disease to the foot and select revascularisation that supports tissue preservation and wound closure.
Ulceration with suspected limb ischaemia needs immediate acute referral and multidisciplinary vascular involvement; a normal or high ABPI cannot safely exclude PAD in diabetes.
Keep purpose-specific thresholds separate: severe ischaemia uses ABI <0.4, ankle <50 mmHg, toe <30 mmHg, TcPO2 <30 mmHg or monophasic or absent waveforms for urgent consultation; prognosis worsens with toe <30 mmHg or TcPO2 <25 mmHg. No single value dictates every decision.
Revascularisation aims to restore durable in-line flow to at least one foot artery, preferably supplying the ulcer region, while preserving future treatment options.
Key red flags
Clinical ischaemia—absent pulses, monophasic or absent pedal waveforms, ankle pressure <100 mmHg or toe pressure <60 mmHg—supports vascular consultation and revascularisation consideration. Severe ischaemia—ABI <0.4, ankle <50 mmHg, toe <30 mmHg, TcPO2 <30 mmHg, or monophasic or absent waveforms—requires urgent vascular consultation.
Rapidly enlarging necrosis, gangrene, rest pain, a cold mottled foot or loss of Doppler signals indicates threatened tissue and possible acute-on-chronic ischaemia.
Purulence, spreading erythema, deep abscess or systemic illness with PAD requires urgent joint vascular and surgical decisions about source control and inflow.
Failure to reduce wound area despite four weeks of sound infection, wound and offloading care should trigger reassessment and vascular consultation even if bedside tests looked acceptable.
Investigation priorities
01
Doppler waveforms, ABPI and TBIFirst step
Identify PAD with complementary tests and reveal incompressible ankle arteries before relying on one ratio.
Management branches
Urgent pathwaySevere ischaemia or infected tissue loss
Gangrene, ulcer with severe perfusion deficit, rapid deterioration, rest pain, infection or systemic illness threatens the limb.
Refer immediately when NICE limb-threatening features are present and obtain urgent vascular, surgical and multidisciplinary foot assessment while treating sepsis and infection.
Perform rapid bedside haemodynamic testing when it does not delay care, then obtain complete anatomical imaging to the foot and decide drainage and revascularisation sequence.
Preferred branchNon-healing ulcer despite good care
A PAD-associated ulcer shows less than 50% reduction in wound area after about four weeks despite appropriate infection and glucose control, wound care and offloading.
Key medicines
ClopidogrelGive clopidogrel 75 mg orally once daily for established symptomatic PAD unless contraindicated; continue long term while benefit exceeds bleeding risk and review around procedures. The SmPC specifies no numeric renal adjustment because experience in renal impairment is limited, so use caution rather than assuming equivalence.Check active bleeding, bleeding disorders, severe hepatic impairment and interactions including omeprazole or esomeprazole; renal impairment has limited therapeutic experience and requires caution without an evidence-based alternate dose. Coordinate perioperative interruption with the vascular team, and avoid routine pregnancy use unless specialist benefit outweighs uncertainty.
AtorvastatinOffer atorvastatin 80 mg orally once daily for secondary prevention in people with CVD, including symptomatic PAD, unless contraindications, interactions, adverse-effect risk or preference require a lower dose. For a person with CKD, NICE NG238 instead says to start atorvastatin 20 mg once daily for primary or secondary prevention; increase the dose if the lipid target is unmet and eGFR is at least 30 mL/min/1.73 m², but agree any higher dose with a renal specialist if eGFR is below 30 mL/min/1.73 m².Keep two renal statements distinct: the product SmPC reports no pharmacokinetic dose adjustment for renal impairment, while NICE sets a CKD-specific 20 mg starting regimen and specialist agreement boundary for higher doses when eGFR is below 30 mL/min/1.73 m². Check baseline liver enzymes and major CYP3A4 interactions, counsel about unexplained muscle symptoms, and avoid in pregnancy; active liver disease is contraindicated. Reassess for intolerance and measure lipids to confirm response.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 13 Sept 2026; clinical approval remains outstanding.