National Expert Consensus on the Diagnosis and Surgical Treatment of Diabetic Foot Ulcers Complicated with Lower Extremity Vasculopathy (2024 Version)

Basic Information

• Official English Title: National expert consensus on the diagnosis and surgical treatment of diabetic foot ulcers complicated with lower extremity vasculopathy (2024 version)
• Issuing Institutions: Burns and Trauma Branch of Chinese Geriatrics Society, Chinese Burn Association (Chinese Medical Association), Wound Repair Professional Committee of Chinese Medical Doctor Association
• Publication Details: Published online in PMC on December 13, 2025; bilingual registration on the International Practice Guideline Registry Platform (Registration No.: PREPARE-2022CN733)
• Core Purpose: To standardize screening, diagnosis, risk stratification, revascularization, wound repair, and multidisciplinary collaborative management for DFU patients with concurrent lower-extremity vascular disease, reduce major adverse limb events (MALE) and amputation rates, and promote homogeneous clinical practice.
• Target Users: Surgeons (burn/plastic, vascular, wound care), endocrinologists, and multidisciplinary teams involved in diabetic foot management.

Core Framework & Key Recommendations

1. Clinical Assessment & Diagnostic Pathway

1.1 Stratified Evaluation Systems

• Integrated grading tools: Wagner, IWGDF, Texas, SINBAD, WIfI (wound–ischemia–foot infection) for ulcer severity, ischemia, and infection stratification; TASC II for anatomical classification of peripheral arterial disease (PAD).
• Vascular physiological tests:
  • Ankle–brachial index (ABI): First-line screening; ABI > 0.9 suggests normal perfusion; 0.4–0.9 indicates mild–moderate ischemia; < 0.4 denotes severe ischemia.
  • Toe–brachial index (TBI) & transcutaneous oxygen pressure (TcPO₂): Compensatory tests for calcified vessels (false-negative ABI); TcPO₂ < 40 mmHg correlates with poor healing and high amputation risk.
   
• Imaging ladder: Color Doppler ultrasound (initial screening) → CTA/MRA (anatomical mapping) → DSA (gold standard for intervention planning).

1.2 Diagnostic Decision Thresholds

• ABI < 0.4 or TcPO₂ < 40 mmHg or DSA-proven infrapopliteal occlusion: Mandatory revascularization evaluation.
• Ulcers unhealed > 1 month despite standard care: Prompt DSA to rule out occult vascular impairment.

2. Medical & Risk Factor Management

• Metabolic control: Intensive glycemic, blood pressure, and lipid modulation as foundational therapy.
• Antithrombotic therapy (Evidence Level A, Strong Recommendation):
  • Aspirin (75–325 mg qd) monotherapy or clopidogrel (75 mg qd) monotherapy reduces major vascular events.
  • Symptomatic PAD: Aspirin plus low-dose rivaroxaban (2.5 mg bid) to lower major adverse limb events.
   
• Adjunctive pharmacotherapy: Vasodilators and antiplatelet agents to improve peripheral perfusion; anti-infectives targeted to pathogen cultures after revascularization.

3. Revascularization Strategies (Timing & Techniques)

3.1 Timing Principles

• For Rutherford 4–5 (rest pain, ulceration, gangrene): Revascularization within 72 hours of infection control (Evidence Level A, Strong Recommendation).
• For critical limb ischemia (Rutherford 3): Individualized timing based on symptom progression and comorbidities.

3.2 Endovascular & Surgical Options

4. Wound Care & Reconstruction

• Debridement: Surgical debridement (≥ weekly) for WIfI wound/infection grade ≥1; urgent radical debridement for abscess, gangrene, or necrotizing fasciitis.
• Reconstructive ladder:
  • Split-thickness skin grafting (STSG) as first-line for well-perfused wounds; NPWT fixation enhances graft take.
  • Preconditioning (antibiotic-loaded bone cement, transverse tibial bone transport, NPWT) for exposed tendon/bone in severely ischemic wounds before flap coverage.
  • Local/free flaps for defects with viable vascular beds; minimize retrograde flap designs to reduce necrosis risk.
   

5. Amputation Criteria & Principles

• Amputation indicated for high-risk WIfI classification with irreversible ischemia unresponsive to revascularization.
• Objective: Preserve maximum limb length while ensuring wound healing and functional outcome.

6. Multidisciplinary Care (MDT) & Surveillance

• Core MDT members: Vascular surgeon, wound specialist, endocrinologist, infectious disease specialist, podiatrist, and rehabilitation therapist.
• Surveillance protocol: Annual ABI + TcPO₂ screening for diabetic patients; periodic imaging and wound reassessment post-intervention to detect restenosis/recurrence.

Access Links

1. Full-text English version: https://pmc.ncbi.nlm.nih.gov/articles/PMC11630131/
2. Chinese original: Chinese Journal of Burns and Wounds, 2024, Vol.40, No.3

Methodology Note