Aortoiliac claudicant with a diabetic foot ulcer in the family — exercise prescription, revascularisation restraint, and arterial assessment of every ulcer

Candidate tasks and model management

Prescribe the claudicant's exercise plan with numbers, not adjectives. Supervised exercise first: Cochrane pooling gives pain-free distance up 82.11 m and maximum distance up 120.36 m across 32 trials with 1835 participants, high-quality evidence, with benefits to two years and no ABI, mortality or amputation signal.^[16] Set expectations with CLEVER: at 18 months peak walking gains run 5.0 minutes with exercise and 3.2 with stenting against 0.2 with medical care alone, exercise versus stenting statistically tied.^[14] Add smoking-cessation, diet, exercise and foot-care counselling plus best medical therapy classes per GVG, and address his smoking directly — current smoking carries the highest PAD meta-odds at 2.72 in high-income settings.^[1]

Justify procedural restraint — and name when stenting earns its place. Decline first-line stenting: ERASE long-term follow-up shows the 1-year combination walking advantage fading to a nonsignificant 53 m at 5.4 years, with lifetime procedure totals of 65 versus 149 favouring exercise-only despite a 2.50-fold hazard of later revascularisation in the exercise-only arm.^[15] Reserve stenting for durable disease-specific quality-of-life gains in aortoiliac disease per CLEVER, or for progression toward CLTI — claudication itself is a function problem, not a threat problem.^[14] Offer cilostazol only with full modesty: initial distance up 26.49 m and absolute up 39.57 m with headache odds of 2.83 and no hard-outcome verdict.^[17]

Assess the sister's ulcer as a PAD case first. Approximately half of diabetic foot ulcers carry PAD with raised limb and cardiovascular risk, so absent pulses make hers an arterial case until proven otherwise — not a dressing-clinic case.^[19] Work the IWGDF structure: five recommendations for diagnosis with and without ulcer or gangrene, five for prognosis of healing and amputation, fifteen for treatment covering prioritisation, procedure choice and post-surgical care.^[19] If CLTI criteria are met (ulcer beyond 2 weeks on a PAD leg), refer urgently to vascular surgery, stage by WIfI with toe pressures, decide by PLAN and conduit, and set long-term limb surveillance after any revascularisation.^[4]