Diabetic Peripheral Arteriopathy: A Tale of Two Diseases

Peripheral arterial disease is a major risk factor for amputation in patients with diabetes. Its presentation is different from that of the occlusive arterial disease in patients without diabetes. In diabetes, peripheral arterial disease develops at a younger age and women and men are equally affected. The vascular changes have a predominantly distal distribution with the crural vessels being the most severely affected by long occlusions. There is controversy as to whether the presentation of ischaemic foot disease in diabetes can be explained by one disease, namely, atherosclerosis with particular features such as distal arterial involvement or by the occurrence of 2 diseases: a diabetic macroangiopathy, a term for non-atherosclerotic arterial disease, and classical atherosclerosis. The main component of diabetic macroangiopathy is medial arterial calcification of the muscular arteries, which may be accompanied by intimal pathology. This condition has a predilection of disease below the knee. Classic atherosclerosis is noted in the proximal arteries of the diabetic limb, namely, iliac, femoral and popliteal disease. The risk factors for this proximal site disease are hypercholesterolemia and smoking. Further studies are needed to investigate the interaction between macroangiopathy and atherosclerosis in diabetes for improved understanding of the pathogenesis of this severe complication.