Arterial calcification can also make interpretation of the images more difficult, although the information may be beneficial in planning some forms of intervention. Angiography.

Conventional SGI-1776 clinical trial angiography has traditionally been the ‘Gold standard’ and has the added advantage that it can be combined with simultaneous intervention. Diagnostic angiography alone is rarely performed as it is an invasive procedure that requires cannulation of the femoral vessels to inject intra-arterial contrast. The management of CLI in patients with diabetes should be planned within the MDFT, including diabetes and vascular specialists, along with the patient. Amputation rates do vary considerably across England and could in part be due to variations in Y-27632 mouse care delivery.1 MDFTs have been shown to reduce amputation rates.26,27 Multidisciplinary

working with integrated pathways of care has been increasingly emphasised over recent years for optimal care of the diabetes patient with foot disease.22 General management should include a review of metabolic control, assessment and management of cardiovascular risk factors, and antiplatelet therapy instigated (unless contraindicated). It is of vital immediate importance to treat any associated foot infection early on as this can cause a rapid deterioration in an ischaemic or neuroischaemic foot.28 If surgical drainage of the foot is needed, then this should not be delayed. The combination of PAD and infection has a significant negative impact on ulcer healing.16 Historically, the treatment for CLI has relied on bypass surgery, amputation or conservative measures. The role of surgery as the

primary treatment Resveratrol strategy has changed with the development of minimally invasive endovascular techniques (angioplasty, with or without stenting). Endovascular treatment is less invasive practically and physiologically, and so is an attractive option; however, both surgical and endovascular treatments are not mutually exclusive, and can be performed together (‘hybrid’ techniques) to simultaneously manage multi-level arterial disease. Patients with diabetes often have arterial disease involving the below knee vessels which are more complex to treat due to their small calibre and lower blood flows.12 Fortunately, the majority of patients with CLI can still be offered some form of revascularisation in the form of endovascular intervention or open surgery including distal revascularisation.15 Revascularisation techniques, either initially angioplasty or open surgery, have tended to show similar medium-term outcomes although, in patients who survive for more than two years following intervention, surgery may be more effective.