Medical Management, Risk Factor Modification, Wound Care, and Amputation
Risk factor modification
Smoking cessation is the single most powerful intervention - combine counseling with varenicline, which outperforms nicotine replacement. Prescribe high-intensity statin for every patient with peripheral arterial disease or aneurysm, targeting LDL below 70 mg/dL (below 55 in very high risk), adding ezetimibe or a PCSK9 inhibitor if needed. Use aspirin 75–325 mg or clopidogrel if intolerant. After peripheral revascularization, low-dose rivaroxaban 2.5 mg twice daily plus aspirin reduced major adverse limb events in VOYAGER at the cost of more bleeding. Treat hypertension toward 130/80 and diabetes toward an HbA1c near 7%, favoring SGLT2 inhibitors or GLP-1 receptor agonists that also lower cardiovascular risk. Cilostazol improves claudication but is contraindicated in heart failure.
Wounds and the diabetic foot
Grade with a validated system such as Wagner, assess perfusion and infection, offload with a total contact cast or boot, and debride. Apply the TIME framework and moist wound healing; wet-to-dry dressings are outdated. Venous ulcers need compression, arterial ulcers need revascularization, and neuropathic ulcers need offloading. Osteomyelitis usually requires bone resection plus prolonged antibiotics.
Amputation
Choose the lowest level likely to heal. Below-knee amputation preserves energy efficiency and rehabilitation potential; a guillotine amputation controls sepsis before definitive closure. Fit prostheses early and involve rehabilitation before the wound is closed.
Rule of thumb: no wound heals without perfusion, no diabetic ulcer heals without offloading, and no smoker's arterial disease stabilizes without quitting.