Pedal acceleration time-Guided management of diabetic foot ulcers with borderline ischemia

Background: The management of diabetic foot ulcers (DFUs) with borderline ischemia remains challenging due to the absence of reliable physiological markers to guide revascularization decisions. Pedal acceleration time (PAT) is a Doppler-derived measure of distal perfusion that may improve risk stratification. This study aimed to evaluate a PAT-guided management strategy in patients with DFUs and borderline perfusion by assessing its ability to guide treatment allocation, and its association with wound healing and amputation-free survival (AFS). Methods: In this prospective quasi-experimental study, 263 consecutive patients with DFUs and abnormal ankle-brachial index (ABI) findings were enrolled. PAT was measured using duplex ultrasound of the pedal arteries. A predefined cutoff of ⩾ 180 ms was used to guide treatment allocation: patients with a PAT ⩾ 180 ms underwent endovascular revascularization, whereas those with a PAT < 180 ms underwent debridement alone. Primary outcomes included AFS, wound healing, major adverse limb events (MALE), and major adverse cardiovascular events (MACE) at 24 months. The diagnostic accuracy of PAT for detecting significant infrapopliteal stenosis was assessed using conventional angiography as the reference standard. Results: At 24 months, AFS was higher in the revascularization group than in the debridement-alone group, although this difference was not statistically significant (64.2% vs 58.4%; p = 0.344). However, a Kaplan-Meier analysis demonstrated a significant difference in AFS over the follow-up period (log-rank p < 0.05). Overall survival and freedom from reintervention did not differ significantly between groups. Multivariable analysis identified advanced stages of the Wound, Ischemia, and foot Infection (WIfI) classification and a higher PAT category as predictors of major amputation. Advanced WIfI stage was also associated with nonhealing, and the PAT category showed a borderline association with nonhealing. A receiver operating characteristic (ROC) analysis demonstrated excellent diagnostic performance of PAT for detecting significant arterial stenosis, with an area under the curve (AUC) of 0.88. At a cutoff ⩾ 180 ms, sensitivity was 84.0% (95% CI 76.6-89.4) and specificity was 81.2% (95% CI 73.8-86.8), with an overall accuracy of 82.5%. Conclusions: PAT provides a useful physiological adjunct to distal perfusion assessment in DFUs with borderline ischemia. A threshold of ⩾ 180 ms identifies patients with hemodynamically significant disease, and it is associated with improved risk stratification for revascularization. These findings support further evaluation of PAT as an adjunctive assessment tool in patients with borderline ischemia.