Outcomes of Peripheral Arterial Disease in Patients With Diabetic Foot Ulcers in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Peripheral arterial disease (PAD) compromises tissue perfusion in diabetic foot ulcers (DFUs) and is a principal driver of amputation and mortality. The prevalence, risk factor profile, and clinical consequences of PAD in DFU populations specific to low- and middle-income countries (LMICs) have not been systematically synthesized. The aim of this study was to synthesize the available evidence on the prevalence, determinants, and clinical outcomes of PAD among patients with DFUs in LMICs. We conducted a systematic review and meta-analysis of observational studies reporting PAD prevalence, associated risk factors, or clinical outcomes among DFU patients in LMICs. Electronic searches of PubMed, Web of Science, Scopus, and Lens.org were supplemented by manual reference screening. Random-effects meta-analysis with restricted maximum likelihood (REML) estimation was applied. Risk of bias was assessed using design-specific Joanna Briggs Institute critical appraisal tools. Publication bias was evaluated by Egger's regression, Kendall's tau, and Rosenthal’s fail-safe N. Seventeen observational studies with 4,831 participants across nine LMICs were included. The pooled PAD prevalence was 43.00% (95% confidence interval (CI) 29.42%-57.74%; k = 11; N = 3,481; I² = 84.52%). Leave-one-out sensitivity analysis confirmed robustness of this estimate (range 39.37%-46.80%). Smoking was associated with more than twice the odds of PAD (pooled odds ratio (OR) 2.36; 95% CI 1.12-4.94; k = 6; I² = 61.9%), and hypertension nearly doubled the odds (pooled OR 1.84, 95% CI 1.20-2.82; k = 6; I² = 0.0%). PAD conferred a greater than fourfold increase in the odds of lower extremity amputation (pooled OR 4.14; 95% CI 2.24-7.63; k = 6; I² = 52.0%). Narrative evidence demonstrated reduced limb salvage, prolonged hospitalization, and excess mortality in PAD-affected cohorts. PAD is highly prevalent among DFU patients. Smoking and hypertension are consistent modifiable risk factors. These findings highlight the need for cardiovascular risk management within diabetic foot care in LMICs.