Assessment and management of Assessment and management of peripheral vascular disease in the peripheral vascular disease in the

diabetic patientdiabetic patient

Francis DixFrancis Dix

Consultant vascular and endovascular surgeonConsultant vascular and endovascular surgeon

Peripheral vascular disease with diabetesPeripheral vascular disease with diabetes

• diabetes teamdiabetes team• clinical effects of combined diseaseclinical effects of combined disease• pathophysiologypathophysiology• assessmentassessment• treatment – casestreatment – cases

Multidisciplinary teamwork with holistic approach

podiatry

hyperbaric oxygen therapy

Consultant in

orthopaedics

diabetes nurse

orthotics

Consultant in

vascular surgery

Consultant in

diabetes

patient

GP and community services

Hospital services

What are the issues?What are the issues?

Diabetes may cause first fall in life expectancy for 200 yearsDiabetes may cause first fall in life expectancy for 200 yearsJeremy Laurance, health editor, The Independent October 2008Jeremy Laurance, health editor, The Independent October 2008

The World Health Organisation has predicted that deaths from diabetesThe World Health Organisation has predicted that deaths from diabetesin Britain would rise from 33,000 a year in 2005 to 41,000 by 2015 but in Britain would rise from 33,000 a year in 2005 to 41,000 by 2015 but Professor Alberti said that figure underestimated its true impact. More Professor Alberti said that figure underestimated its true impact. More than 80 per cent of sufferers die from heart attacks or strokes and more than 80 per cent of sufferers die from heart attacks or strokes and more than 1,000 a year suffer kidney failure requiring dialysis.than 1,000 a year suffer kidney failure requiring dialysis.

"The WHO figure [for deaths] was very conservative," he said. "Large "The WHO figure [for deaths] was very conservative," he said. "Large numbers die from heart disease and strokes [linked with diabetes] and numbers die from heart disease and strokes [linked with diabetes] and they do not include those.“they do not include those.“

It costs the NHS £1m an hour to treat. One pound in every £10 spent It costs the NHS £1m an hour to treat. One pound in every £10 spent on the hospital service is for diabetes and its complications.on the hospital service is for diabetes and its complications.

PVD in diabetics has a poor prognosisPVD in diabetics has a poor prognosis

• PVD is 20 x more common in diabetics than non diabetics PVD is 20 x more common in diabetics than non diabetics

• lower limb amputation is 15 x more common in diabetics lower limb amputation is 15 x more common in diabetics

• ten year cumulative incidence of lower limb amputation is 5.4% in ten year cumulative incidence of lower limb amputation is 5.4% in type I diabetes and 7.3% in type IItype I diabetes and 7.3% in type II

• 10% of diabetics get an ulcer (10% are purely ischaemic, 45% are 10% of diabetics get an ulcer (10% are purely ischaemic, 45% are ischaemic with associated neuropathy, infection, biomechanical ischaemic with associated neuropathy, infection, biomechanical abnormalities and Charcot deformity)abnormalities and Charcot deformity)

Increased risk of CVD, CAD, nephropathy, Increased risk of CVD, CAD, nephropathy, retinopathy and deathretinopathy and death

What is the pathophysiology?What is the pathophysiology?

Atherosclerosis in diabetesAtherosclerosis in diabetes

• same atherosclerosissame atherosclerosis - endothelial damage- endothelial damage- platelet aggregation- platelet aggregation- lipid deposition- lipid deposition- plaque formation- plaque formation

• same risk factorssame risk factors

• distribution is differentdistribution is different - mainly below knee disease - mainly below knee disease and profunda femoris artery and profunda femoris artery disease disease

Macrocirculation and microcirculationMacrocirculation and microcirculation

MacrocirculationMacrocirculation- - large vessel calcification large vessel calcification

- atherosclerotic plaque- atherosclerotic plaque

Microcirculation Microcirculation - - thickening of capillary basement membranethickening of capillary basement membrane

- increased microvascular flow (hence warm foot)- increased microvascular flow (hence warm foot)- oedema secondary to impaired postural vasoconstriction- oedema secondary to impaired postural vasoconstriction- increased metabolic requirement- increased metabolic requirement- impaired ability to respond to trauma - impaired ability to respond to trauma - platelet degranulation increased- platelet degranulation increased

Assessment of the Assessment of the

peripheral circulationperipheral circulation

Assessment for PVDAssessment for PVD

• Clinical assessment Clinical assessment

• ABPI and waveformABPI and waveform

• Duplex Duplex

• Angiography (CTA, MRA, catheter angiogram)Angiography (CTA, MRA, catheter angiogram)

Clinical assessmentClinical assessment

• symptoms and signssymptoms and signs may be obvious or subtlemay be obvious or subtle- history of rest pain at night - history of rest pain at night - gangrene- gangrene

• colourcolour- white- white- red (hyperaemic skin)- red (hyperaemic skin)

• temperaturetemperature- cool- cool

• Pulses and ABPIPulses and ABPI

Pulses and ABPIPulses and ABPI

ABPIABPI

Diabetes

WaveformWaveform

Duplex waveformDuplex waveform

Treatment of vascular diseaseTreatment of vascular disease

Treatment optionsTreatment options

• risk factor management and modificationrisk factor management and modification• training, education and counsellingtraining, education and counselling• wound debridementwound debridement• angioplastyangioplasty• vascular reconstructionvascular reconstruction• amputationamputation

Medical treatmentMedical treatment

• good diabetic controlgood diabetic control• stop smokingstop smoking• regular exercise regular exercise • antiplateletsantiplatelets• statinsstatins• ACE inhibitorACE inhibitor

Surgical treatmentSurgical treatment

Surgery for the infected diabetic footSurgery for the infected diabetic foot

• be aggressivebe aggressive• be thoroughbe thorough• don`t suture the wounddon`t suture the wound• appropriate antibioticsappropriate antibiotics• post-operative TNPpost-operative TNP• MRI?MRI?• regular wound reviewregular wound review

Surgery for the infected diabetic footSurgery for the infected diabetic foot

Surgery for the infected diabetic footSurgery for the infected diabetic foot

Case 1 – male 73yrsCase 1 – male 73yrs

Duplex left leg – case 1Duplex left leg – case 1

Catheter angiogram – case 1Catheter angiogram – case 1

Angioplasty – Angioplasty – Case 1Case 1

Angioplasty – case 1Angioplasty – case 1

Surgery – case 1Surgery – case 1

Case 2 – male, 83yrsCase 2 – male, 83yrs

Duplex and CTA – case 2Duplex and CTA – case 2

Catheter angiogram - Case 2Catheter angiogram - Case 2

Catheter angiogram – case 2Catheter angiogram – case 2

Angioplasty – case 2Angioplasty – case 2

Surgery – case 2Surgery – case 2

Vascular reconstructionVascular reconstruction

• for salvageable limbs where for salvageable limbs where angioplasty will fail (long angioplasty will fail (long occlusions, multiple stenoses)occlusions, multiple stenoses)

• use autologous vein where use autologous vein where possiblepossible

The long-term results of the BypassThe long-term results of the Bypassversus Angioplasty in Severeversus Angioplasty in SevereIschaemia of the Leg (BASIL) trialIschaemia of the Leg (BASIL) trialfavour surgery rather thanfavour surgery rather thanangioplasty if there is a good veinangioplasty if there is a good veinand the patient is fit. Some patientsand the patient is fit. Some patientswith critical lower limb ischemia arewith critical lower limb ischemia arebest treated by analgesia or primarybest treated by analgesia or primaryamputationamputation

ReconstructionReconstruction

similar long term outcomes of revascularisation in patients with and without diabetes

Karacagil S et al. Diabet Med 1995; 12: 537-541

AmputationAmputation

can be a very positive end point after months of can be a very positive end point after months of hospitalisation and chronic ill healthhospitalisation and chronic ill health

don`t try to salvage unsalvageable limbsdon`t try to salvage unsalvageable limbs

level of amputation depends on degree of tissue level of amputation depends on degree of tissue disease, level of arterial occlusion and expected disease, level of arterial occlusion and expected postoperative mobility (general health and motivation)postoperative mobility (general health and motivation)

discuss the possibility of amputation as early as possiblediscuss the possibility of amputation as early as possible

AmputationAmputation

Heel ulcersHeel ulcers

Forefoot amputationForefoot amputation

Below knee amputationBelow knee amputation

Above knee amputationAbove knee amputation

SummarySummary

Diabetes and PVDDiabetes and PVD• common but complications often preventablecommon but complications often preventable

• holistic approach through multidisciplinary teamholistic approach through multidisciplinary team

• good community diabetic caregood community diabetic care

• clinical assessment is easy (don`t worry about a high clinical assessment is easy (don`t worry about a high ABPI in the absence of symptoms)ABPI in the absence of symptoms)

• early referral of symptomatic patientsearly referral of symptomatic patients