Assessment and management of peripheral vascular disease in the diabetic patient

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Assessment and management of peripheral vascular
disease in the diabetic patient

• Francis Dix
• Consultant vascular and endovascular surgeon

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Peripheral vascular disease with diabetes

• diabetes team
• clinical effects of combined disease
• pathophysiology
• assessment
• treatment cases

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Multidisciplinary teamwork with holistic approach
GP and community services
Hospital services
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What are the issues?
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Diabetes may cause first fall in life expectancy
for 200 yearsJeremy Laurance, health editor, The
Independent October 2008

• The World Health Organisation has predicted that
  deaths from diabetes
• 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
• than 80 per cent of sufferers die from heart
  attacks or strokes and more
• than 1,000 a year suffer kidney failure requiring
  dialysis.
• "The WHO figure for deaths was very
  conservative," he said. "Large
• numbers die from heart disease and strokes
  linked with diabetes and
• they do not include those.
• 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.

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PVD in diabetics has a poor prognosis

• PVD is 20 x more common in diabetics than non
  diabetics
• lower limb amputation is 15 x more common in
  diabetics
• ten year cumulative incidence of lower limb
  amputation is 5.4 in
• type I diabetes and 7.3 in type II
• 10 of diabetics get an ulcer (10 are purely
  ischaemic, 45 are ischaemic with associated
  neuropathy, infection, biomechanical
  abnormalities and Charcot deformity)
• Increased risk of CVD, CAD, nephropathy,
• retinopathy and death

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• What is the pathophysiology?

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Atherosclerosis in diabetes

• same atherosclerosis - endothelial damage
• - platelet aggregation
• - lipid deposition
• - plaque formation
• same risk factors
• distribution is different - mainly below knee
  disease
• and profunda femoris artery disease

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Macrocirculation and microcirculation

• Macrocirculation
• - large vessel calcification
• - atherosclerotic plaque
• Microcirculation
• - thickening of capillary basement membrane
• - increased microvascular flow (hence warm foot)
• - oedema secondary to impaired postural
  vasoconstriction
• - increased metabolic requirement
• - impaired ability to respond to trauma
• - platelet degranulation increased

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• Assessment of the
• peripheral circulation

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Assessment for PVD

• Clinical assessment
• ABPI and waveform
• Duplex
• Angiography (CTA, MRA, catheter angiogram)

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Clinical assessment

• symptoms and signs
• may be obvious or subtle
• - history of rest pain at night
• - gangrene
• colour
• - white
• - red (hyperaemic skin)
• temperature
• - cool
• Pulses and ABPI

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Pulses and ABPI
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ABPI
Diabetes
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Waveform
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Duplex waveform
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Treatment of vascular disease
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Treatment options

• risk factor management and modification
• training, education and counselling
• wound debridement
• angioplasty
• vascular reconstruction
• amputation

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Medical treatment

• good diabetic control
• stop smoking
• regular exercise
• antiplatelets
• statins
• ACE inhibitor

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Surgical treatment
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Surgery for the infected diabetic foot

• be aggressive
• be thorough
• dont suture the wound
• appropriate antibiotics
• post-operative TNP
• MRI?
• regular wound review

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Surgery for the infected diabetic foot
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Surgery for the infected diabetic foot
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Case 1 male 73yrs
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Duplex left leg case 1
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Catheter angiogram case 1
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Angioplasty Case 1
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Angioplasty case 1
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Surgery case 1
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Case 2 male, 83yrs
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Duplex and CTA case 2
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Catheter angiogram - Case 2
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Catheter angiogram case 2
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Angioplasty case 2
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Surgery case 2
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Vascular reconstruction

• for salvageable limbs where angioplasty will fail
  (long occlusions, multiple stenoses)
• use autologous vein where possible
• The long-term results of the Bypass
• versus Angioplasty in Severe
• Ischaemia of the Leg (BASIL) trial
• favour surgery rather than
• angioplasty if there is a good vein
• and the patient is fit. Some patients
• with critical lower limb ischemia are
• best treated by analgesia or primary
• amputation

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Reconstruction
similar long term outcomes of revascularisation
in patients with and without diabetes Karacagil S
et al. Diabet Med 1995 12 537-541
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Amputation

• can be a very positive end point after months of
  hospitalisation and chronic ill health
• dont try to salvage unsalvageable limbs
• level of amputation depends on degree of tissue
  disease, level of arterial occlusion and expected
  postoperative mobility (general health and
  motivation)
• discuss the possibility of amputation as early as
  possible

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Amputation
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Heel ulcers
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Forefoot amputation
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Below knee amputation
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Above knee amputation
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Summary
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Diabetes and PVD

• common but complications often preventable
• holistic approach through multidisciplinary team
• good community diabetic care
• clinical assessment is easy (dont worry about a
  high ABPI in the absence of symptoms)
• early referral of symptomatic patients