Peripheral vascular disease and diabetes by l62idC8


									Assessment and management of
peripheral vascular disease in the
         diabetic patient

                   Francis Dix
  Consultant vascular and endovascular surgeon
Peripheral vascular disease with diabetes

        •   diabetes team
        •   clinical effects of combined disease
        •   pathophysiology
        •   assessment
        •   treatment – cases
            Multidisciplinary teamwork with
                   holistic approach

GP and                                                 surgery
community                                                             Hospital
services                                                              services

              oxygen                                      orthotics

What are the issues?
Diabetes may cause first fall in life expectancy for 200 years
     Jeremy 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.
        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
What is the pathophysiology?
        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
Macrocirculation and microcirculation

   - large vessel calcification
    - atherosclerotic plaque

   - 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
 Assessment of the
peripheral circulation
       Assessment for PVD

•   Clinical assessment

•   ABPI and waveform

•   Duplex

•   Angiography (CTA, MRA, catheter angiogram)
                     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
Pulses and ABPI

Duplex waveform
Treatment of vascular disease
         Treatment options

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

•   good diabetic control
•   stop smoking
•   regular exercise
•   antiplatelets
•   statins
•   ACE inhibitor
Surgical treatment
Surgery for the infected diabetic foot

    •   be aggressive
    •   be thorough
    •   don`t suture the wound
    •   appropriate antibiotics
    •   post-operative TNP
    •   MRI?
    •   regular wound review
Surgery for the infected diabetic foot
Surgery for the infected diabetic foot
Case 1 – male 73yrs
Duplex left leg – case 1
Catheter angiogram – case 1
Angioplasty –
Case 1
Angioplasty – case 1
Surgery – case 1
Case 2 – male, 83yrs
Duplex and CTA – case 2
Catheter angiogram - Case 2
Catheter angiogram – case 2
Angioplasty – case 2
Surgery – case 2
                 Vascular reconstruction

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

•   use autologous vein where

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

    similar long term outcomes of
    revascularisation in patients with and
    without diabetes
    Karacagil S et al. Diabet Med 1995; 12: 537-541
   can be a very positive end point after months of
    hospitalisation and chronic ill health

   don`t 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
Heel ulcers
Forefoot amputation
Below knee amputation
Above knee amputation
               Diabetes and PVD
•   common but complications often preventable

•   holistic approach through multidisciplinary team

•   good community diabetic care

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

•   early referral of symptomatic patients

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