Diabetic Foot Dr Hussein Safar, MD, FRCS Consultant Vascular Surgeon Diabetic Foot: Risk Factors Risk Factors for Atherosclerosis Older age (> 40 years) Male gender Smoking Diabetes Hypertension Hyperlipidaemia Homocysteinuria Family History When risk factors coexist, the risk increases several-fold Am J Cardiol 2001; 87 (suppl): 3D-13D NEJM 2001; 344: 1608-1621 Murabito JM et al. Circulation 1997;96:44–49; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:2910–2913; Malinow MR et al. Circulation 1989;79:1180–1188; Brigden ML. Postgrad Med 1997;101:249–262. Diabetic Foot: Presentation Presentation Acute 6Ps [pulseless, paresthesia, paralysis, pain, pallor, parse cold ] Chronic Intermittent claudicating (typical or atypical) Critical limb ischemia (rest pain or ulceration or gangrene) Neuropathic ulcer / gangrene without ischemia Diabetic Foot: Ulcer Ischaemic Pulse Coldness Sensation Necrotic Delayed Digits Neuropathic Granulating Normal Pressure area Ulcer Hyper-keratotic edges Atrophic appearing skin (shiny, thin, dry) capillary return time Pain Site Diabetic Foot: Classification 0 A Pre or postulcerative lesion completely epithelialized I II III Superficial wound, not Wound penetrating Wound involving tendon, penetrating to to tendon or capsule, or bone bone or joint capsule Superficial wound, not involving tendon, capsule, or bone with infection Wound penetrating to tendon or capsule with infection Wound penetrating to bone or joint with infection B Pre or postulcerative lesion, completely epithelialized with infection C Pre or postulcerative lesion, completely epithelialized with Superficial wound, not involving tendon, capsule, or bone with ischemia Superficial wound, not involving tendon, capsule, or bone with infection and ischemia Wound penetrating to tendon or capsule with ischemia Wound penetrating to tendon or capsule with infection and ischemia Wound penetrating to bone or joint with ischemia Wound penetrating to bone or joint with infection and ischemia ischemia D Pre or postulcerative lesion, completely epithelialized with infection and ischemia The University of Texas Health Science Center San Antonio Diabetic Wound Classification System Diabetic Foot: Investigations Investigations Plain X-ray Hand-Held Doppler Vascular Lab (Arterial Doppler study) MRA Angiography Plain X-ray Hand-Held Doppler Vascular Lab. ABI Normal Claudication Rest Pain 1.0 0.5-1.0 0.3-0.5 Wave Form Tri-phasic Bi /Tri-phasic Mono-phasic Exercise AP<50 Rest AP<40 AP&TP Tissue Loss < 0.3 Mono-phasic TP<30 Rest AP<60 TP <40 ABI=Ankle-Brachial Index, AP=ankle pressure, TP=toe pressure (mmHg) Arterial Doppler ABI = 1 ABI = 0.4 MRA Angiography Diabetic Foot: Management • Goals in claudication 1. Relieve of symptoms 2. Improve their walking capacity 3. Improve their quality of life • Goals in critical leg ischemia 1. Relieving ischemic rest pain 2. Healing ischemic ulceration 3. Preventing limb loss Diabetic Foot: Management Management Modification of risk factors Medical Intervention radiologist Surgical Diabetic Foot: Management Exercise • Walking to near-maximal pain for least 6 months. • Should be part of the standard medical care for patients with intermittent claudication. » Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 274(12):975-80, 1995 Sep 27. Diabetic Foot: Management Smoking Cessation • Slows progression of the disease • Reduces the risks of MI & death • Nicotine-replacement therapy & use antidepressant drugs. »Daughton D, Susman J, Sitorius M, et al. Transdermal nicotine therapy and primary care. Importance of counseling, demographic, and participant selection factors on 1-year quit rates. The Nebraska Primary Practice Smoking Cessation Trial Group. Arch Fam Med 1998;7:425-30. Diabetic Foot: Management Antiplatelet & Anticoagulant Drug Therapy • 25% reduction in all vascular events. – – – – – ASA Clopidogrel Pentoxifylline Dipyridamole Cilostazol Diabetic Foot: Management Prostaglandins • Used in patients with critical leg ischemia (ulcer & gangrene). • May reduces major amputation rate. » Eur J Vasc Endovasc Surg. 2000 Oct;20(4):358-62. » Minerva Cardioangiol. 1998 Oct;46(10 Suppl 1):59-63. » Eur J Vasc Surg. 1991 Oct;5(5):511-6. Diabetic Foot: Management • • • Radiological Intervention PTA & Stenting Surgical 1. Embolectomy and thrombectomy 2. Endarterectomy 3. Patch angioplasty 4. Anatomical or extra anatomical bypass 5. Amputations PTA & Stenting Bypass Surgeries Anatomical (Fem-Pop) & (Fem-Tib.) Bypass Surgeries Extra anatomical (Fem-Fem) & (Fem-Axill.) Bypass Surgeries Patch Angioplasty Rest Pain & small ulcer ABI pre Rt 0.1 Lt 0.7 post Rt 0.7 Lt 0.7 Rx Iliac Artery PTA & Stent Gangrene ABI pre Rt 0.7 Lt 0.7 post Rt 0.7 Lt 1.0 Rx Lt fem-Pop Bypass pre Lt 0.7 post Lt 1.0 Rx LVF & EF 35% Rest Pain & Gangrene ABI pre Rt 0.2 Lt 0.3 post Rt 0.7 Lt 0.3 Axillo-Rt Femoral Artery Bypass Rest Pain & Gangrene ABI pre Rt 0.5 Lt 0.5 post Rt 1.0 Lt 1.0 Rx Aorto-Bi-Femoral Bypass Gangrene ABI pre Rt 0.88 Lt 0.59 Rx No run off, conservative & amputation Ulcer ABI pre Rt 1.6 Lt 1.5 Rx No arch conservative & amputation • Gangrene • ABI pre Lt 0.3 post 1.0 • Rx after Pop-post tibial artery bypass • infection and Gangrene • ABI pre Lt 0.8 • Angio only peroneal artery patent till the ankle joint • Rx only amputation • • • • DM foot ulceration ABI pre Lt 1.0 with palpable pulse X-ray bone osteomylitis Rx only debridment • • • • Bed-ridden Gangrene ABI Not done Rx Primary Amputation Smoking activity Diabetes BP Lipid Homocyst. Help Help !!! Diabetic foot Conclusion Management of DM Foot Prevention Stop Smoking Exercise Treatment Thrombolysis Angioplasty Diet Control Anti Lipid Anti HTN Embolectomy Thrombectomy Bypass ASA & Plavix Folic Acid Vitamin „B‟ complex Vitamin „C‟ & „E‟ Amputation Thank you Anti Coagulant Diabetic Foot: Chronic Limb Ischaemia (Clinical Categories) Grade Category Clinical description Objective Criteria 0 I II III 0 1 2 3 4 5 6 Asymptomatic Mild Claudication Moderate Severe Ischaemic Rest Pain Minor Tissue Loss Major Normal ABI Exercise AP >50 Category 1 & 3 Exercise AP <50 Resting AP <40 or TP < 30 Resting AP <60 or TP < 40 Rutherford 97 AP=ankle pressure, TP=toe pressure (in mmHg), ABI=Ankle-Brachial Index Diabetic Foot: Classification Stage I Non-blanchable erythema of intact skin, “ lesion of skin ulceration”. Diabetic Foot: Classification Stage II Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater Diabetic Foot: Classification Stage III Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Diabetic Foot: Classification Stage IV Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule).