Francis Dix Consultant vascular and endovascular surgeon 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 community services Hospital services

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 disease

Macrocirculation and microcirculation - 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

peripheral circulation 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

ABPI Diabetes

Waveform

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 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

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

Amputation 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

Amputation

Heel ulcers

Forefoot amputation

Below knee amputation

Above knee amputation

Summary

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