1. 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

2. Peripheral vascular disease with diabetes
diabetes team
clinical effects of combined disease
pathophysiology
assessment
treatment – cases

3. Multidisciplinary teamwork with holistic approach
GP and community services
Hospital services

4. What are the issues?

5. 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.

6. 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

7. What is the pathophysiology?

8. 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

9. 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

10. peripheral circulation
Assessment of the
peripheral circulation

11. Assessment for PVD Clinical assessment ABPI and waveform Duplex
Angiography (CTA, MRA, catheter angiogram)

12. 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

13. Pulses and ABPI

14. ABPI
Diabetes

15. Waveform

16. Duplex waveform

17. Treatment of vascular disease

18. Treatment options risk factor management and modification
training, education and counselling
wound debridement
angioplasty
vascular reconstruction
amputation

19. Medical treatment good diabetic control stop smoking regular exercise
antiplatelets
statins
ACE inhibitor

20. Surgical treatment

21. Surgery for the infected diabetic foot
be aggressive
be thorough
don`t suture the wound
appropriate antibiotics
post-operative TNP
MRI?
regular wound review

22. Surgery for the infected diabetic foot

23. Surgery for the infected diabetic foot

24. Case 1 – male 73yrs

25. Duplex left leg – case 1

26. Catheter angiogram – case 1

27. Angioplasty – Case 1

28. Angioplasty – case 1

29. Surgery – case 1

30. Case 2 – male, 83yrs

31. Duplex and CTA – case 2

32. Catheter angiogram - Case 2

33. Catheter angiogram – case 2

34. Angioplasty – case 2

35. Surgery – case 2

36. 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

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

38. 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

39. Amputation

40. Heel ulcers

41. Forefoot amputation

42. Below knee amputation

43. Above knee amputation

44. Summary

45. 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