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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 154-157

Incidence and role of large vessel disease in diabetic foot


1 Department of General Surgery, KIMSHEALTH Hospital, Thiruvananthapuram, Kerala, India
2 Department of Family Medicine, KIMSHEALTH Hospital, Thiruvananthapuram, Kerala, India

Date of Submission18-Nov-2022
Date of Decision02-Dec-2022
Date of Acceptance29-Dec-2022
Date of Web Publication30-Jan-2023

Correspondence Address:
Dr. Akash Sasidharan
Department of General Surgery, KIMSHEALTH Hospital, Thiruvananthapuram - 695 029, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_42_22

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  Abstract 


Introduction: Diabetic patients are at risk for considerable morbidity as a result of chronic foot ulceration and infection, including limb loss. Diabetic foot infections are usually a consequence of skin ulceration from ischaemia or trauma to a neuropathic foot. The accurate diagnosis of the underlying cause is very important in planning the treatment. The aim of the study was to study the incidence and role of large vessel disease in patients with diabetic foot. Materials and Methods: Seventy-five patients admitted with features of diabetic foot and its complications were included in the study after excluding patients of comorbid medical illness. The presence of macrovasculopathy was assessed by examination for peripheral pulses, followed by assessment using arterial Doppler amongst patients with macrovasculopathy, those with gangrene or non-healing ulcers and those who underwent amputations or disarticulations were analysed. Results: Clinically, dorsalis pedis artery pulses were absent in 81.3% and posterior tibial artery pulses were absent in 54.7%. In arterial Doppler, involvement is 66.7% for dorsalis pedis and 68% for posterior tibial. Fifty-six percentage of patients ended up having poor outcomes in the form of amputations or disarticulations. There is a significant incidence of large vessel disease, especially in elderly patients who were diabetic for more than 10 years. Large vessel disease seems to have a significant role in the final outcome of diabetic foot complications. Conclusions: Vasculopathy is a strong risk factor in the development of diabetic foot lesions. An arterial Doppler will help detect involvement early in cases presenting with diabetic foot complications. The presence of diabetic microvascular disease imparts an even greater importance on the early detection and treatment of significant macrovascular disease.

Keywords: Amputation, diabetic foot infection, macrovasculpothy, peripheral arterial disease


How to cite this article:
Sasidharan A, Khan Shafy S L, Khan Firoz M H, Namita U. Incidence and role of large vessel disease in diabetic foot. Kerala Surg J 2022;28:154-7

How to cite this URL:
Sasidharan A, Khan Shafy S L, Khan Firoz M H, Namita U. Incidence and role of large vessel disease in diabetic foot. Kerala Surg J [serial online] 2022 [cited 2023 Mar 25];28:154-7. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/154/368599




  Introduction Top


Diabetes mellitus with its associated complications is a major cause of morbidity and mortality worldwide.[1] Patients with diabetes are at risk for considerable morbidity as a result of chronic foot ulceration and infection, including limb loss.[2] Diabetic foot infections are usually a consequence of skin ulceration from ischaemia or trauma to a neuropathic foot.[2]

The pathophysiology of primary diabetic lower limb complications has three main components: peripheral neuropathy, peripheral vascular disease and immunodeficiency. Altered foot biomechanics and gait caused by the painless collapse of ligamentous support, foot joints and foot arches change weight-bearing patterns. Blunted pain allows cutaneous fissuring and ulceration to progress. Multiflora infections are established amongst local immunodeficiency and microvasculopathy. Cutaneous ulcerations may chronically deteriorate relatively painlessly involving deeper tissues, including bone. Persistent soft-tissue infection and osteomyelitis, worsened by microvasculopathy and immunodeficiency, end in gangrene and amputation.[3] Despite advances in our understanding and treatment of diabetes mellitus, diabetic foot disease remains a terrifying problem.[4]

An increase in the frequency of peripheral occlusive arterial disease in patients with diabetes mellitus has been demonstrated often. This combination is particularly devastating because of the risk of severe ischaemia, gangrene and amputation. The course of early peripheral occlusive arterial disease in diabetic patients is not well known. Furthermore, the rates of development of peripheral arterial disease and of progression of established peripheral occlusive arterial disease in diabetic and non-diabetic patients are incompletely understood.[5] Diabetes is recognised as the most common cause of non-traumatic lower limb amputation in the western world, with individuals over 20 times more likely to undergo an amputation compared to the rest of the population.[6] There is growing evidence that the vascular contribution to diabetic foot disease is greater than was previously realised. This is important because, unlike peripheral neuropathy, peripheral arterial occlusive disease (PAOD) due to atherosclerosis, is generally far more amenable to therapeutic intervention. PAOD, as indicated by a low TcPO2 on the dorsum of the foot, has been demonstrated to be a greater risk factor than neuropathy in both foot ulceration and lower limb amputation in patients with diabetes.[7]

Diabetes is associated with microvascular and macrovascular complications. The term peripheral vascular disease may be more appropriate when referring to lower limb tissue perfusion in diabetes, as this includes the influence of both microvascular dysfunction and PAOD.[7] For evaluation of the vascular status in these patients, different invasive and non-invasive methods are available such as arteriography, Doppler and duplex scanning.[8] Doppler scanning is widely preferred as it is simple, versatile and handy. The accurate diagnosis of the underlying cause is very important in planning the treatment. This study aims at finding the incidence and role of macrovasculopathy in patients with diabetic foot using different imaging modalities.


  Materials and Methods Top


The aim of the study was to study the incidence and role of large vessel disease in patients with diabetic foot. We found the incidence of large vessel disease in patients with diabetic foot and also we found the role of large vessel disease in the healing of diabetic foot ulcers.

It was a prospective, descriptive study from July 2015 to June 2017 on all patients admitted with features of diabetic foot and its complications at the department of general surgery in our tertiary care centre. Non-diabetic patients and patients with vasculitis and Raynaud's disease were excluded from the study.

Sample size estimation

Formula for calculating sample size



According to the similar study,[4] 56.6% of the patients were detected to have vasculopathy using Doppler ultrasound.

Estimated sample size – 74. Actual sample size 75

All patients admitted with diabetic foot complications including cellulitis, abscess formation, necrotising infection, ulceration and gangrene were assessed for the presence of macrovasculopathy by examination for peripheral pulses, followed by assessment using imaging modalities. Arterial Doppler was done in all cases, and computed tomography angiogram and magnetic resonance (MR) angiogram were done wherever indicated according to hospital protocol in planning further management. Arterial Doppler was the primary tool in assessment.

Amongst patients with macrovasculopathy, those with gangrene or non-healing ulcers and those who underwent amputations or disarticulations were made in percentage. The collected data were analysed using the statistical software SPSS version 16.0 (IBM Delhi).


  Results Top


We found that age distribution amongst 72 study patients, 31–40 years were 2 (2.7%), 41–50 years were 7 (9.3%), 51–60 years were 16 (21.3%), 61–70 years were 28 (37%), 71–80 years were 18 (24%) and 81–90 years were 4 (5.3%). Gender-wise, 51 (68%) were male and 24 (32%) were female.

Thirty-one patients (41.3%) were <10-year duration of diabetes and more than 10 years of duration were 44 patients (58.7%) which is statistically not significant (P - 0.039).

We found that clinical vasculopathy was present in 61 patients, dorsalis pedis pulse being absent in 61 (81%), posterior tibial pulse absent in 41 (54%), popliteal pulse absent in 9 (12%) and femoral pulse absent in 1 patient (1.3%) [Figure 1].
Figure 1: Clinical examination findings of peripheral pulses in our study population

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However, an arterial Doppler scan revealed the involvement of the dorsalis pedis in 50 cases, posterior tibial in 51 cases, popliteal in 20 cases and femoral in 11 cases.

Amongst 72 patients, arterial Doppler showed dorsalis pedis with the normal flow in 25 (33.3%), biphasic flow in 8 (10.7%), monophasic flow in 28 (37.3%) and absent flow in 14 cases (18.7%) which are statistically significant (P < 0.001) and posterior tibial with the normal flow in 24 (32%), biphasic flow in 20 (26.7%) and monophasic flow in 31 (41.3%) cases which are statistically significant (P < 0.001).

MR angiogram was done only for five patients and revealed findings similar to that of arterial Doppler.

Out of the 75 patients, 22 presented with gross gangrene, 13 with necrotising infections, 8 with abscesses, 20 with non-healing ulcers and 12 with cellulitis. Amongst them, 42 (56%) patients ended in poor outcomes (25 underwent disarticulations, 9 underwent amputations and 8 underwent below-knee amputations). Amongst the 42 patients with poor outcomes, 36 (48%) patients had affected flow in the Doppler scan. One patient who presented with necrotising infection expired even after a below-knee amputation.


  Discussion Top


The data in this study showed male preponderance and 88% of the study population consisted of people more than 50 years of age. The study also showed that 58.7% were diabetic for more than 10 years. There is a significant incidence of large vessel disease, especially in elderly patients who were diabetic for more than 10 years.

Clinically, dorsalis pedis artery (DPA) pulses were absent in 81.3% and posterior tibial artery (PTA) pulses were absent in 54.7%. In arterial Doppler, biphasic, monophasic and absent flow were taken as abnormal and revealed that involvement is 66.7% for DPA and 68% for PTA. Amongst the 75 patients, 56% of patients ended up having poor outcomes in the form of amputations or disarticulations.

Amongst the 42 patients with poor outcomes, 48% of patients had affected flow in the Doppler scan. One patient who presented with necrotising infection expired even after a below-knee amputation. We found that large vessel disease seems to have a significant role in the final outcome of diabetic foot complications. The higher incidence of poor outcome may also be due to severe necrotising infections.

In a cohort of 558 people, only 345 (62%) healed after primary treatment, 123 (22%) healed after surgery and 90 (16%) died unhealed.[9] In deep infections, the rate of healing without surgery can drop to 40%,[10] with a median healing time of 24 weeks; with surgery, this rate increases to 52 (minor amputation) and 38 weeks (major amputation). Of 389 ulcers (in 179 people, newly referred), only 33% healed without surgery within 3 months. Of those who followed up for 6 months, 48% healed without surgery, while 40% were unhealed; six patients lost a lower limb and ten died. Piaggesi et al. reported 79% healing at 25 weeks in neuropathic ulcers after conventional treatment, compared with 96% after excision of the ulcer and adjacent bone.[11] However, despite good management, healing rates in large multicentre trials were 24% at 12 weeks and 31% at 20 weeks.[12]

Jirkovská et al. conducted the comparison of a simple standardized non-invasive examination of neuropathy and angiopathy with routine diagnostic practice (Doppler ultrasound) in community diabetes clinics for the identification of patients at risk of foot ulceration. It showed that patients with angiopathy at risk of developing diabetic foot ulcers (ABI d”0.8) had been diagnosed, in diabetes clinics, to have peripheral arterial disease in 50% (they reported claudications in 41%, had femoral artery bruits detected in 29% and non-palpable peripheral pulsations in 12%).[13] This highlights the importance of using standardized simple non-invasive testing methods to increase the accuracy of identifying patients at risk for diabetic foot at the community level. Richards-George found that Doppler measurements of ankle/brachial pressure index (A/BI) revealed that 23% of the diabetics had peripheral occlusive arterial disease (POAD) which was mostly asymptomatic.[14] This underscores the need for regular Doppler A/BI testing to improve the recognition and treatment of POAD. Berry et al. used Doppler flow volume to show a 29% reduction in systemic arterial compliance.[15] Rydén Ahlgren et al. also showed increased arterial stiffness amongst women with type-I diabetes.[16] Uperz et al. studied 31 diabetic patients on insulin therapy and found an inverse correlation between small artery compliance and the duration of diabetes.[17]


  Conclusions Top


This study shows that vasculopathy is a strong risk factor in the development of diabetic foot lesions. The clinical examination is subjective and usual symptoms and signs of lower limb ischaemia may not be always present and indeed may be misleading in diabetic foot disease. Hence, an arterial Doppler will help detect involvement early in cases presenting with diabetic foot complications. The presence of diabetic microvascular disease imparts an even greater importance on the early detection and treatment of significant macrovascular disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amini M, Parvaresh E. Prevalence of macro and microvascular complications among patients with type 2 diabetes in Iran: A systematic review. Diabetes Res Clin Pract 2009;83:18-25.  Back to cited text no. 1
    
2.
Barie PS. Sabiston Textbook of Surgery. 19th ed. New York: Elsevier; 2013.  Back to cited text no. 2
    
3.
Losee JE, Gimbel M, Rubin JP, Wallace CG, Wei F. Plastic and reconstructive surgery. In: Brunicardi FC, Andersen DK, Hunter JG, Billiar TR, Matthews JB, Dunn DL, et al., editors. Schwartz's Principles of Surgery. 9th ed. Pennsylvania: McGraw-Hill; 2010. p. 1693.  Back to cited text no. 3
    
4.
Rahman A, Moizuddin M, Ahmad M, Salim M. Vasculopathy in patients with diabetic foot using Doppler ultrasound. Pak J Med Sci 2009;25:428-33.  Back to cited text no. 4
    
5.
Osmundson PJ, O'Fallon WM, Zimmerman BR, Kazmier FJ, Langworthy AL, Palumbo PJ. Course of peripheral occlusive arterial disease in diabetes. Vascular laboratory assessment. Diabetes Care 1990;13:143-52.  Back to cited text no. 5
    
6.
van Houtum WH, Lavery LA, Harkless LB. The impact of diabetes-related lower-extremity amputations in the Netherlands. J Diabetes Complications 1996;10:325-30.  Back to cited text no. 6
    
7.
Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22:1029-35.  Back to cited text no. 7
    
8.
Williams DT, Pugh ND, Coleman DP, Harding KG, Patricia P. The laboratory evaluation of lower limb perfusion in diabetes mellitus. A clinical review. Brit J Diabet Vasc Dis 2005;5:64-70.  Back to cited text no. 8
    
9.
Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med 1993;233:485-91.  Back to cited text no. 9
    
10.
Tennvall GR, Apelqvist J, Eneroth M. Costs of deep foot infections in patients with diabetes mellitus. Pharmacoeconomics 2000;18:225-38.  Back to cited text no. 10
    
11.
Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, et al. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: A randomized trial. Diabet Med 1998;15:412-7.  Back to cited text no. 11
    
12.
Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. Diabetes Care 1999;22:692-5.  Back to cited text no. 12
    
13.
Jirkovská A, Boucek P, Wosková V, Bartos V, Skibová J. Identification of patients at risk for diabetic foot: A comparison of standardized noninvasive testing with routine practice at community diabetes clinics. J Diabetes Complications 2001;15:63-8.  Back to cited text no. 13
    
14.
Richards-George P. Vasculopathy in the diabetic foot. West Indian Med J 2001;50 Suppl 1:18-20.  Back to cited text no. 14
    
15.
Berry KL, Skyrme-Jones RA, Cameron JD, O'Brien RC, Meredith IT. Systemic arterial compliance is reduced in young patients with IDDM. Am J Physiol 1999;276:H1839-45.  Back to cited text no. 15
    
16.
Rydén Ahlgren A, Länne T, Wollmer P, Sonesson B, Hansen F, Sundkvist G. Increased arterial stiffness in women, but not in men, with IDDM. Diabetologia 1995;38:1082-9.  Back to cited text no. 16
    
17.
Uperz D, DeBuyzere M, Tuyttens C, Rottiers R, Clement D, Cohn J. Small artery elasticity but not large artery elasticity index is related to the disease duration in early onset insulin dependent diabetes mellitus (abstract). J Hypertens 1999;17 Suppl 3:95.  Back to cited text no. 17
    


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