Assessment and management of peripheral vascular disease in the diabetic patient

1. 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 yearsJeremy 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 Macrocirculation - 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. 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: 537-541

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