Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview

Peripheral Arterial Disease and the Diabetic Foot Syndrome: Neuropathy Makes the Difference! A Narrative Review

Background: In vascular medicine, peripheral arterial disease (PAD) and diabetic foot syndrome (DFS) are often considered synonymous with respect to the need for revascularization. In PAD patients, clinical symptoms reflect the degree of atherosclerotic disease, since peripheral innervation, including pain sensation, is not usually compromised. In DFS patients, however, symptoms of relevant foot ischemia are often absent and progression of ischemia goes unnoticed owing to diabetic polyneuropathy, the loss of nociception being the main trigger for foot ulcers. This review analyzes the fundamental differences between PAD and DFS against the background of polyneuropathy. Methods: The literature research for the 2014 revision of the German evidence-based S3-PAD-guidelines was extended to 2023. Results: Vascular examination is imperative for both, PAD and DFS. Stage-dependent revascularization is of utmost importance in PAD patients, especially those suffering from critical limb-threatening ischemia (CLTI). Successful therapy of DFS goes further, including infection and metabolic control, wound management, offloading the foot and lifelong prophylaxis in the course of a multidisciplinary treatment concept. Revascularization is not needed in all cases of DFS. Conclusions: There are fundamental differences between PAD and DFS with respect to pathophysiology, the anatomical distribution of arterial occlusive processes, the clinical symptoms, the value of diagnostic tools such as the ankle-brachial index, and classification. Also, therapeutic concepts differ substantially between the two patient populations.

Revascularization Outcomes Stratified by Glycemic Control in Patients with Diabetes Mellitus and Chronic Limb-Threatening Ischemia

BACKGROUND

The prevalence of chronic limb-threatening ischemia (CLTI) has increased alongside rising rates of diabetes mellitus (DM). While diabetic patients with CLTI have worse outcomes compared to patients without diabetes, conflicting data exist on the relationship between the severity of DM and CLTI outcomes. Close inspection of the relationship between DM severity and outcomes in CLTI may benefit surgical decision-making and patient education.

METHODS

We retrospectively reviewed patients who received endovascular intervention or surgical bypass for CLTI at our multidisciplinary Limb Preservation Program from 2013 to 2019 to collect patient characteristics using Society for Vascular Surgery (SVS) reporting standards, arterial lesion characteristics from recorded angiograms, and outcomes, including survival, amputation, wound healing, and revascularization patency. Controlled DM was defined as SVS Grade 1 (controlled, not requiring insulin) and Grade 2 (controlled, requiring insulin), while uncontrolled DM was defined as SVS Grade 3 (uncontrolled), and DM severity was assessed using preoperative hemoglobin A1c (HgbA1c) values. Product-limit Kaplan-Meier was used to estimate survival functions. Univariable Cox proportional hazards analyses guided variable selection for multivariable analyses.

RESULTS

Our Limb Preservation Program treated 177 limbs from 141 patients with DM. Patients with uncontrolled DM were younger (60.44 ± 10.67 vs. 65.93 ± 10.89 years old, P = 0.0009) and had higher HgbA1c values (8.97 ± 1.85% vs. 6.79 ± 1.10%, P < 0.0001). Fewer patients with uncontrolled DM were on dialysis compared to patients with controlled DM (15.6% vs. 30.9%, P = 0.0278). By Kaplan-Meier analysis, DM control did not affect time to mortality, limb salvage, wound healing, or loss of patency. However, multivariable proportional hazards analysis demonstrated increased risk of limb loss in patients with increasing HgbA1C (hazard ratio (HR) = 1.96 [1.42-2.80], P < 0.0001) or dialysis dependence (HR = 15.37 [3.44-68.73], P = 0.0003), increased risk of death in patients with worsening pulmonary status (HR = 1.70 [1.20-2.39], P = 0.0026), and increased risk of delayed wound healing in patients who are male (HR = 0.48 [0.29-0.79], P = 0.0495). No independent association existed between loss of patency with any of the variables we collected.

CONCLUSIONS

Patients with uncontrolled DM, as defined by SVS reporting standards, do not have worse outcomes following revascularization for CLTI compared to patients with controlled DM. However, increasing HgbA1c is associated with a greater risk for early amputation. Before revascularization, specific attention to the level of glycemic control in patients with DM is important, even if DM is "controlled." In addition to aggressive attempts at improved glycemic control, those with elevated HgbA1c should receive careful education regarding their increased risk of amputation despite revascularization. Future work is necessary to incorporate the severity of DM into risk models of revascularization for the CLTI population.

Predicting future occlusion or stenosis of lower extremity bypass grafts using artificial intelligence to simultaneously analyze all flow velocities collected in current and previous ultrasound examinations

Objective

Routine surveillance with duplex ultrasound (DUS) examination is recommended after femoral-popliteal and femoral-tibial-pedal vein bypass grafts with various intervals postoperatively. The presently used methodology to analyze bypass graft DUS examination does not use all the available data and has been shown to have a significant rate for missing impending bypass graft failure. The objective of this research is to investigate recurrent neural networks (RNNs) to predict future bypass graft occlusion or stenosis.

Methods

This study includes DUS examinations of 663 patients who had bypass graft operations done between January 2009 and June 2022. Only examinations without missing values were included. We developed two RNNs (a bidirectional long short-term memory unit and a bidirectional gated recurrent unit) to predict bypass graft occlusion and stenosis based on peak systolic velocities collected in the 2 to 5 previous DUS examinations. We excluded the examinations with missing values and split our data into training and test sets. Then, we applied 10-fold cross-validation on training to optimize the hyperparameters and compared models using the test data.

Results

The bidirectional long short-term memory unit model can gain an overall sensitivity of 0.939, specificity of 0.963, and area under the curve of 0.950 on the prediction of bypass graft occlusion, and an overall sensitivity of 0.915, specificity of 0.909, and area under the curve of 0.912 predicting the development of a future critical stenosis. The results on different bypass types show that the system performs differently on different types. The results on subcohorts based on gender, smoking status, and comorbidities show that the performance on current smokers is lower than the never smoker.

Conclusions

We found that RNNs can gain good sensitivity, specificity, and accuracy for the detection of impending bypass graft occlusion or the future development of a critical bypass graft stenosis using all the available peak systolic velocity data in the present and previous bypass graft DUS examinations. Integrating clinical data, including demographics, social determinants, medication, and other risk factors, together with the DUS examination may result in further improvements.

Clinical Relevance

Detecting bypass graft failure before it occurs is important clinically to prevent amputations, salvage limbs, and save lives. Current methods evaluating screening duplex ultrasound examinations have a significant failure rate for detecting a bypass graft at risk for failure. Artificial intelligence using recurrent neural networks has the potential to improve the detection of at-risk bypass graft before they fail. Additionally, artificial intelligence is in the news and is being applied to many fields. Vascular surgeons need to know its potential to improve vascular outcomes.

The pathophysiology of diabetic foot: a narrative review

An aging population and changes in dietary habits have increased the incidence of diabetes, resulting in complications such as diabetic foot ulcers (DFUs). DFUs can lead to serious disabilities, substantial reductions in patient quality of life, and high financial costs for society. By understanding the etiology and pathophysiology of DFUs, their occurrence can be prevented and managed more effectively. The pathophysiology of DFUs involves metabolic dysfunction, diabetic immunopathy, diabetic neuropathy, and angiopathy. The processes by which hyperglycemia causes peripheral nerve damage are related to adenosine triphosphate deficiency, the polyol pathway, oxidative stress, protein kinase C activity, and proinflammatory processes. In the context of hyperglycemia, the suppression of endothelial nitric oxide production leads to microcirculation atherosclerosis, heightened inflammation, and abnormal intimal growth. Diabetic neuropathy involves sensory, motor, and autonomic neuropathies. The interaction between these neuropathies forms a callus that leads to subcutaneous hemorrhage and skin ulcers. Hyperglycemia causes peripheral vascular changes that result in endothelial cell dysfunction and decreased vasodilator secretion, leading to ischemia. The interplay among these four preceding pathophysiological factors fosters the development and progression of infections in individuals with diabetes. Charcot neuroarthropathy is a chronic and progressive degenerative arthropathy characterized by heightened blood flow, increased calcium dissolution, and repeated minor trauma to insensate joints. Directly and comprehensively addressing the pathogenesis of DFUs could pave the way for the development of innovative treatment approaches with the potential to avoid the most serious complications, including major amputations.

Angiogenic and Microvascular Status Alterations after Endovascular Revascularization of Lower Limb Arteries among Patients with Diabetic Foot Syndrome: A Prospective 12-Month Follow-Up Study

Peripheral arterial disease (PAD)-induced ischemia is an important component of diabetic foot syndrome (DFS). The results of revascularization of the lower extremity arteries (including percutaneous transluminal angioplasty [PTA]) do not always give satisfactory long-term results, which is due to many factors. The aim of the study was to investigate the alterations in selected circulating angiogenic factors and microcirculation parameters in 41 patients with DFS following PTA and analyze their relationships with clinical outcomes during 1-year follow-up. Our study revealed a general decrease in pro-angiogenic factor levels after PTA and their subsequent stabilization during subsequent observation. The results indicated a significant association between plasma circulating FGF-2 level and poor outcomes (including the incidence of restenosis/reocclusion of treated arteries) during 12 months of observation. The perioperative changes in FGF-2 showed a significant association with LDF alterations after PTA. Follow-up 1-3 months post-intervention showed a tendency towards elevated TcpO2, VEGF-A, and VEGF-R2 levels in patients free from adverse events. These results may provide a basis for further research on the potential use of selected circulating angiogenic factors for monitoring the treatment of patients with DFS following PTA.

Triplanar osteotomy combined with proximal tibial transverse transport to accelerate healing of recalcitrant diabetic foot ulcers

BACKGROUND

Management of recalcitrant diabetic foot ulcers remains challenging. Tibial transverse transport (TTT) is an effective method for enhancing the healing of foot ulcers. This retrospective study reports a novel triplanar osteotomy in the tibia and assesses the clinical outcomes of TTT for diabetic foot ulcers.

METHODS

Fifty-nine patients with recalcitrant diabetic foot ulcers were divided into the TTT (32 patients) and control (27 patients) groups. In the TTT group, the patients underwent triplanar osteotomy of the proximal tibia, followed by 2 weeks of medial distraction and 2 weeks of lateral distraction. In the control group, the patients received conventional management, including debridement, revascularization, and reconstruction. Ulcer healing and healing time, amputation, recurrence, and complications were assessed at an 18-month follow-up visit. Computed tomography angiography (CTA) was used to evaluate vessel changes in the lower limbs of patients in the TTT group.

RESULTS

The TTT group was superior to the control group in the healing rate (90.6% [29/32] vs. 66.7% [18/27]) and the healing time (4.6 ± 1.7 months vs. 7.4 ± 2.5 months), respectively. The proportions of amputation and recurrence in the TTT group were lower than that in the control group, without statistical difference. After triplanar osteotomy and transverse distraction, CTA demonstrated an increase in small vessels in the wound and ipsilateral limb. All patients achieved satisfactory union of the osteotomized bone fragment after removal of the external fixator.

CONCLUSIONS

Triplanar osteotomy combined with proximal tibial transverse distraction accelerates wound healing and limb salvage caused by severe and recalcitrant diabetic foot ulcers. Triplanar osteotomy not only increases the bone contact area, which is beneficial for rapid bone reconstruction, but also preserves the vascularization of the bone fragment and substantially facilitates capillary angiogenesis during distraction. These results suggest that triplanar osteotomy followed by tibial transverse distraction is an effective method for treating diabetic foot ulcers.

Neutrophil-to-Lymphocyte Ratio Predicts Restenosis After Drug-Coated Balloon Therapy for Femoropopliteal Artery Lesions: A Retrospective Study

Background

Peripheral artery disease (PAD) is a common atherosclerotic vascular disease. The use of drug-coated balloon (DCB) for the treatment of femoropopliteal artery disease has gradually increased. A certain percentage of patients developed target lesion restenosis after DCB treatment of the femoral popliteal artery. The neutrophil-to-lymphocyte ratio (NLR) is closely related to the level of inflammatory activity and has predictive value for atherosclerotic vascular disease. This study aimed to analyze the relationship between NLR and 1-year restenosis after DCB for femoropopliteal artery disease.

Methods

Patients with femoropopliteal artery disease who were treated with DCBs at our hospital from May 2016 to December 2020 were retrospectively included. Baseline data during the patient’s first hospital stay and data during follow-up were collected. Demographic data, laboratory test results, lesion examination results, and major adverse events during the follow-up period were collected. Logistic regression was used to analyze the factors associated with restenosis after DCB.

Results

A total of 117 patients were included. During 1-year follow-up, 19 cases (16.2%) of restenosis were detected. Five of these patients (4.3% of total included patients) were readmitted for symptomatic ischemia. No deaths or amputations occurred. Baseline NLR in patients with restenosis was higher than that in patients without restenosis (2.4 (2.1, 3.4) vs. 1.8 (1.3, 2.3), P &lt; 0.001). Logistic univariate and multivariate analysis showed that baseline hs-CRP level (OR = 1.10, 95%CI: 1.05–1.34), lesion length (OR = 1.04, 95%CI: 1.02–1.27), use of rivaroxaban (OR = 1.08, 95%CI: 1.05–1.39), NLR (OR = 1.47, 95%CI: 1.13–2.48), LDL-C level (OR = 1.25, 95%CI: 1.05–1.52), and diabetes (OR = 1.25, 95%CI: 1.05–1.52) = 1.18, 95%CI: 1.06–1.66) were predictors of restenosis.

Conclusion

Baseline NLR before DCB can predict the risk of restenosis after surgery.

Tibial cortex transverse transport accelerates wound healing via enhanced angiogenesis and immunomodulation

AIMS

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remains a challenge. A novel surgical technique named 'tibial cortex transverse transport' (TTT) has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In the present study, we explored the potential biological mechanisms of TTT surgery using various techniques in a rat TTT animal model.

METHODS

A novel rat model of TTT was established with a designed external fixator, and effects on wound healing were investigated. Laser speckle perfusion imaging, vessel perfusion, histology, and immunohistochemistry were used to evaluate the wound healing processes.

RESULTS

Gross and histological examinations showed that TTT technique accelerated wound closure and enhanced the quality of the newly formed skin tissues. In the TTT group, haematoxylin and eosin (H&E) staining demonstrated a better epidermis and dermis recovery, while immunohistochemical staining showed that TTT technique promoted local collagen deposition. The TTT technique also benefited to angiogenesis and immunomodulation. In the TTT group, blood flow in the wound area was higher than that of other groups according to laser speckle imaging with more blood vessels observed. Enhanced neovascularization was seen in the TTT group with double immune-labelling of CD31 and α-Smooth Muscle Actin (α-SMA). The number of M2 macrophages at the wound site in the TTT group was also increased.

CONCLUSION

The TTT technique accelerated wound healing through enhanced angiogenesis and immunomodulation. Cite this article: Bone Joint Res 2022;11(4):189-199.

Role of miRNAs in diabetic neuropathy: mechanisms and possible interventions

Accelerating cases of diabetes worldwide have given rise to higher incidences of diabetic complications. MiRNAs, a much-explored class of non-coding RNAs, play a significant role in the pathogenesis of diabetes mellitus by affecting insulin release, β-cell proliferation, and dysfunction. Besides, disrupted miRNAs contribute to various complications, diabetic retinopathy, nephropathy, and neuropathy as well as severe conditions like diabetic foot. MiRNAs regulate various processes involved in diabetic complications like angiogenesis, vascularization, inflammations, and various signaling pathways like PI3K, MAPK, SMAD, and NF-KB signaling pathways. Diabetic neuropathy is the most common diabetic complication, characterized mainly by pain and numbness, especially in the legs and feet. MiRNAs implicated in diabetic neuropathy include mir-9, mir-106a, mir-146a, mir-182, miR-23a and b, miR-34a, and miR-503. The diabetic foot is the most common diabetic neuropathy, often leading to amputations. Mir-203, miR-23c, miR-145, miR-29b and c, miR-126, miR-23a and b, miR-503, and miR-34a are associated with diabetic foot. This review has been compiled to summarize miRNA involved in initiation, progression, and miRNAs affecting various signaling pathways involved in diabetic neuropathy including the diabetic foot. Besides, potential applications of miRNAs as biomarkers and therapeutic targets in this microvascular complication will also be discussed.

Biofilms in Diabetic Foot Ulcers: Impact, Risk Factors and Control Strategies

Diabetic foot ulcers (DFUs) are a serious complication from diabetes mellitus, with a huge economic, social and psychological impact on the patients' life. One of the main reasons why DFUs are so difficult to heal is related to the presence of biofilms. Biofilms promote wound inflammation and a remarkable lack of response to host defences/treatment options, which can lead to disease progression and chronicity. In fact, appropriate treatment for the elimination of these microbial communities can prevent the disease evolution and, in some cases, even avoid more serious outcomes, such as amputation or death. However, the detection of biofilm-associated DFUs is difficult due to the lack of methods for diagnostics in clinical settings. In this review, the current knowledge on the involvement of biofilms in DFUs is discussed, as well as how the surrounding environment influences biofilm formation and regulation, along with its clinical implications. A special focus is also given to biofilm-associated DFU diagnosis and therapeutic strategies. An overview on promising alternative therapeutics is provided and an algorithm considering biofilm detection and treatment is proposed.

Provisional focal stenting of complex femoropopliteal lesions using the Multi-LOC multiple stent delivery system – 12-month results from the LOCOMOTIVE EXTENDED study

Summary: Background: This study aimed to evaluate a Multiple Stent Delivery System for provisional focal stenting of the femoropopliteal artery. Patient and methods: The LOCOMOTIVE EXTENDED study (Multi-LOC for flOw liMiting Outcomes after plain old balloon angioplasty and/or drug-coated balloon Treatment in the infrainguinal position with the objectIVE to implant multiple stent segments) is a prospective, single-arm, multicentre observational study. The Multi-LOC Multiple Stent Delivery System (B.Braun, Melsungen, Germany) was used for provisional focal stenting of the femoropopliteal artery. We enrolled 357 patients with 449 femoropopliteal lesions; all had flow-limiting dissections or recoil following angioplasty. Eligibility included Rutherford classification 2 to 5 with a de novo or non-stented restenotic femoropopliteal lesion undergoing plain balloon or drug-coated balloon angioplasty. The 6- and 12-month efficacy endpoints encompassed target lesion revascularisation and primary patency rates. Results: The mean patient age was 71 ± 10 years. The mean lesion length was 16.0 ± 9.7 cm; 44.5% were TASC II C/D lesions and 31.4% were chronic total occlusions. By operator choice, 45% of the patients underwent drug-coated balloon angioplasty. On average, 4.0 stents (each 13 mm long) were placed in each lesion, resulting in a scaffolding proportion of 56% of the total lesion length with a technical success rate of 98.3%. At 6 and 12 months, the freedom from clinically driven target lesion revascularisation was 95.5% and 88.7% and the primary patency rates were 88.7% and 82.3%, respectively. At 12 months, significant improvements were noted in Rutherford categories and ankle-brachial indices. In multiple regression analyses, both diabetes mellitus and no distal run-off vessel showed a trend toward worse TLR, while other factors such as DCB predilation or the lesion length were not predictive. Conclusions: The LOCOMOTIVE EXTENDED study demonstrated the safety and efficacy of the Multi-LOC stent system for focal provisional stenting of complex femoropopliteal lesions.

[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

Association of Diabetes Mellitus With Health Status Outcomes in Patients With Peripheral Artery Disease: Insights From the PORTRAIT Registry

Background

Patients with peripheral artery disease (PAD) and coexisting diabetes mellitus (DM) have greater PAD progression and adverse limb events. Our aim was to study whether PAD‐specific health status differs by DM.

Methods and Results

The PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) trial is a 16‐center international registry that includes patients with recent exacerbations or new‐onset symptomatic PAD presenting to specialty clinics. We assessed PAD‐specific health status initially and at 3, 6, and 12 months (Peripheral Artery Questionnaire [PAQ]). We used hierarchical, multivariable, linear regression, and repeated measures analyses to study the association between DM and baseline health status initially and over 3 to 12 months. Models were adjusted for demographics, socioeconomic factors, PAD severity, comorbidities, and psychosocial characteristics. The interaction of DM with PAD revascularization on 3‐ to 12‐month health status was also tested. Of 1204 patients, 398 (33%) had DM (94% type 2). Patients with versus those without DM had lower unadjusted PAQ summary scores at baseline and 3, 6, and 12 months (46.1 versus 50.8, 63.6 versus 68.2, 65.7 versus 71.7, and 65.4 versus 72.6; P≤0.01). In fully adjusted models, the effect of DM on baseline (mean difference, −0.65; 95% CI, −2.86 to 1.56 [P=0.56]) and over 3‐ to 12‐month PAQ summary scores (mean difference, −1.59; 95% CI, −4.06 to 0.88 [P=0.21]) was no longer significant. Twelve‐month health status gains following revascularization were similar in both groups (P=0.69).

Conclusions

Patients with PAD with coexisting DM have poorer health status, mostly explained by the differences in their psychosocial and other comorbidity burden. Patients with PAD and DM versus those without DM experience similar health status benefits following PAD revascularization.

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) use and risk of amputation: an expert panel overview of the evidence

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are oral antidiabetic agents that exert their glucose-lowering effect by increasing renal excretion of glucose. These drugs have been reported to beneficially affect cardiovascular (CV) and renal outcomes. However, concerns have recently been raised in relation to increased risk of lower-extremities amputation with canagliflozin and it remains unclear whether and to what extent this side effect could also occur with other SGLT2i. The present expert panel overview focuses on the three SGLT2i available and widely used in the US and Europe, i.e. empagliflozin, canagliflozin and dapagliflozin and only refers briefly to other SGLT2i for which less data are available. The results of large CV outcome trials with these SGLT2i are presented, focusing specifically on the data in relation to amputation risk. The potential pathophysiological mechanisms involved in this side effect are discussed. Furthermore, available data reporting amputation cases in SGLT2i users are critically reviewed. The expert panel concludes that, based on current data, increased amputation risk seems to be related only to canagliflozin, thus representing a drug-effect rather than a SGLT2i class-effect. The exact pathways underlying this drug-induced adverse event, possibly related to off-target drug effects rather than SGLT2 inhibition per se, should be elucidated in future studies. Continuous monitoring and pharmacovigilance is necessary and head to head trials would also be essential to provide definitive conclusions.

Comparison of outcomes after carotid endarterectomy between type 2 diabetic and non-diabetic patients with significant carotid stenosis

Background

We aimed to compare early and late outcomes after carotid endarterectomy (CEA) between Korean type 2 diabetic and non-diabetic patients and to investigate the impact of diabetes on the overall incidence of cardiovascular events after CEA.

Methods

We retrospectively analyzed 675 CEAs, which were performed on 613 patients with significant carotid stenosis between January 2007 and December 2014. The CEAs were divided into a type 2 diabetes mellitus (DM) group (n = 265, 39.3%) and a non-DM group (n = 410, 60.7%). The study outcomes included the incidence of major adverse events (MAEs), defined as fatal or nonfatal stroke or myocardial infarction or all-cause mortality, during the perioperative period and within 4 years after CEA.

Results

Patients in the DM and non-DM groups did not differ significantly in the incidence of MAEs or any of the individual MAE manifestations during the perioperative period. However, within 4 years after CEA, the difference in the MAE incidence was significantly greater in the DM group (P = 0.040). Analysis of the individual MAE manifestations indicated a significantly higher risk of stroke in the DM group (P = 0.006). Multivariate analysis indicated that diabetes was not associated with MAEs or individual MAE manifestations during the perioperative period, whereas within 4 years after CEA, diabetes was an independent risk factor for MAEs overall (hazard ratio [HR], 1.62; 95% confidence interval [CI] 1.06–2.48; P = 0.026) and stroke (HR, 2.55; 95% CI 1.20–5.41; P = 0.015) in particular.

Conclusions

Diabetic patients were not at greater risk of perioperative MAEs after CEA; however, the risk of late MAE occurrence was significantly greater in these patients. Within 4 years after CEA, DM was an independent risk factor for the occurrence of MAEs overall and stroke in particular.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0848-7) contains supplementary material, which is available to authorized users.

Stellarex drug-coated balloon for treatment of femoropopliteal arterial disease-The ILLUMENATE Global Study: 12-Month results from a prospective, multicenter, single-arm study

Objectives

The purpose of this study was to assess the safety and performance of Stellarex Drug‐coated balloon (DCB).

Background

DCB coatings differ in excipients, paclitaxel dose, and coating morphologies. Due to these differences, a class effect with DCBs has not been demonstrated. Consequently, each DCB needs to be evaluated independently based on its own clinical study results.

Methods

The ILLUMENATE Global Study is a prospective, multicenter, single‐arm study. Patients with intermittent claudication or ischemic rest pain due to superficial femoral artery (SFA) and/or popliteal peripheral artery disease (PAD) were treated with the Stellarex DCB. The primary efficacy endpoint was primary patency, defined as freedom from restenosis with peak systolic velocity ratio ≤2.5 or clinically‐driven target lesion revascularization (CD‐TLR) at 12 months. The primary safety endpoint was freedom from device and procedure‐related death through 30 days postprocedure and freedom from target limb major amputation and CD‐TLR through 12 months.

Results

In total, 417 lesions were treated in 371 patients. The mean lesion length was 7.5 ± 5.3 cm, 40.8% of lesions were severely calcified per core laboratory fluoroscopy criteria and 31.3% were total occlusions. Primary patency by independent duplex core lab evaluation was 81.4% and the freedom from CD‐TLR was 94.8% day 365 per Kaplan‐Meier estimate. The majority of patients experienced improvements in their Rutherford classification (90.3%) and walking impairment questionnaire score (83.6%) at 12 months compared to baseline.

Conclusions

This study validated previous positive findings and confirms the strong safety profile and effectiveness outcomes.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies

This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.

The Etiopathogenesis of the Diabetic Foot: An Unrelenting Epidemic

Diabetes mellitus is a metabolic disease that is associated with hyperglycemia affecting various organ systems of the body. One of the most dreaded complications of this disease is the diabetic foot. The diabetic foot is the end result of multiple causal pathways, which include peripheral neuropathy and vascular disease. The problem is compounded by the increased incidence of infection. This article deals with the various pathogenic pathways associated with the development of the diabetic foot.

[The diabetic foot]

In the last 20 years the prevalence of diabetes in Germany has increased by approximately 50%. Associated with this is a distinct rise of diabetes-induced comorbidities and long-term consequences. One of the most frequent consequences is the diabetic foot or the diabetic foot syndrome. This is an ulceration of neuropathic and angiopathic origin, which often reaches a chronic stadium due to a poor healing tendency. Despite the disease management program for diabetes in Germany which mainly concentrates on the prophylaxis and multidisciplinary treatment of chronic diseases, there are approximately 250,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years. To achieve a reduction of the amputation rate identification of the main reasons is necessary. In addition a professional therapy of the vascular disorders and a stage-adjusted wound therapy have to take place in an interdisciplinary collaboration in a centre for wound care. Last but not least this aim can only be achieved by a preventive education of diabetics.

Early detection of lesions of dorsal artery of foot in patients with type 2 diabetes mellitus by high-frequency ultrasonography

This study evaluated the value of high-frequency ultrasonograpy for early detection of dorsal artery of foot in patients with type 2 diabetes mellitus (MD). Eighty subjects including 40 patients with type 2 MD (T2DM group) and 40 healthy volunteers (NC group) were recruited. The intima-media thickness (IMT), the inner diameter and the perfusion of dorsal artery of foot were measured by using high-frequency ultrasonograpy. Meanwhile, the parameters of vascular elasticity, including stiffness parameter (beta), pressure-strain elastic modulus (Erho), arterial compliance (AC), augment index (AI), and pulse wave conducting velocity (PWVbeta) were detected by means of echo-tracking technique. The results showed that no significant difference was found in the IMT, systolic diameter (Ds), diastolic diameter (Dd) and peak systolic velocity (PSV) between T2DM and NC groups. Erho and PWVbeta were increased, and AC was decreased in T2DM group as compared with those in NC group with the differences being significant (P<0.05 for all). There was no significant difference in beta and AI between T2DM and NC groups. It was concluded that high-frequency ultrasonography in combination with echo-tracking technique is sensitive and non-invasive, and can be used for early detection of sclerosis of the lower extremity artery in patients with type 2 MD.