Use and utility of ankle brachial index in patients with diabetes

Editor's Choice - Association of Pedal Acceleration Time With Healing and Amputation Free Survival in Patients With Ulceration and Gangrene

OBJECTIVE

Pedal acceleration time (PAT) is a novel non-invasive perfusion measurement that may be useful in the management of patients with ulceration and gangrene. The objective of this study was to report the association between PAT and wound healing, amputation free survival (AFS), and mortality at one year.

METHODS

This prospective observational study reviewed all patients who underwent PAT after presentation with ulceration or gangrene from 1 January 2020 to 30 June 2022. PAT was defined as the time (in milliseconds) from the onset of systole to the peak of systole in the mid artery. The final PAT of a limb was used to assess outcomes (presenting PAT if no revascularisation, or post-revascularisation PAT). Wound healing, major limb amputation, and death at one year were collected. Healing was assessed with Fine-Gray competing risks model, AFS via logistic regression, and survival using Cox proportional hazards model.

RESULTS

Overall, 265 patients (307 limbs) were included. The median patient age was 71 years and 74.0% (196/265) had diabetes mellitus. Patient demographics were similar among the final PAT category cohorts. Compared with a final PAT category 1, analysis of one year outcomes showed that the final PAT categories 2 - 4 had lower wound healing (category 2, hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.43 - 0.9, p = .012; category 3, HR 0.21, 95% CI 0.08 - 0.58, p = .002; category 4, HR 0.12, 95% CI 0.04 - 0.34, p < .001), lower AFS (category 2, odds ratio [OR] 2.86, 95% CI 1.64 - 5.0, p < .001; category 3, OR 5.1, 95% CI 1.71 - 15.22, p = .003; category 4, OR 12.59, 95% CI 4.34 - 36.56, p < .001), and lower survival (category 2, HR 1.89, 95% CI 1.17 - 3.03, p =.009; category 3, HR 2.37, 95% CI 1.05 - 5.36, p = .039; category 4, HR 4.52, 95% CI 2.48 - 8.21, p < .001).

CONCLUSION

The final PAT measurement is associated with wound healing, AFS, and death at one year. PAT may be a valuable tool to assess perfusion of the foot.

Longitudinal Patterns of Ankle-Brachial Index and Their Association With Progression of CKD in Patients With Type 2 Diabetes and Elevated Body Mass Index

RATIONALE & OBJECTIVE

Ankle-brachial index (ABI) is used to screen for vascular complications in the setting of diabetes. This study sought to examine the relationship of longitudinal ABI data and chronic kidney disease (CKD) progression in patients with type 2 diabetes (T2D) and elevated body mass index (BMI).

STUDY DESIGN

A post-hoc analysis of the Look AHEAD trial.

SETTING & PARTICIPANTS

This study included 3,631 participants in the Look AHEAD trial with a baseline glomerular filtration rate (eGFR) >60 ml/min/1.73 m2.

EXPOSURES

Average ABI and average annual change in ABI were calculated based on annual ABI measurements during the first 4 years of the study.

OUTCOME

CKD progression, defined as kidney failure requiring maintenance dialysis or the occurrence of eGFR<60 ml/min/1.73 m2 with a drop of ≥30% at a follow-up visit relative to the first eGFR measurement.

ANALYTICAL APPROACH

Restricted cubic spline and Cox proportional hazards models were fit to estimate associations and to explore non-linearity.

RESULTS

Over a median follow-up of 10.1 years, 1,051 participants developed CKD progression. There was a reversed J-shaped relationship of CKD progression with average ABI (when ABI <1.17: HR (per SD decrement), 1.23; 95%CI, 1.06-1.42; when ABI ≥ 1.17: HR (per SD increment), 1.10; 95%CI, 1.00-1.22) and average annual change in ABI (when change in ABI <-0.007: HR (per SD decrement), 1.37; 95%CI, 1.12-1.66; when change in ABI ≥-0.007: HR (per SD increment), 1.13; 95%CI, 1.03-1.24).

LIMITATIONS

Observational study, potential unmeasured confounding.

CONCLUSIONS

Low and high average ABI, even at clinically normal values, as well as decreasing and increasing average annual ABI, were associated a higher risk of CKD progression in patients with T2D and elevated BMI. Monitoring ABI and its changes over time may facilitate CKD risk stratification in patients with T2D.

Advancements in risk stratification and management strategies in primary cardiovascular prevention

Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of morbidity and mortality worldwide, highlighting the urgent need for advancements in risk assessment and management strategies. Although significant progress has been made recently, identifying and managing apparently healthy individuals at a higher risk of developing atherosclerosis and those with subclinical atherosclerosis still poses significant challenges. Traditional risk assessment tools have limitations in accurately predicting future events and fail to encompass the complexity of the atherosclerosis trajectory. In this review, we describe novel approaches in biomarkers, genetics, advanced imaging techniques, and artificial intelligence that have emerged to address this gap. Moreover, polygenic risk scores and imaging modalities such as coronary artery calcium scoring, and coronary computed tomography angiography offer promising avenues for enhancing primary cardiovascular risk stratification and personalised intervention strategies. On the other hand, interventions aiming against atherosclerosis development or promoting plaque regression have gained attention in primary ASCVD prevention. Therefore, the potential role of drugs like statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, omega-3 fatty acids, antihypertensive agents, as well as glucose-lowering and anti-inflammatory drugs are also discussed. Since findings regarding the efficacy of these interventions vary, further research is still required to elucidate their mechanisms of action, optimize treatment regimens, and determine their long-term effects on ASCVD outcomes. In conclusion, advancements in strategies addressing atherosclerosis prevention and plaque regression present promising avenues for enhancing primary ASCVD prevention through personalised approaches tailored to individual risk profiles. Nevertheless, ongoing research efforts are imperative to refine these strategies further and maximise their effectiveness in safeguarding cardiovascular health.

Difference in right and left cardio-ankle vascular index as a useful marker for evaluation of leg ischemia in patients with lower extremity arterial disease

OBJECTIVES

Cardio-ankle vascular index (CAVI) is a blood pressure-independent measure of heart-ankle pulse wave velocity and is used as an indicator of arterial stiffness. However, there is a paradox that CAVI is inversely associated with leg ischemia in patients with lower extremity arterial disease (LEAD). The aim of this study was to clarify the significance of the absolute value of left and right difference in CAVI (diff-CAVI).

METHODS

The subjects were 165 patients with LEAD who had received medication therapy. Relationships between diff-CAVI and leg ischemia were investigated. Leg ischemia was evaluated by decrease in leg arterial flow using ankle-brachial index (ABI) and by symptoms using the Rutherford classification.

RESULTS

There was a significant inverse correlation between diff-CAVI and ABI. The odds ratio for low ABI of the 3rd versus 1st tertile groups of diff-CAVI was 7.03 with a 95% confidence interval of 2.71 ∼ 18.22. In ROC analysis, the cutoff value of diff-CAVI for low ABI was 1.05 with a sensitivity of 61.1% and a specificity of 87.1%. The median of diff-CAVI was significantly higher in subjects with grade 2 of the Rutherford classification than in subjects with its grade 1.

CONCLUSIONS

diff-CAVI showed an inverse association with ABI and a positive association with symptoms of leg ischemia. Thus, diff-CAVI is thought to be a useful indicator of leg ischemia in LEAD patients.

Neutrophil Extracellular Traps (NETs) Are Associated with Type 2 Diabetes and Diabetic Foot Ulcer Related Amputation: A Prospective Cohort Study

INTRODUCTION

The prevalence of diabetes mellitus and its sequelae has been on the rise, and diabetic foot ulcer (DFU) is the leading cause of non-traumatic lower limb amputation globally. The rising occurrence and financial burden associated with DFU necessitate improved clinical assessment and treatment. Diabetes has been found to enhance the formation of neutrophil extracellular traps (NETs) by neutrophils, and excessive NETs have been implicated in tissue damage and impaired wound healing. However, there is as yet insufficient evidence to clarify the value of NETs in assessing and predicting outcomes of DFU.

METHODS

We designed this prospective study with three cohorts formed from type 2 diabetes mellitus (T2DM) patients with DFU (n = 200), newly diagnosed T2DM patients (n = 42), and healthy donors (n = 38). Serum levels of NETs were detected for all groups, and the prognostic value for DFU-related amputation was analyzed.

RESULTS

The results showed that serum NET levels of the DFU group were significantly higher than in the T2DM group (P < 0.05), which also had significantly elevated serum NET levels compared to healthy donors (P < 0.05). Multivariate Cox regression showed that serum NET levels, diabetic foot surgical history, and Wagner grade were the risk factors for amputation (P < 0.05), and these three variables also exhibited the highest coefficient values in additional Lasso Cox regression. For patients with DFU, Kaplan-Meier curves showed that high serum NET levels associated with higher amputation probability (HR = 0.19, P < 0.01) and ROC curve based on NET value showed good validity for amputation (AUC: 0.727, CI 0.651-0.803).

CONCLUSION

Elevated serum NET levels serve as an easily accessible serological prognostic marker for assessing the risk of DFU-related amputation, thereby offering evaluation metrics for healthcare providers. Further investigations are necessary to understand the mechanisms driving this relationship.

Arm and ankle blood pressure indices, and peripheral artery disease, and mortality: a cohort study

BACKGROUND AND AIMS

Few studies have compared arm and ankle blood pressures (BPs) with regard to peripheral artery disease (PAD) and mortality. These relationships were assessed using data from three large prospective clinical trials.

METHODS

Baseline BP indices included arm systolic BP (SBP), diastolic BP (DBP), pulse pressure (arm SBP minus DBP), ankle SBP, ankle-brachial index (ABI, ankle SBP divided by arm SBP), and ankle-pulse pressure difference (APPD, ankle SBP minus arm pulse pressure). These measurements were categorized into four groups using quartiles. The outcomes were PAD (the first occurrence of either peripheral revascularization or lower-limb amputation for vascular disease), the composite of PAD or death, and all-cause death.

RESULTS

Among 40 747 participants without baseline PAD (age 65.6 years, men 68.3%, diabetes 50.2%) from 53 countries, 1071 (2.6%) developed PAD, and 4955 (12.2%) died during 5 years of follow-up. Incident PAD progressively rose with higher arm BP indices and fell with ankle BP indices. The strongest relationships were noted for ankle BP indices. Compared with people whose ankle BP indices were in the highest fourth, adjusted hazard ratios (95% confidence interval) for each lower fourth were 1.64 (1.31-2.04), 2.59 (2.10-3.20), and 4.23 (3.44-5.21) for ankle SBP; 1.19 (0.95-1.50), 1.66 (1.34-2.05), and 3.34 (2.75-4.06) for ABI; and 1.41 (1.11-1.78), 2.04 (1.64-2.54), and 3.63 (2.96-4.45) for APPD. Similar patterns were observed for mortality. Ankle BP indices provided the highest c-statistics and classification indices in predicting future PAD beyond established risk factors.

CONCLUSIONS

Ankle BP indices including the ankle SBP and the APPD best predicted PAD and mortality.

Validation of a New Ankle Brachial Index Measurement System Using Pulse Wave Velocity

Peripheral artery disease (PAD) is a common circulatory disorder characterized by the accumulation of fats, cholesterol, and other substances in the arteries that restrict blood flow to the extremities, especially the legs. The ankle brachial index (ABI) is a highly reliable and valid non-invasive test for diagnosing PAD. However, the traditional method has limitations. These include the time required, the need for Doppler equipment, the training of clinical staff, and patient discomfort. PWV refers to the speed at which an arterial pressure wave propagates along the arteries, and this speed is conditioned by arterial elasticity and stiffness. To address these limitations, we have developed a system that uses electrocardiogram (ECG) and photoplethysmography (PPG) signals to calculate pulse wave velocity (PWV). We propose determining the ABI based on this calculation. Validation was performed on 22 diabetic patients, and the results demonstrate the accuracy of the system, maintaining a margin of ±0.1 compared with the traditional method. This confirms the correlation between PWV and ABI and positions this technique as a promising alternative to overcome some of the limitations of the conventional method.

Two-year incidence and risk factors of diabetic foot ulcer: second phase report of Ahvaz diabetic foot cohort (ADFC) study

AIM/INTRODUCTION

This study was designed as the second phase of a prospective cohort study to evaluate the incidence and risk factors of diabetic foot ulcers (DFU).

MATERIALS AND METHODS

The study was conducted in a university hospital in Iran. Each participant was checked and followed up for two years in terms of developing newfound DFU as ultimate outcome. We investigated the variables using univariate analysis and then by backward elimination multiple logistic regression.

RESULTS

We followed up 901 eligible patients with diabetes for two years. The mean age of the participants was 53.24 ± 11.46 years, and 58.53% of them were female. The two-year cumulative incidence of diabetic foot ulcer was 8% (95% CI 0.071, 0.089) [Incidence rate: 49.9 /1000 person-years]. However, the second-year incidence which was coincident with the COVID-19 pandemic was higher than the first-year incidence (4.18% and 1.8%, respectively). Based on our analysis, the following variables were the main risk factors for DFU incidence: former history of DFU or amputation [OR = 76.5, 95% CI(33.45,174.97), P value < 0.001], ill-fitting foot-wear [OR = 10.38, 95% CI(4.47,24.12), P value < 0.001], smoking [OR = 3.87,95%CI(1.28, 11.71),P value = 0.016], lack of preventive foot care [OR = 2.91%CI(1.02,8.29),P value = 0.045], and insufficient physical activity[OR = 2.25,95% CI(0.95,5.35),P value = 0.066].

CONCLUSION

Overall, the two-year cumulative incidence of diabetic foot ulcer was 8% [Incidence rate: 49.9 /1000 person-years]; however, the second-year incidence was higher than the first-year incidence which was coincident with the COVID-19 pandemic (4.18% and 1.8%, respectively). Independent risk factors of DFU occurrence were prior history of DFU or amputation, ill-fitting footwear, smoking, lack of preventive foot care, and insufficient physical activity.

Vascular resistance index and the immediate hemodynamic success of lower limb distal artery revascularization

Background

Revascularization surgery is used to attempt to restore blood flow to the foot in patients with critical ischemia (CI) caused by peripheral arterial occlusive disease of the lower limbs (LL). Ultrasonography with Doppler (USD) SAH emerged in recent years as a highly valuable method for planning this surgical intervention.

Objectives

To evaluate the relationship between the resistance index (RI), measured with USD, and immediate hemodynamic success of LL revascularization surgery in patients with CI.

Methods

The study design was a prospective cohort assessing 46 patients with LL CLI who underwent operations to perform infrainguinal revascularization by angioplasty or bypass from August 2019 to February 2022. All patients underwent preoperative clinical vascular assessment with USD including measurement of the RI of distal LL arteries, LL arteriography, and measurement of the ankle-brachial index (ABI). All patients had their ABI measured again in the immediate postoperative period.

Results

Forty-six patients were assessed, 25 (54.3%) of whom were male. Age varied from 32 to 89 years (mean: 67.83). Hemodynamic success was assessed by comparison of preoperative and postoperative ABI, showing that hemodynamic success was achieved in 31 (67.4%) patients after revascularization surgery (ABI increased by 0.15 or more). A positive correlation (p ≤ 0.05) was observed between the RI of the distal revascularized LL artery and immediate hemodynamic success assessed by ABI (lower RI and hemodynamic success).

Conclusions

This study observed a positive correlation between the resistance index of the distal artery and immediate hemodynamic success of lower limb revascularizations, as assessed by the ankle-brachial index, so that the lower the RI the greater the hemodynamic success achieved.

Gujarati translation, validity and reliability of Walking Impairment Questionnaire in people with intermittent claudication due to peripheral artery disease

INTRODUCTION

The Walking Impairment Questionnaire (WIQ) is a common and easy-to-use assessment of walking incapacity in people with claudication due to peripheral artery disease (PAD). It has four subscales: pain severity, walking distance, walking speed, and ability to climb stairs. It has not been translated into Gujarati, which limits its use in Indian subjects.

AIM

This study aims to translate and assess the validity and reliability of a Gujarati version of WIQ.

MATERIALS AND METHODS

This study had three phases: 1. Forward and backward translation and Cultural adaptation of WIQ into the Gujarati language by two independent translators, 2. Face and content validation by six clinical reviewers and 10 participants with PAD and Type II diabetes, 3. Concurrent and construct validity, test-retest reliability, and internal consistency of Gujarati, the WIQ was assessed on 160 participants with PAD and Type II diabetes who had a mean Ankle Brachial Index (standard deviation) <0.40 (0.1). The concurrent and construct validity of the WIQ was analyzed by correlating the WIQ distance and speed score with 6-minute walk distance (6MWD) and speed and WIQ total score with the Medical Outcome Study Questionnaire Short Form 36 (SF-36) score using Pearson's correlation coefficient. Test-retest reliability was analyzed using an intraclass correlation coefficient (ICC) with a seven-day interval between two questionnaire applications. Internal consistency of the total WIQ score was determined using Cronbach's alpha.

RESULTS

Following translation, the Gujarati WIQ was considered acceptable and understandable by people with PAD. There was excellent correlation between the WIQ distance score and 6-minute walk test distance (r = 0.95, P < .05)) , the WIQ speed score and 6-minute walk test speed score (r = 0.89, P < .05)) and the Gujarati WIQ total score and total score of physical functioning domain of SF- 36 (r = 0.99, P < .05). There was excellent test-retest reliability over 7 days for total WIQ score (ICC = 0.94). The Cronbach's alpha for internal consistency of 0.97 for total WIQ score were excellent. This demonstrates the sufficient homogeneity of the total questionnaire.

CONCLUSION

The Gujarati version of the WIQ is reliable and valid and can be used to assess self-reported walking impairment in Gujarati-speaking people with PAD and Type II Diabetes.

Diabetic Foot Ulcer Management and Treatment: An Overview of Published Patents

BACKGROUND

One of the most challenging effects of diabetes is diabetic foot ulceration (DFU). DFU may occur in up to one-third of individuals with diabetes mellitus (D.M.) at some point in their lives. The major cause of morbidity in D.M. patients is DFU. The length of treatment is difficult, and DFU recurrence is common.

OBJECTIVE

The most crucial element for the treatment and prevention of DFUs require a multidisciplinary approach. Patients who are at risk should be identified, depending on the type of risk, prophylactic actions etc. It is imperative to identify at-risk patients and take preventative measures accordingly.

METHOD

The at-risk diabetes-related foot ulcer was identified based on the risk category classification, while the foot ulcers were evaluated using Wagner's classification system.

RESULTS

Literature reported that patients with lower limb vascular insufficiency, loss of vibratory sensation, or protective sensation loss have an increased risk of developing foot ulcers. Proper categorization and therapeutic measures will be implemented after the DFU has been formed. The appropriate assessment and management of general health status should include glycemic control, the diagnosis and treatment of vascular disease, standard care for wounds, diagnosis, and infection treatments.

CONCLUSION

The review reflects the updated awareness of the treatment and management of DFU based on the current and past literature and patent analysis.

Incoherent optical fluctuation flowmetry for detecting limbs with hemodynamically significant stenoses in patients with type 2 diabetes

INTRODUCTION

The development of new highly accurate, inexpensive and accessible methods for the detection of lower-extremity peripheral artery disease (LE-PAD) in diabetic patients is required. The aim of this study was to evaluate the accuracy of a new incoherent optical fluctuation flowmetry (IOFF) method in detecting legs with hemodynamically significant stenoses compared to ankle brachial index (ABI) and transcutaneous oximetry (TcPO2) in patients with diabetes mellitus (DM).

MATERIALS AND METHODS

Patients were recruited into 2 groups. Group 1 included patients with DM without LE-PAD and/or diabetic foot syndrome; Group 2 included patients with DM and LE-PAD. All patients underwent the following measurements: ultrasound (reference method), ABI, TcPO2, and the new IOFF method.

RESULTS

The new IOFF method showed a sensitivity of 79.5% and a specificity of 89.8% in detecting limbs with hemodynamically significant stenosis (AUC 0.890, CI 0.822-0.957). TcpO2 allows the diagnosis of LE-PAD with 69.2% sensitivity and 86.2% specificity (AUC 0.817, CI 0.723-0.911). Using a standard ABI cut-off of less than 0.9, the sensitivity and specificity for this parameter were 34.5% and 89.7%, respectively. Increasing the diagnostic cut-off of the ABI on the study group to 0.99 improved sensitivity to 84.6% and specificity to 78% (AUC,0.824 CI 0.732-0.915).

CONCLUSIONS

The new IOFF technique has demonstrated high sensitivity and specificity in the detection of LE-PAD in patients with DM. The high accuracy, rapid measurement, and potential availability suggest that the new IOFF method has a high potential for clinical application in the detection of PAD.

The correlation between transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography in the evaluation of lower extremity perfusion according to angiosome

The increased peripheral arterial disease (PAD) incidence associated with aging and increased incidence of cardiovascular conditions underscores the significance of assessing lower limb perfusion. This study aims to report on the correlation and utility of two novel non-invasive instruments: transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography. A total of 68 patients diagnosed with diabetic foot ulcer and PAD who underwent vascular studies at a single institution between March 2022 and March 2023 were included. Cases with revascularization indications were treated by a cardiologist. Following the procedure, ambient TcPO2 and FLIR thermography were recorded on postoperative days 1, 7, 14, 21 and 28. In impaired limbs, TcPO2 was 12.3 ± 2 mmHg and FLIR thermography was 28.7 ± 0.9°C. TcPO2 (p = 0.002), FLIR thermography (p = 0.015) and ankle-brachial index (p = 0.047) values significantly reduced with greater vascular obstruction severity. Revascularization (n = 39) significantly improved TcPO2 (12.5 ± 1.7 to 19.1 ± 2.2 mmHg, p = 0.011) and FLIR (28.8 ± 1.8 to 32.6 ± 1.6°C; p = 0.018), especially in severe impaired angiosomes. TcPO2 significantly increased immediately post-procedure, then gradually, whereas the FLIR thermography values plateaued from day 1 to 28 post-procedure. In conclusion, FLIR thermography is a viable non-invasive tool for evaluating lower limb perfusion based on angiosomes, comparable with TcPO2 .

Global burden of peripheral artery disease and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Peripheral artery disease is a growing public health problem. We aimed to estimate the global disease burden of peripheral artery disease, its risk factors, and temporospatial trends to inform policy and public measures.

METHODS

Data on peripheral artery disease were modelled using the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019 database. Prevalence, disability-adjusted life years (DALYs), and mortality estimates of peripheral artery disease were extracted from GBD 2019. Total DALYs and age-standardised DALY rate of peripheral artery disease attributed to modifiable risk factors were also assessed.

FINDINGS

In 2019, the number of people aged 40 years and older with peripheral artery disease was 113 million (95% uncertainty interval [UI] 99·2-128·4), with a global prevalence of 1·52% (95% UI 1·33-1·72), of which 42·6% was in countries with low to middle Socio-demographic Index (SDI). The global prevalence of peripheral artery disease was higher in older people, (14·91% [12·41-17·87] in those aged 80-84 years), and was generally higher in females than in males. Globally, the total number of DALYs attributable to modifiable risk factors in 2019 accounted for 69·4% (64·2-74·3) of total peripheral artery disease DALYs. The prevalence of peripheral artery disease was highest in countries with high SDI and lowest in countries with low SDI, whereas DALY and mortality rates showed U-shaped curves, with the highest burden in the high and low SDI quintiles.

INTERPRETATION

The total number of people with peripheral artery disease has increased globally from 1990 to 2019. Despite the lower prevalence of peripheral artery disease in males and low-income countries, these groups showed similar DALY rates to females and higher-income countries, highlighting disproportionate burden in these groups. Modifiable risk factors were responsible for around 70% of the global peripheral artery disease burden. Public measures could mitigate the burden of peripheral artery disease by modifying risk factors.

FUNDING

Bill & Melinda Gates Foundation.

Evaluation of Lower Extremity Calcium Score as a Measure of Peripheral Arterial Disease Burden and Amputation Risk

BACKGROUND

The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable in the presence of calcified vessels. In this study, we aimed to demonstrate the utility of the lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease burden and predicting the risk of amputation in patients with PAD.

METHODS

Patients who were evaluated in the vascular surgery clinic at Emory University for PAD and who underwent noncontrast computed tomography of the aorta and lower extremities were included in the study. Aortoiliac, femoral-popliteal, and tibial calcium scores were measured using the Agatston method. ABI and TBI that were obtained within 6 months of the computed tomography scan were noted and divided into categories of PAD severity. Associations between ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate ordinal regression analyses were performed to predict the outcome of amputation. Receiver operating characteristic analysis was performed to compare LECS with other variables in its ability to predict amputation.

RESULTS

Fifty patients included in the study cohort were divided into LECS quartiles, with 12-13 patients in each quartile. The highest quartile tended to be older (P = 0.016), had a higher percentage of diabetics (P = 0.034), and had a higher frequency of major amputations (P = 0.004) compared to the other quartiles. Patients in the highest quartile of tibial calcium score were more likely to have stage 3 chronic kidney disease (CKD) or greater (P = 0.011) and also had a higher frequency of amputation (P < 0.005) and mortality (P = 0.041). We found no significant association between each anatomic LECS and ABI/TBI categories. On univariate analysis, CKD (Odds Ratio [OR] 12.92 (95% CI 2.01 to 82.83), P = 0.007), diabetes mellitus (OR 5.47 (95% CI 1.27 to 23.64), P = 0.023), tibial calcium score (OR 6.62 (95% CI 1.79 to 24.54), P = 0.005), and total bilateral calcium score (OR 6.32 (95% CI 1.18 to 33.78), P = 0.031) were associated with increased risk of amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score were identified as important predictors of amputation, with hyperlipidemia and CKD increasing the overall prediction of the model. On Receiver operating characteristic analysis, the addition of the tibial calcium score (area under the curve 0.94, standard error 0.048) significantly improved the prediction of amputation compared to hyperlipidemia, CKD, and TBI alone (area under the curve 0.82, standard error 0.071, P = 0.022).

CONCLUSIONS

The addition of tibial calcium score to other known PAD risk factors may improve the prediction of amputation in patients with PAD.

Efficacy and safety of unilateral tibial cortex transverse transport on bilateral diabetic foot ulcers: A propensity score matching study

Background

Tibial Cortex Transverse Transport (TTT) has been demonstrated to be an effective treatment for unilateral diabetic foot ulcers (UDFUs). However, this retrospective study was designed to compare the efficacy and safety of unilateral TTT on bilateral diabetic foot ulcers (BDFUs).

Methods

This retrospective study included a review of patients with TTT treated from January 2017 to August 2019, Propensity Score Matching (PSM) was performed to compare patients with BDFUs to those with UDFUs. Ulcer healing, recurrence, and major amputation rates were evaluated at 1-year follow-up. Changes in foot vessels were assessed in the BDFUs group using computed tomography angiography (CTA).

Results

A total of 140 patients with DFUs (106 UDFUs and 34 BDFUs) were included in the study. UDFUs and BDFUs were matched in a 1:1 ratio (34 in each group) using PSM. No significant difference was observed at 1-year-follow-up [91.2% (31/34) vs. 76.5% (26/34), OR 0.315 (95% CI 0.08 to 1.31), P ​= ​0.10] and 6-month-follow-up [70.6% (24/34) vs. 50.0% (17/34), OR 0.85 (95% CI 0.15 to 1.13), P ​= ​0.08] in two groups. Significant differences in rates of major amputation and recurrence between the groups (P ​> ​0.05) were not observed. The BDFUs group appeared more angiogenesis of the foot by CTA after 8 weeks of operation.

Conclusion

Results of this study suggest that severe BDFUs can be effectively treated by unilateral TTT. TTT is easy to operate and effective, which may be a good alternative for treating severe BDFUs.

The translational potential of this article

In previous retrospective clinical studies, TTT has demonstrated promising clinical outcomes in the management of diabetic foot ulcers. In this current study, we aim to investigate the potential use of TTT in treating distant tissue defects by evaluating the limited availability and safety of TTT for the management of bilateral diabetic foot. While additional basic and clinical research is necessary to fully elucidate the underlying mechanisms, our study offers insight into the potential therapeutic use of TTT for this condition.

Comparison of resting/postexercise ankle-brachial index and transcutaneous partial pressure of oxygen for noninvasive diagnosis of peripheral artery disease in type 2 diabetes mellitus

Background Type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a strong risk factor for peripheral artery disease (PAD) and PAD diagnosis in T2DM may indicate coexisting coronary artery disease as well. Postexercise ankle brachial index (ABI) and transcutaneous partial pressure of oxygen (TcPO2) have not been evaluated for PAD diagnosis among Indian T2DM patients. This study aimed to evaluate the performance of resting + postexercise(R + PE) ABI and R + PE-TcPO2 for PAD diagnosis among T2DM patients at increased PAD risk, using colour duplex ultrasound (CDU) as reference standard.

Methods

This prospectively conducted diagnostic accuracy study involved T2DM patients at increased PAD risk. R-ABI≤0.9 or PE-ABI decline >20% from resting value in those with R-ABI between 0.91 and 1.4, R-TcPO2 <30 mm Hg or PE decline of TcPO2 to <30 mm Hg in those with R-TcPO2 ≥30 mm Hg, CDU showing >50% stenosis or complete occlusion of lower extremity arteries constituted PAD.

Results

Among 168 patients enrolled, R + PE-ABI diagnosed PAD in 19(11.3%), R + PE-TcPO2 in 61 (36.3%) and 17 (≈10%) had PAD finally confirmed by CDU. Sensitivity, specificity, PPV and NPV of R + PE-ABI for PAD diagnosis were 82.3%, 96.7%, 73.7% and 98% and that of R + PE-TcPO2 were 76.5%, 68.2%, 21.3% and 96.2%, respectively. PE-ABI increased the sensitivity of ABI by ≈ 18% and had 100% PPV for PAD. When both ABI and TcPO2 (R + PE tests) were normal, PAD could be safely excluded in 88% of patients.

Conclusion

PE-ABI should be routinely employed and TcPO2(R/PE) is unreliable as a stand-alone test for PAD detection among moderate to high risk T2DM patients.

The ankle-brachial index for assessing the prevalence of peripheral artery disease and cardiovascular risk in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Type 2 diabetes mellitus (T2DM) is an important risk factor for peripheral artery disease (PAD). Ankle-Brachial Index (ABI) was found associated with a higher cardiovascular (CV) risk and mortality. The main goals of this study were to establish the prevalence of PAD in a T2DM population, and assess the relationship between PAD and the CV risk calculated with the CUORE Project score (CPS) (https://www.cuore.iss.it/). The association between the ABI, the main risk factors for PAD and T2DM complications was also investigated.

METHODS AND RESULTS

Two hundred patients were consecutively enrolled. The prevalence of PAD in this population was 17%. The CV risk tended to be higher (p = 0.0712) in the group with a pathological ABI than in the group with a normal ABI. Glycated hemoglobin (r = -0.1591; p = 0.0244), total cholesterol (r = -0.1958; p = 0.0054), LDL cholesterol (r = -0.1708; p = 0.0156) and systolic blood pressure (r = -0.1523; p = 0.0313) correlated significantly and inversely with the left ABI. The frequency of diabetic retinopathy was significantly higher in the group with a pathological ABI (p = 0.0316).

CONCLUSIONS

The data reveal a high prevalence of PAD in patients with T2DM. The CPS confirmed that patients with a pathological ABI have tendency to a higher CV risk. The results point to the importance of an accurate CV assessment - also measuring individuals' ABI and calculating their CPS - to better pinpoint those at high risk of PAD, especially among patients with T2DM.

An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction

Heel ulceration in patients with diabetes mellitus (DM) is a major clinical challenge, manifesting with a protracted and uncertain healing process. The prefer treatment of heel ulceration is still controversial. This study aims at describing a newly alternative surgical method with the proximal transverse tibial bone transport technique, as an attempt to achieve wound healing in diabetic patients with large heel ulceration. Retrospective clinical study. A total of 21 diabetic patients with large heel ulceration were enrolled and followed up at least 6 months. The following parameters were assessed: Visual analogue scale (VAS), healing time, ulcer healing rate, ulcer recurrence rate and limb salvage rate. All patients got fully follow-up and achieved wound healing uneventfully. Eighteen patients returned to independent walking without any helper while three patients walked using a crutch. Limb salvage was achieved in all 21 patients (100%). The mean wound area was 67.43 ± 13.31 cm2 (range: 46-97 cm2 ). The mean healing time was 128.62 ± 16.76 days (range: 91-160 days). 16 out of 21 patients without calcaneal osteomyelitis achieved ulcer healing with a mean duration of 124.69 ± 14.42 days (range: 91-143 days), while the other five patients with calcaneal osteomyelitis were 141.20 ± 19.12 days (range: 110-160 days). 2 out of 21 patients got superficial rupture at the previous wounds and healed after outpatient dressing change combined with oral antibiotics. The novel technique described is particularly applicable for large heel ulceration in diabetic patients. It offers a better alternative for achieving wound healing with a favourable encouraging outcome.

Subclinical atherosclerosis burden in non-diabetic hypertensives treated in primary care center: the IMTABI study

BACKGROUND

Identifying patients at high risk of cardiovascular disease in primary prevention is a challenging task. This study aimed at detecting subclinical atherosclerosis burden in non-diabetic hypertensive patients in a primary care centre.

METHODS

Clinical, anthropometric and analytical data were collected from patients with hypertension who were free from clinical vascular disease and diabetes. The cardiovascular risk was assessed using the SCORE system. Subclinical atherosclerosis burden was assessed by carotid ultrasonography (intima-medial thickness [IMT] and plaque) and measurement of the ankle-brachial index (ABI).

RESULTS

Out of 140 patients, 59 (42%) have carotid plaque, 32 (23%) have IMT higher than 75% and 12 (9%) have an ABI < 0.9. Total atherosclerosis burden was present in 91 (65%) of the subjects. Consequently, 59 (42%) patients were re-classified into the very high-risk category. In multivariate analyses, smoking, creatinine levels and duration of hypertension were associated with atherosclerosis burden. In contrast, only smoking and age were associated with the presence of carotid plaque. Almost 90% of patients were treated with hypotensive drugs, half of them combined several drugs and 60% were well-controlled. Only 30% received statins in monotherapy and only less than 20% had an LDL cholesterol < 100 mg/dL.

CONCLUSIONS

In non-diabetic hypertensive patients managed at a primary care centre, 4 out of 10 had subclinical atherosclerosis burden and were re-classified into the very high- risk category. There was clear undertreatment with lipid-lowering drugs of most LDL cholesterol inappropriate levels, according to current clinical guidelines.

The association between time in the glucose target range and abnormal ankle-brachial index: a cross-sectional analysis

BACKGROUND

Time in range (TIR), a novel proxy measure of glucose control, is found closely related to diabetic microangiopathy and some other chronic complications, but the correlation between TIR and lower limb angiopathy has not been studied yet. Our purpose is to explore the relationship between TIR and abnormal ankle-brachial index(ABI) in type 2 diabetes.

METHODS

We retrospectively collected patients' information from the database and performed cross-sectional analysis. A total of 405 type 2 diabetes patients were enrolled in this study. ABI was measured and patients were stratified into low, normal, and high groups according to ≤ 0.9, > 0.9 and < 1.3, ≥ 1.3 ABI values. All patients underwent continuous glucose monitoring(CGM), and TIR was defined as the percentage of time in which glucose was in the range of 3.9-10 mmol/L during a 24-h period. Correlations between TIR and abnormal ABI were analyzed using Spearman analysis. And logistic regression was used to explore whether TIR is an independent risk factor for abnormal ABI.

RESULTS

The overall prevalence of abnormal ABI was 20.2% (low 4.9% and high 15.3%). TIR was lower in patients with abnormal ABI values (P = 0.009). The prevalence of abnormal ABI decreased with increasing quartiles of TIR (P = 0.026). Abnormal ABI was negatively correlated with TIR and positively correlated with hypertension, age, diabetes duration, UREA, Scr, ACR, TAR, MBG, and M values (P < 0.05). The logistic regression revealed a significant association between TIR and abnormal ABI, while HbA1C and blood glucose variability measures had no explicit correlation with abnormal ABI. Additionally, there was a significant difference in LDL between the low and high ABI groups (P = 0.009), and in Scr between normal and low groups (P = 0.007). And there were significant differences in TIR (P = 0.003), age (P = 0.023), UREA (P = 0.006), ACR (P = 0.004), TAR (P = 0.015), and MBG (P = 0.014) between normal and high ABI groups, and in diabetes duration between both normal and low (P = 0.023) and normal and high (P = 0.006) groups.

CONCLUSIONS

In type 2 diabetes patients, abnormal ABI is associated with lower TIR, and the correlation is stronger than that with HbA1C. Therefore, the role of TIR should be emphasized in the evaluation of lower limb vascular diseases.

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.

Incoherent Optical Fluctuation Flowmetry: A New Method for the Assessment of Foot Perfusion in Patients with Diabetes-Related Lower-Extremity Complications

(1) Background: To date, there are no studies evaluating the ability of the incoherent optical fluctuation flowmetry (IOFF) method to assess foot tissue perfusion. The aim of this study was to evaluate the correlation between perfusion values measured by IOFF and TcPO2 in patients with diabetes-related lower-extremity complications. (2) Methods: This was an observational, cross-sectional, two-center study. Diabetic patients with peripheral artery disease and/or diabetic foot ulcers were studied (n = 27, examinations were carried out on 54 legs). Perfusion in the foot tissues was assessed using TcPO2 (reference standard for this study) and the IOFF method. (3) Results: High correlation coefficients of all perfusion parameters measured by IOFF with TcPO2 (Rs 0.7 to 0.76) were shown. The study demonstrated that the IOFF method allows, with a sensitivity of 85.7% and a specificity of 90.0%, the identification of patients with a critical decrease in TcPO2 < 20 mmHg. (4) Conclusions: The high correlation of IOFF parameters with TcPO2 and the moderately high sensitivity and specificity in detecting patients with severe ischemia of foot tissues shows the promise of the method for assessing a tissue perfusion in patients with diabetes-related lower-extremity complications.

Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study

Background

Management of recalcitrant diabetic foot ulcer (DFU) remains difficult. Distraction osteogenesis mediates new bone formation and angiogenesis in the bone itself and the surrounding tissues. Recently it was reported that tibial cortex transverse transport (TTT) was associated with neovascularization and increased perfusion at the foot in patients with recalcitrant DFUs and facilitated healing and limb salvage. However, the findings were from several single-center studies with relatively small populations, which need to be confirmed in multicenter cohort studies with relatively large populations. Furthermore, the effect of this technique on patient's health-related quality of life is still unclear.

Methods

We treated patients with recalcitrant (University of Texas wound grading system 2-C to 3-D and not responding to prior routine conservative and surgical treatments for at least 8 weeks) DFUs from seven centers using TTT (a 5 ​cm ​× ​1.5 ​cm corticotomy followed by 4 weeks of medial and lateral distraction) between July 2016 and June 2019. We analyzed ulcer healing, major amputation, recurrence, health-related quality of life (physical and mental component summary scores), and complications in the 2-year follow-up. Foot arterial and perfusion changes were evaluated using computed tomography angiography and perfusion imaging 12 weeks postoperatively.

Results

A total of 1175 patients were enrolled. Patients who died (85, 7.2%) or lost to follow-up (18, 1.7%) were excluded, leaving 1072 patients for evaluation. Most of the patients were male (752, 70.1%) and with a mean age of 60.4 ​± ​9.1 years. The mean ulcer size was 41.0 ​± ​8.5 ​cm² and 187 (16.6%) ulcers extended above the ankle. During the follow-up, 1019 (94.9%) patients healed in a mean time of 12.4 ​± ​5.6 weeks, 53 (4.9%) had major amputations, and 33 (3.1%) experienced recurrences. Compared to preoperatively, the patients had higher physical (26.2 ​± ​8.3 versus 41.3 ​± ​10.6, p ​= ​0.008) and mental (33.6 ​± ​10.7 versus 45.4 ​± ​11.3, p ​= ​0.031) component summary scores at the 2-year follow-up. Closed tibial fracture at the corticotomy site was found in 8 (0.7%) patients and was treated using external fixation and healed uneventfully. There were 23 (2.1%) patients who had pin site infections and were treated successfully with dressing changes. Compared to preoperatively, the patients had more small arteries and higher foot blood flow (8.1 ​± ​2.2 versus 28.3 ​± ​3.9 ml/100 ​g/min, p ​= ​0.003) and volume (1.5 ​± ​0.3 versus 2.7 ​± ​0.4 ml/100 ​g, p ​= ​0.037) 12 weeks postoperatively.

Conclusion

TTT promotes healing, limb salvage, and health-related quality of life in patients with recalcitrant DFUs as demonstrated in this multicenter cohort study. The surgical procedure was simple and straightforward and the complications were few and minor. The effect of this technique was associated with neovascularization and improved perfusion at the foot mediated by the cortex distraction. The findings are required to confirm in randomized controlled trials.The Translational Potential of this Article: TTT can be used as an effective treatment in patients with recalcitrant DFUs. The mechanism is associated with neovascularization and consequently increased perfusion in the foot after operation.

Angiosome-directed endovascular intervention and infrapopliteal disease: Intraoperative evaluation of distal hemodynamic changes and foot blood volume of lower extremity

Objectives

To evaluate foot blood volume and hemodynamics and explore whether quantitative techniques can guide revascularization.

Materials and methods

A prospective single-center cohort study included thirty-three patients with infrapopliteal artery occlusion who underwent percutaneous transluminal angioplasty (PTA) between November 2016 and May 2020. The time-to-peak (TTP) from color-coded quantitative digital subtraction angiography (CCQ-DSA) and parenchymal blood volume (PBV) were used to evaluate the blood volume and hemodynamic changes in different regions of the foot before and after the operation.

Results

After the intervention procedure, the overall blood volume significantly increased from 25.15 ± 21.1 ml/1,000 ml to 72.33 ± 29.3 ml/1,000 ml (p &lt; 0.001, with an average increase of 47.18 ml/1,000 ml. The overall TTP decrease rate, postoperative blood flow time significantly faster than those preoperatively, from 22.93 ± 7.83 to 14.85 ± 5.9 s (p &lt; 0.001, with an average decrease of 8.08 s). Direct revascularization (DR) resulted in significant blood volume improvement than compared with indirect revascularization (IR) [188% (28, 320) vs.51% (10, 110), p = 0.029]. Patients with DR had a significantly faster blood flow time than those with IR [80% (12, 180) vs. 26% (5, 80), p = 0.032]. The ankle-brachial index (ABI) of the affected extremity also showed an significant change from 0.49 ± 0.3 to 0.63 ± 0.24 (p &lt; 0.001) after the intervention. The relative values of ΔTTP and ΔABI showed a weak correlation (r = −0.330).

Conclusions

The quantitative measurement results based on PBV and CCQ-DSA techniques showed that the overall blood volume increased significantly and that the foot distal hemodynamics were significantly improved after endovascular treatment. DR in the ischemic area could r improve foot perfusion.

Clinical Characteristics of Lower-Limb Ischemia in Japanese Patients with Type 2 Diabetes and Usefulness of the Great Toe Blood Flow as a Predictive Indicator of Leg Arterial Obstruction

Nurses are required to make quantitative, evidence-based observations when implementing diabetic foot care. This study aimed to clarify the characteristics of lower-limb ischemia in patients with type 2 diabetes using subjective and objective symptoms and physiological indicators and whether the physiological characteristics are established as predictive indicators of arterial obstruction. Fifty Japanese patients with type 2 diabetes (100 limbs) were classified into three groups using the ankle–brachial index (ABI). Patients with an ABI of ≤0.69 had subjective and objective symptoms of blood flow disturbance, such as pain at rest, cold sensation, pale skin, and imperceptibility to the dorsalis pedis artery. Blood flow in the first toe was the lowest. Binary logistic regression analysis established hallux perfusion as a predictive model for lower-limb arterial occlusion (odds ratio = 0.979, 95% confidence interval 0.900–0.999). Thus, when nurses perform diabetic foot care, it is necessary to evaluate not only subjective and objective symptoms, but also blood flow at the microcirculatory level of the great toe.

Minor Forefoot Amputations in Patients with Diabetic Foot Ulcers

The prevalence of diabetes mellitus, particularly type 2 diabetes, is increasing worldwide. Also, the incidence of both lower limb revascularizations and amputations is increasing. We have less transtibial amputations due to improved diabetes care, but also due to modern treatments, vascular surgery, and development of plastic surgery. With well-planned minor amputations, more limbs can be saved. Minor limb-saving amputations are preferred especially to older diabetes patients, because they have a high-risk contralateral amputations. Losing both limbs causes major problems for patients and their life, risk for lifetime ward is high.

Analysis of peripheral arterial disease (PAD) patients by laser speckle measurement techniques

Diabetic foot is a well-known problem among patients suffering from peripheral arterial diseases (PAD). This article presents an optical sensor for contactless measurement of the anatomical site based on laser speckle techniques. The sensor illuminates the inspected tissue and analyzes the captured back-reflected light from the time-changing speckle patterns. An occlusion test was implemented to provide a statistical parameter to differentiate between a low perfused and a healthy foot. A clinical study of 15 subjects was conducted. The video was analyzed by two methods: dynamic laser speckle (DLS) and laser speckle contrast analysis (LASCA). Data analysis included several classification models, where the KNN model exhibited maximum performance. These findings suggest that a simple and inexpensive system for PAD monitoring can be designed for home use and/or in community clinics.

Glycated albumin and HbA1c as markers of lower extremity disease inUS adults with and without diabetes

AIM

We evaluated the associations of two biomarkers of hyperglycemia-hemoglobin A1c(HbA1c) and glycated albumin-with lower extremity disease in US adultsoverall and by diabetes status.

METHODS

We conducted a cross-sectional study of adult participants aged ≥ 40 years who attended the National Health and Nutrition Examination Survey (NHANES) 1999-2004 (unweighted N = 5,785). We used logistic regression to evaluate the associations of HbA1c and glycated albumin with lower extremity disease: peripheral neuropathy (assessed by monofilament test), peripheral artery disease (assessed by ankle-brachial index), history of foot ulcer, or amputation. All analyses were weighted and accounted for the complex NHANES sample survey design.

RESULTS

The prevalence of lower extremity disease was 17.4% (15.9% in adults without diabetes and 33.2% in adults with diabetes). HbA1c and glycated albumin were not significantly associated with lower extremity disease in adults without diabetes. However, we observed significant associations of both HbA1c (OR 1.19 per 1-% point increase, 95 %CI 1.06-1.34) and glycated albumin (OR 1.06 per 1-% point increase, 95 %CI 1.02-1.10) with lower extremity disease in adults with diabetes after adjustment. The patterns of association were similar for HbA1c and glycated albumin (P-for-seemingly-unrelated-regression = 0.60), with strong linear associations observed at high (diabetic) levels of both biomarkers.

CONCLUSIONS

Our study suggests the importance of diabetes prevention and glycemic control in adults with diabetes to reduce the burden of lower extremity disease.

Duplex ultrasound derived maximal systolic acceleration can be a reliable and rapid alternative to ankle brachial pressure indices for the diabetic population with lower extremity arterial disease; a prospective, observational cohort study

Objectives: Ankle brachial pressure index (ABPI) is limited for diabetic patients. This can have costly impacts upon patient's quality of life along with healthcare budgets, with diabetic care equating to approximately 10% of NHS expenditure.¹¹ We aimed to determine whether ultrasound waveform parameters are an alternative for quantifying lower extremity peripheral arterial disease (PAD) where ABPI is unreliable. Design: This was a prospective, observational study. Waveform parameters, systolic rise time (SRT), maximal systolic acceleration (AccMax) and peak systolic velocity (PSV) were recorded at ankle and compared to the ABPI and an aorta-ankle duplex ultrasound scan (DUS) as gold standard. Setting: Measurements were obtained by a Clinical Vascular Scientist at the Royal Free Hospital. Participants: Participants (≥18yrs) with known PAD, but without previous vascular intervention were allocated to non-diabetic control (n = 24) and diabetic test groups (n = 22). Outcome measures: The primary outcome measure was the correlation of novel ultrasound derived indices to PAD severity. The secondary outcome was the efficacy of this correlation in the diabetic population. Results: AccMax was most powerful in detecting PAD in both groups when compared to ABPI in the controls (r = 0.805; p < 0.01) and to DUS in control and test groups (r = −0.633 to −0.643; p < 0.01). In the test group, PSV did not consistently quantify PAD. SRT measurements were inconclusive throughout. Conclusion: AccMax is a rapid alternative tool for diagnosing PAD in diabetic patients. With further research, this simple test may prove useful for monitoring PAD progression in patients unsuitable for ABPI, reducing the need for lengthy repeat duplex scans.

Management of diabetic foot ulcers and the challenging points: An endocrine view

Diabetic foot ulcers (DFU) are one of the most challenging complications of diabetes. Up to one-third of patients with diabetes mellitus (DM) may suffer from DFUs during their life. DFU is one of the leading causes of morbidity in patients with DM. The treatment period is challenging, and the recurrence rate of DFUs is high. Hence, establishing prevention strategies is the most important point to be emphasized. A multidisciplinary approach is necessary in the prevention and treatment of DFUs. Patients at risk should be identified, and prevention measures should be taken based on the risk category. Once a DFU is formed, the appropriate classification and evidence-based treatment interventions should be executed. Glycemic control, diagnosis and treatment of vascular disease, local wound care, diagnosis, and treatment of infection should be addressed along with the proper evaluation and management of general health status.

The many faces of diabetes. Is there a need for re-classification? A narrative review

The alarming rise in the worldwide prevalence of obesity and associated type 2 diabetes mellitus (T2DM) have reached epidemic portions. Diabetes in its many forms and T2DM have different physiological backgrounds and are difficult to classify. Bariatric surgery (BS) is considered the most effective treatment for obesity in terms of weight loss and comorbidity resolution, improves diabetes, and has been proven superior to medical management for the treatment of diabetes. The term metabolic surgery (MS) describes bariatric surgical procedures used primarily to treat T2DM and related metabolic conditions. MS is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Originally, BS was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with T2DM. MS is more effective than lifestyle or medical management in achieving glycaemic control, sustained weight loss, and reducing diabetes comorbidities. New guidelines for T2DM expand the use of MS to patients with a lower body mass index.Evidence has shown that endocrine changes resulting from BS translate into metabolic benefits that improve the comorbid conditions associated with obesity, such as hypertension, dyslipidemia, and T2DM. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect.This review aims to examine the physiological mechanisms in diabetes, risks for complications, the effects of bariatric and metabolic surgery and will shed light on whether diabetes should be reclassified.

Patients with Type 2 Diabetes Exhibit a More Mineralized Deep Cartilage Layer Compared with Nondiabetic Controls: A Pilot Study

OBJECTIVE

To assess differences in biochemical composition of the deep cartilage layer in subjects with type 2 diabetes mellitus (T2DM) and nondiabetic controls using UTE (ultra-short echo time) T2* mapping and to investigate the association of vascular health and UTE T2* measurements.

DESIGN

Ten subjects with T2DM matched for age, sex, and body mass index with 10 nondiabetic controls. A 3D UTE sequence with 6 echo times was acquired using 3T magnetic resonance imaging of the knee. For UTE T2* analysis, the deep cartilage layer was segmented and analyzed in 5 compartments (patella, medial, and lateral femur and tibia). The ankle brachial index (ABI) was obtained in all subjects. Linear regression analyses were used to assess associations of T2DM and UTE T2* relaxation times and the associations of ABI measurements and UTE measurements.

RESULTS

Compared with nondiabetic controls, T2DM subjects had significantly lower mean T2*-UTE in the patella (mean difference 4.87 ms; 95% confidence interval [CI] 1.09-8.65; P = 0.015), the lateral tibia (mean difference 2.26 ms; 95% CI 0.06-4.45; P = 0.045), and the lateral femur (mean difference 4.96 ms; 95% CI 0.19-9.73; P = 0.043). Independent of diabetic status, subjects with higher ABI values, indicating better vascular health, had higher T2*-UTE of the patella (coefficient 15.2; 95% CI 3.3-21.4; P = 0.017), the medial tibia (coefficient 9.8; 95% CI 1.0-18.6; P = 0.031), and the lateral femur (coefficient 18.8; 95% CI 3.3-34.3; P = 0.021).

CONCLUSIONS

T2*-UTE measurements of the deep cartilage layer were consistently lower in subjects with T2DM and in subjects with impaired vascular health, likely indicating increased mineralization of this layer.

Urinary pteridines as a discriminator of atherosclerotic risk in patients with diabetes

Background and aims

We have recently proposed urinary pteridine level as a useful biomarker of oxidative stress in a general population. However, the significance of urinary pteridines in patients with diabetes is unknown.

Methods

The relationships of the level of urinary pteridine derivatives with d-dimer, ankle-brachial pressure index (ABI), and known cardiovascular risk factors were investigated in patients with type 2 diabetes.

Results

Urinary pteridine level showed significant positive correlations with urinary15-isoprostane F2t, female gender, history of smoking and d-dimer and significant inverse correlations with history of alcohol drinking, body mass index (BMI) and ABI. ABI was significantly lower and d-dimer was significantly higher in the highest tertile group of pteridines than in the lowest tertile group. The odds ratios of the highest vs. lowest tertiles for low ABI and high d-dimer were significantly higher than the reference level. The above relationships of urinary pteridines with ABI and d-dimer were not altered when age, gender, BMI, hemoglobin A1c and history of alcohol drinking were used as explanatory variables in multivariable analyses. History of smoking confounded the relation of pteridines with ABI but not that with d-dimer. However, in logistic regression analysis, the association between pteridines and ABI remained significant with adjustment for history of smoking.

Conclusion

Urinary pteridine level was associated with d-dimer and ABI, which reflect blood coagulability and arterial flow to the lower extremities, respectively, and is thus thought to be a useful discriminator of thromboatherosclerotic risk in patients with diabetes.

Toe pressure and toe brachial index are predictive of cardiovascular mortality regardless of the most diseased arterial segment in symptomatic lower-extremity artery disease-A retrospective cohort study

OBJECTIVE

Although lower extremity arterial disease (LEAD) is most often multisegmental, the predominant disease location and risk factors differ between patients. Ankle-brachial index (ABI), toe-brachial index (TBI), and toe pressure (TP) are predictive of outcome in LEAD patients. Previously, we reported a classification method defining the most diseased arterial segment (MDAS); crural (CR), femoropopliteal (FP), or aortoiliac (AOI). Current study aimed to analyze the associations between MDAS, peripheral pressure measurements and cardiovascular mortality.

MATERIALS AND METHODS

We reviewed retrospectively 729 consecutive LEAD patients (Rutherford 2-6) who underwent digital subtraction angiography between January, 2009 to August, 2011 and had standardized peripheral pressure measurements.

RESULTS

In Cox Regression analyses, cardiovascular mortality was associated with MDAS and non-invasive pressure indices as follows; MDAS AOI, TP <30 mmHg (HR 3.00, 95% CI 1.13-7.99); MDAS FP, TP <30 mmHg (HR 2.31, 95% CI 1.36-3.94), TBI <0.25 (HR 3.20, 95% CI 1.34-7.63), ABI <0.25 (HR 5.45, 95% CI 1.56-19.0) and ≥1.30 (HR 6.71, 95% CI 1.89-23.8), and MDAS CR, TP <30 mmHg (HR 4.26, 95% CI 2.19-8.27), TBI <0.25 (HR 7.71, 95% CI 1.86-32.9), and ABI <0.25 (HR 2.59, 95% CI 1.15-5.85).

CONCLUSIONS

Symptomatic LEAD appears to be multisegmental with severe infrapopliteal involvement. Because of this, TP and TBI are strongly predictive of cardiovascular mortality and they should be routinely measured despite the predominant disease location or clinical presentation.

Differences Between Patients With Intermittent Claudication and Critical Limb Ischemia Undergoing Endovascular Intervention: Insights From the Excellence in Peripheral Artery Disease Registry

BACKGROUND

There are limited data on differences in angiographic distribution of peripheral artery disease and endovascular revascularization strategies in patients presenting with intermittent claudication (IC) and critical limb ischemia (CLI). We aimed to compare anatomic features, treatment strategies, and clinical outcomes between patients with IC and CLI undergoing endovascular revascularization.

METHODS

We examined 3326 patients enrolled in the Excellence in Peripheral Artery Disease registry from 2006 to 2019 who were referred for endovascular intervention for IC (n=1983) or CLI (n=1343). The primary outcome was 1-year major adverse limb events, which included death, repeat target limb revascularization, or target limb amputation.

RESULTS

Patients with CLI were older and more likely to have diabetes and chronic kidney disease and less likely to receive optimal medical therapy compared with IC. Patients with IC had higher femoropopliteal artery interventions (IC 87% versus CLI 65%; P<0.001), while below the knee interventions were more frequent in CLI (CLI 47% versus IC 12%; P<0.001). Patients with CLI were more likely to have multilevel peripheral artery disease (CLI 32% versus IC 15%, P<0.001). Patients with IC were predominantly revascularized with stents (IC 48% versus CLI 37%; P<0.001) while balloon angioplasty was more frequent in CLI (CLI 37% versus IC 25%; P<0.001). All-cause mortality was higher in patients with CLI (CLI 4% versus IC 2%; P=0.014). Major adverse limb event rates for patients with IC and CLI were 16% and 26%, respectively (P<0.001) and remained higher in CLI after multivariable adjustment of baseline risk factors.

CONCLUSIONS

Patients with IC and CLI have significant anatomic, lesion, and treatment differences with significantly higher mortality and adverse limb outcomes in CLI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01904851. Graphic Abstract: A graphic abstract is available for this article.

Pedal arterial calcification score is associated with the risk of major amputation in chronic limb-threatening ischemia

OBJECTIVE

The medial arterial calcification (MAC) score is a simple metric that describes the burden of inframalleolar calcification using a plain foot radiograph. We hypothesized that a higher MAC score would be independently associated with the risk of major amputation in patients with chronic limb-threatening ischemia (CLTI).

METHODS

We performed a single-institution, retrospective study of 250 patients who had undergone infrainguinal revascularization for CLTI from January 2011 to July 2019 and had foot radiographs available for MAC score calculation. A single blinded reviewer assigned MAC scores of 0 to 5 using two-view minimum plain foot radiographs, with 1 point each for calcification of >2 cm in the dorsalis pedis, plantar, and metatarsal arteries and >1 cm in the hallux and non-hallux digital arteries.

RESULTS

The MAC score was 0 in 36%, 1 in 5.2%, 2 in 8.4%, 3 in 14%, 4 in 14%, and 5 in 21%. The MAC score was trichotomized to facilitate analysis and clinical utility (mild, MAC score 0-1; moderate, MAC score 2-4; and severe, MAC score 5). The variables independently associated with a higher MAC score were male sex, diabetes, end-stage renal disease, and the global limb anatomic staging system pedal score. The MAC score was not associated with the Society for Vascular Surgery WIfI (wound, ischemia, foot infection) grade or overall WIfI stage (P = .58). The median follow-up was 759 days (interquartile range, 264-1541 days). A higher MAC score was significantly associated with the risk of major amputation (P < .0001). In a Cox proportional hazards multiple regression model for major amputation that included the trichotomized MAC score, diabetes, end-stage renal disease, and WIfI stage (1-3 vs 4). The MAC score (MAC score 5: hazard ratio [HR], 4.9; 95% confidence interval [CI], 1.9-13.1; P = .001; MAC score 2-4: HR, 3.4; 95% CI, 1.3-8.8; P = .01) and WIfI stage (WIfI stage 4: HR, 2.1; 95% CI, 1.1-3.9; P = .03) were significantly associated with the risk of major amputation. In the subsets of patients with the most advanced WIfI stage of 3 to 4 (191 of 250; 76%) and patients with diabetes (185 of 250; 74%), the MAC score further stratified the risk of major amputation on univariate and multivariate analyses.

CONCLUSIONS

The MAC score is a simple, practical tool and a strong independent predictor of major amputation in patients with CLTI. It provides novel clinical data that are currently unmeasured using any validated CLTI staging system. The MAC score is a promising standardized measure of inframalleolar disease burden that can be used in conjunction with the WIfI staging system to help improve outcomes stratification and determine the optimal treatment strategies for patients with CLTI.

Systemic sclerosis is associated with lower limb vascular stiffness and microvascular impairment: results from a prospective study

OBJECTIVE

Systemic sclerosis (SSc) is a connective tissue disease characterized by microangiopathy. Peripheral arterial disease, increasingly studied during SSc, is responsible for digital ulcers, associated with a high risk of amputation. The aim of our study was to assess the frequency of lower limb arterial impairment in SSc patients by measuring ankle-brachial index (ABI), toe pressure (TP), and toe-brachial index (TBI).

METHODS

Systemic sclerosis patients were included prospectively during 1 year in Tenon and Saint-Antoine Hospitals, Paris. Clinical and biological data were recorded. For each patient, ABI, TP, and TBI were measured and an arterial duplex ultrasonography was prescribed in case of abnormal results.

RESULTS

Eighty-six patients were included (94% women, median age 62 years). Only 24% of them had no lower limb hemodynamic vascular abnormalities; 44% had an isolated microvascular abnormality (normal ABI and TBI<0.75); 31% had at least a macrovascular injury associated or not with microvascular impairment (abnormal ABI) and 12.6% had a TP<50 mmHg. During follow-up, there was a trend towards association of low TBI with more major adverse event (all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and lower limb ischemic manifestations) than normal TBI.

CONCLUSION

By measuring ABI and TP, we showed that 76% of SSc patients had hemodynamic arterial lower limb abnormalities related to macro- and/or microvascular impairment and that 28% had vascular stiffness. In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying micro- and macrovascular changes. Key Points • The presence of lower limb macro-and/or microvascular involvement was detected in 76% of SSc patients. • In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying microvascular changes and frequent arterial stiffness.

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.

A 16-Week Home-Based Progressive Resistance Tube Training Among Older Adults With Type-2 Diabetes Mellitus: Effect on Glycemic Control

Research has proven that aerobic exercise improves glucose homeostasis among patients with type 2 diabetes mellitus (T2DM). Elastic resistance (tube or band) is suggested as a good alternative for home-based strength training among older adults including those with T2DM due to its low cost, simplicity, portability, and versatility. This study aimed to measure the effects of 16-week home-based progressive resistance training (PRT), using a resistance tube on glucose homeostasis and cardiovascular risk factors among older adults with T2DM. A total of 70 participants aged 61.68 (5.50) years with T2DM were assigned to the intervention (n = 35) and control (n = 35) groups in this quasi-experimental trial. The intervention group underwent 16 weeks of home-based PRT using a resistance tube. Significant improvements in HbA1c (-1.34% point, p < 0.001), fasting blood glucose (-1.30 mmol/L, p < 0.001), and systolic blood pressure (-1.42 mmHg, p < 0.05) were observed after 16 weeks of intervention. However, no significant changes were observed in lipid profile, diastolic blood pressure, resting heart rate, and ankle-brachial index. The finding suggests that 16 weeks of home-based PRT using a resistance tube has the potential to improve glycemic control and reduce systolic blood pressure among older adults with T2DM and caused no adverse events.

A systematic evaluation of cutaneous microcirculation in the foot using post-occlusive reactive hyperemia

OBJECTIVES

Cutaneous microcirculatory impairments are associated with skin injury to the foot. Post-Occlusive reactive hyperemia (PORH) is one of the quick and easy methods to assess microcirculatory function. However, there are variations in the protocols currently used. Hence, this study aimed to systematically investigate the reproducibility of PORH protocols with minimal occlusion time in the foot.

METHODS

Post-Occlusive reactive hyperemia was measured using 12 different protocols (three occlusion times, two occlusion sites and with or without temperature control) in 25 healthy adults. Each of the 12 different protocols was repeated three times, and the intraclass correlation coefficient (ICC) was calculated.

RESULTS

Intraclass correlation coefficient showed that that ankle level occlusion produced moderate to excellent reproducibility for most PORH measures. In the right foot, 30- and 60-s ankle level occlusion without temperature control showed ICC of >0.40 for all parameters except the area of hyperemia (ICC = -0.36) and biological zero to peak flow percent change (ICC = -0.46). In the left foot, 30-s ankle level occlusion without temperature control showed ICC of >0.40 for all parameters except time to latency (ICC = 0.29), after hyperemia (ICC = 0.37), and max (ICC = -0.01), and area of hyperemia (ICC = -0.36). But the 60-s protocol showed ICC > 0.40 for all except time to max (ICC = 0.38). In the hallux protocols, all three 10-, 30-, and 60-s protocols without temperature control showed moderate to excellent reproducibility (ICC > 0.40). In most cases, the temporal and area under the perfusion-time curve parameters showed poor reproducibility.

CONCLUSION

Post-Occlusive reactive hyperemia can be tested efficiently with a minimal occlusion time of 10 s with hallux occlusion and 30 s with ankle occlusion in the foot. This can suggest that microcirculatory assessment is feasible in routine practice and can potentially be included for routine assessment of foot in people with diabetes.

Predictive value of abnormal ankle-brachial index in patients with diabetes: A meta-analysis

AIMS

This meta-analysis aimed to examine the association of abnormal ankle brachial index (ABI) with adverse prognosis in patients with diabetes.

METHODS

We systematically searched PubMed and Embase databases from inception to October 31, 2020 for observational studies investigating the predictive utility of abnormal ABI in patients with diabetes. The normal ABI is usually defined by 0.9-1.3 or 1.4.

RESULTS

Data were collected from 9 studies involving 9673 patients. When compared with the reference normal ABI, abnormal ABI was associated with a higher risk of cardiovascular mortality (risk ratio [RR] 1.98; 95% confidence intervals [CI] 1.66-2.37), all-cause mortality (RR 2.12; 95% CI 1.81-2.49), and major adverse cardiovascular events ([MACEs] RR 2.37; 95% CI 1.73-3.26). Subgroup analysis indicated that the pooled RR of cardiovascular mortality was similar in individuals with abnormally low ABI (RR 1.98; 95% CI 1.64-2.39) or high ABI (RR 2.00; 95% CI 1.12-3.59).

CONCLUSIONS

Abnormal ABI independently predicts subsequent risk of cardiovascular or all-cause mortality and MACEs in patients with diabetes. However, the predictive role of abnormal ABI is largely dominated by the low ABI rather than the high ABI.

The risk of micro and macrovascular disease in Egyptian patients with diabetes and peripheral arterial disease

Aim: The aim of this study was to assess the prevalence of micro- and macrovascular disease in Egyptian patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Methods: The study included 161 Egyptian patients with DM and PAD (91.3% had type 2 DM and 67.1% were females). Mean diabetes duration was 14.2 ± 5.2 years. Full history, clinical and fundus examination as well as laboratory investigations were done. PAD was diagnosed through assessment of ankle/brachial index (ABI) by Doppler ultrasonography. Results: ABI was <0.9 in 33.5% and >1.3 in 66.5% of patients. A significant positive correlation was found between abnormal ABI and diabetes duration, ischemic heart disease (IHD), diabetic retinopathy and neuropathy, foot ulcers, elevated blood pressure (BP), creatinine, urine albumin/creatinine ratio (ACR) and triglycerides and a significant negative correlation with HDL. Multivariate regression analysis revealed that the independent predictors for PAD in patients with ABI< 0.9 were neuropathy, creatinine, triglyceride, LDL, urine ACR and low HDL, and in patients with ABI >1.3 were IHD, neuropathy, elevated diastolic BP and triglyceride. Conclusion: The risk of micro- and macrovascular disease is high in Egyptian patients with diabetes and PAD. Early diagnosis and good control of risk factors could reduce PAD progression.

Pilot study of contrast-free MRI reveals significantly impaired calf skeletal muscle perfusion in diabetes with incompressible peripheral arteries

Patients with diabetes mellitus (DM) are more likely to have densely calcified lesions in the below-the-knee tibial arteries. However, the relationship between peripheral arterial calcification and local skeletal muscle perfusion has not been explored. Thirty subjects were prospectively recruited into three groups in this pilot study: (1) Non-DM: 10 people without DM; (2) DM, ABI < 1.3: 10 people with DM and normal ankle-brachial index (ABI) (0.9-1.3); and (3) DM, ABI ⩾ 1.3: 10 people with DM and ABI ⩾ 1.3. All subjects underwent calf perfusion measurements at rest and during an isometric plantarflexion contraction exercise within the magnetic resonance imaging (MRI) system. The noncontrast MRI techniques were applied to quantitatively assess skeletal muscle blood flow (SMBF) and oxygen extraction fraction (SMOEF) in medial gastrocnemius and soleus muscles. Both SMBF and SMOEF reserves were calculated as the ratio of the exercise value to the resting value. Exercise SMBF and SMOEF values in the medial gastrocnemius muscle were lower in the two DM groups than in the non-DM group (p < 0.05). The SMBF reserve in medial gastrocnemius was significantly lower in the DM, ABI ⩾ 1.3 group compared to the DM, ABI < 1.3 group (p < 0.05). This study demonstrates that people with DM and calcified arteries had lower perfusion in gastrocnemius muscle compared to those without DM and those with DM and a normal ABI.

Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers

OBJECTIVE

The treatment of recalcitrant not-diabetic leg ulcers remains challenging. Distraction osteogenesis is accompanying by angiogenesis and neovascularization in the surrounding tissues. We previously applied tibial cortex transverse transport (TTT) to patients with recalcitrant diabetic foot ulcers and found neovascularization and increased perfusion in the foot and consequently enhanced healing and limb salvage and reduced recurrence. However, the effects of TTT on recalcitrant non-diabetic leg ulcer remains largely unknown.

METHODS

Consecutive patients (n ​= ​85) with recalcitrant non-diabetic leg ulcers (University of Texas Grade 2-B to 3-D, ie, wound penetrating to the tendon, capsule, bone, or joint with infection and/or ischemia) were recruited and divided into TTT (n ​= ​42) and control (n ​= ​43) groups based on the treatment they received. There were 36 (85.7%) arterial ulcers, 4 (9.5%) venous ulcers and 2 (4.8%) mixed ulcers in the TTT group and 32 (74.4%) arterial ulcers, 7 (16.7%) venous ulcers and 4 (9.3%) mixed ulcers in the control group (p ​> ​0.05). The two groups were matched on demographic and clinical characteristics. Patients in the TTT group underwent tibial corticotomy followed by 4 weeks of distraction medially then laterally, while those in the control group received conventional surgeries (debridements, revascularization, reconstruction with flaps, or skin grafts or equivalents). Ulcer healing and healing time, limb salvage, recurrence, and patient death were evaluated at a 1-year follow-up. Changes in leg small vessels were assessed in the TTT group using computed tomography angiography (CTA).

RESULTS

TTT group had higher healing rates at 1-year follow-up than the control group (78.6% [33/42] vs. 58.1% [25/43], OR 2.64 [95% CI 1.10 to 6.85], p ​= ​0.04). The healing time of the TTT group was shorter than the control group (4.5 vs. 6.1 months, mean difference -1.60 [95% CI -2.93 to -0.26], p ​= ​0.02). There were no significant differences in rates of major amputation, reulceration, or mortality between the groups (p ​> ​0.05). TTT group displayed more small vessels 4 weeks postoperatively at the wound area, the foot, and the calf of the ipsilateral side in CTA. All patients in the TTT group achieved good union at the osteotomy site and had no skin or soft tissue necrosis or infection around the incision area.

CONCLUSION

The findings showed that TTT facilitated the healing of recalcitrant non-diabetic leg ulcers and reduced the healing time compared with conventional surgeries. They suggest that TTT is an effective procedure to treat recalcitrant non-diabetic foot ulcers compared with standard surgical therapy. The procedure of TTT is relatively simple. Randomized controlled trials are required to confirm these findings.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

TTT can be used as an effective treatment for recalcitrant non-diabetic leg ulcers in patients. The mechanism may be associated with the neovascularization in the ulcerated foot induced by TTT and consequently increased perfusion. Together with previous findings from recalcitrant diabetic leg ulcers, the findings suggest TTT as an effective procedure to treat recalcitrant chronic leg ulcers.

Use of ABI to detect peripheral arterial disease in diabetes - A recommendation for primary care physicians

Background

India is considered the diabetes capital of the world. As per current practice, most of the diabetes patients go to primary care physicians for their monitoring and follow up. One of the dreaded complications of long-term diabetes is peripheral arterial disease.

Methods

A cross-sectional observational study was conducted in a diabetes workshop. Totally, 48 patients were selected who satisfied the inclusion criteria. All were subjected to ankle-brachial index measurement (ABI) and doppler ultrasound was done to assess patency of the lower extremity arteries. The results were compared. The ankle-brachial index of less than 0.99 was considered abnormal.

Results

Out of a total of 48 included patients 26 patients had normal ABI and 22 patients were found to have abnormal ABI. Out of those with normal ABI, 2 patients had features of peripheral arterial disease proved by doppler, whereas 3 patients with abnormal ABI had no feature of peripheral arterial disease in doppler. MedCalc software was used for statistical comparison.

Conclusion

In the selected diabetic population prevalence of peripheral arterial disease was found to be 56.25%. Measurement of ABI was found to be quite a sensitive and specific method for diagnosing peripheral arterial disease of diabetics.