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Ghirardini F, Martini R. Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1179. [PMID: 39064610 PMCID: PMC11279131 DOI: 10.3390/medicina60071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.
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Affiliation(s)
| | - Romeo Martini
- Department of Angiology, San Martino Hospital, 32100 Belluno, Italy;
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2
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Duarte EG, Lopes CF, Gaio DRF, Mariúba JVDO, Cerqueira LDO, Manhanelli MAB, Navarro TP, Castro AA, de Araujo WJB, Pedrosa H, Galli J, de Luccia N, de Paula C, Reis F, Bohatch MS, de Oliveira TF, da Silva AFV, de Oliveira JCP, Joviliano EÉ. Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot. J Vasc Bras 2024; 23:e20230087. [PMID: 38803655 PMCID: PMC11129855 DOI: 10.1590/1677-5449.202300872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/12/2023] [Indexed: 05/29/2024] Open
Abstract
The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.
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Affiliation(s)
- Eliud Garcia Duarte
- Hospital Estadual de Urgência e Emergência do Estado do Espírito Santo – HEUE, Departamento de Cirurgia Vascular, Vitória, ES, Brasil.
| | - Cicero Fidelis Lopes
- Universidade Federal da Bahia – UFBA, Departamento de Cirurgia Vascular, Salvador, BA, Brasil.
| | | | | | | | | | - Tulio Pinho Navarro
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
| | - Aldemar Araújo Castro
- Universidade Estadual de Ciências da Saúde de Alagoas – UNCISAL, Departamento de Cirurgia Vascular, Maceió, AL, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Hermelinda Pedrosa
- Hospital Regional de Taguatinga – HRT, Departamento de Cirurgia Vascular, Brasília, DF, Brasil.
| | - Júnio Galli
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Nelson de Luccia
- Universidade de São Paulo – USP, Faculdade de Medicina, Hospital das Clínicas – HC, São Paulo, SP, Brasil.
| | - Clayton de Paula
- Rede D’or São Luiz, Departamento de Cirurgia Vascular, São Paulo, SP, Brasil.
| | - Fernando Reis
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | - Milton Sérgio Bohatch
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | | | | | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia Vascular, Rio de Janeiro, RJ, Brasil.
| | - Edwaldo Édner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Departamento de Cirurgia Vascular, Ribeirão Preto, SP, Brasil.
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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Lazzarini PA, Raspovic KM, Meloni M, van Netten JJ. A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care. Diabetes Metab Res Rev 2024; 40:e3747. [PMID: 37997627 DOI: 10.1002/dmrr.3747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
The 1989 Saint Vincent Declaration established a goal of halving global diabetes-related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro-osteoarthropathy is more prevalent than previously thought. Most cases respond well to non-removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline-based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.
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Affiliation(s)
- Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
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Chuter V, Schaper N, Hinchliffe R, Mills J, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, David R, van den Berg JC, Venermo M, Fitridge R. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3701. [PMID: 37493206 DOI: 10.1002/dmrr.3701] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes-related foot ulcer (DFU). Determining performance of non-invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non-invasive bedside tests for PAD to predict DFU healing, healing post-minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene. METHODS A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non-invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6-month follow-up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle-brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe-brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2 ) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post-minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non-healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10). CONCLUSIONS Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post-revascularisation bedside testing, and heterogenous subpopulations.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St. Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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McNeil S, Waller K, Poy Lorenzo YS, Mateevici OC, Telianidis S, Qi S, Churilov I, MacIsaac RJ, Galligan A. Detection, management, and prevention of diabetes-related foot disease in the Australian context. World J Diabetes 2023; 14:942-957. [PMID: 37547594 PMCID: PMC10401446 DOI: 10.4239/wjd.v14.i7.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.
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Affiliation(s)
- Scott McNeil
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Kate Waller
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Podiatry, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Yves S Poy Lorenzo
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Pharmacy, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
| | - Olimpia C Mateevici
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Stacey Telianidis
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Sara Qi
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Irina Churilov
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Rehabilitation Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Richard J MacIsaac
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- the Australian Centre for Accelerating Diabetes Innovations, School of Medicine, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Anna Galligan
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
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11
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Piñar-Gutiérrez A, Gros-Herguido N, Losada-Viñau F, Farfán-Díaz F, Enríquez-Macías M, Pérez-Morales A, González-Navarro I, Acosta-Delgado D, Guerrero-Vázquez R, Martínez-Ortega AJ, Pumar-López A, Mangas-Cruz MÁ, Bataller-de Juan E, Tallón-Aguilar L, Soto-Moreno A. Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2023; 70:381-388. [PMID: 37356875 DOI: 10.1016/j.endien.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/29/2021] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit. RESEARCH DESIGN AND METHODS Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ2 test for the comparison of proportions in qualitative variables were performed. RESULTS Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03). CONCLUSIONS The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Noelia Gros-Herguido
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fernando Losada-Viñau
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fátima Farfán-Díaz
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Ana Pérez-Morales
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | | | | | - Alfonso Pumar-López
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Luis Tallón-Aguilar
- UGC Cirugía General, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alfonso Soto-Moreno
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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12
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Altmann D, Waibel FWA, Forgo G, Grigorean A, Lipsky BA, Uçkay I, Schöni M. Timing of Revascularization and Parenteral Antibiotic Treatment Associated with Therapeutic Failures in Ischemic Diabetic Foot Infections. Antibiotics (Basel) 2023; 12:antibiotics12040685. [PMID: 37107047 PMCID: PMC10135376 DOI: 10.3390/antibiotics12040685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
For ischemic diabetic foot infections (DFIs), revascularization ideally occurs before surgery, while a parenteral antibiotic treatment could be more efficacious than oral agents. In our tertiary center, we investigated the effects of the sequence between revascularization and surgery (emphasizing the perioperative period of 2 weeks before and after surgery), and the influence of administering parenteral antibiotic therapy on the outcomes of DFIs. Among 838 ischemic DFIs with moderate-to-severe symptomatic peripheral arterial disease, we revascularized 608 (72%; 562 angioplasties, 62 vascular surgeries) and surgically debrided all. The median length of postsurgical antibiotic therapy was 21 days (given parenterally for the initial 7 days). The median time delay between revascularization and debridement surgery was 7 days. During the long-term follow-up, treatment failed and required reoperation in 182 DFI episodes (30%). By multivariate Cox regression analyses, neither a delay between surgery and angioplasty (hazard ratio 1.0, 95% confidence interval 1.0–1.0), nor the postsurgical sequence of angioplasty (HR 0.9, 95% CI 0.5–1.8), nor long-duration parenteral antibiotic therapy (HR 1.0, 95% CI 0.9–1.1) prevented failures. Our results might indicate the feasibility of a more practical approach to ischemic DFIs in terms of timing of vascularization and more oral antibiotic use.
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Affiliation(s)
- Dominique Altmann
- Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Gabor Forgo
- Department of Angiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Alexandru Grigorean
- Department of Angiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98195-6420, USA
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Infectiology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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13
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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14
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Elghazaly H, Howard T, Sanjay S, Mohamed OG, Sounderajah V, Mehar Z, Davies AH, Jaffer U, Normahani P. Evaluating the prognostic performance of bedside tests used for peripheral arterial disease diagnosis in the prediction of diabetic foot ulcer healing. BMJ Open Diabetes Res Care 2023; 11:e003110. [PMID: 36918215 PMCID: PMC10016246 DOI: 10.1136/bmjdrc-2022-003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/21/2022] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Diabetic foot ulceration (DFU) is a common and challenging complication of diabetes. Risk stratification can guide further management. We aim to evaluate the prognostic performance of bedside tests used for peripheral arterial disease (PAD) diagnosis to predict DFU healing. RESEARCH DESIGN AND METHODS Testing for Arterial Disease in Diabetes (TrEAD) was a prospective observational study comparing the diagnostic performance of commonly used tests for PAD diagnosis. We performed a secondary analysis assessing whether these could predict DFU healing. Follow-up was performed prospectively for 12 months. The primary outcome was sensitivity for predicting ulcer healing. Secondary endpoints were specificity, predictive values, and likelihood ratios for ulcer healing. RESULTS 123 of TrEAD participants with DFU were included. In 12 months, 52.8% of ulcers healed. The best negative diagnostic likelihood ratio (NDLR) was observed for the podiatry ankle duplex scan (PAD-scan) monophasic or biphasic with adverse features(NDLR 0.35, 95% CI 0.14-0.90). The highest positive likelihood ratios were observed for toe brachial pressure index of ≤0.2 (positive diagnostic likelihood ratio (PDLR) 7.67, 95% CI 0.91-64.84) and transcutaneous pressure of oxygen of ≤20 mm Hg (PDLR 2.68, 95% CI 0.54-13.25). Cox proportional hazards modeling demonstrated significantly greater probabilities of healing with triphasic waveforms (HR=2.54, 95% CI 1.23-5.3, p=0.012) and biphasic waveforms with non-adverse features (HR=13.67, 95% CI 4.78-39.1, p<0.001) on PAD-scan. CONCLUSIONS No single test performed well enough to be used in isolation as a prognostic marker for the prediction of DFU healing. TRIAL REGISTRATION NUMBER NCT04058626.
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Affiliation(s)
- Hussein Elghazaly
- Section of Vascular Surgery, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Theodore Howard
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Sharan Sanjay
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Omer G Mohamed
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Viknesh Sounderajah
- Section of Vascular Surgery, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Zaheer Mehar
- Department of Vascular Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Usman Jaffer
- Section of Vascular Surgery, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
| | - Pasha Normahani
- Section of Vascular Surgery, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College NHS Healthcare Trust, London, UK
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15
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Liao X, Li SH, El Akkawi MM, Fu XB, Liu HW, Huang YS. Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide. Front Surg 2022; 9:1003339. [PMID: 36425891 PMCID: PMC9679004 DOI: 10.3389/fsurg.2022.1003339] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/19/2022] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear. METHODS To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved. RESULTS A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future. CONCLUSION This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.
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Affiliation(s)
- Xuan Liao
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou, China
| | - Sheng-Hong Li
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou, China
| | - Mariya Mohamad El Akkawi
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou, China
| | - Xiao-bing Fu
- Wound Healing and Cell Biology Laboratory, Institute for Basic Research, Trauma Center of Postgraduate Medical College, General Hospital of PLA, Beijing, China
| | - Hong-wei Liu
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou, China
| | - Yue-sheng Huang
- Department of Wound Repair; Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology Hospital, Southern University of Science and Technology School of Medicine, Shenzhen, China
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16
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Mantri Y, Mishra A, Anderson CA, Jokerst JV. Photoacoustic imaging to monitor outcomes during hyperbaric oxygen therapy: validation in a small cohort and case study in a bilateral chronic ischemic wound. BIOMEDICAL OPTICS EXPRESS 2022; 13:5683-5694. [PMID: 36733747 PMCID: PMC9872873 DOI: 10.1364/boe.472568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 06/18/2023]
Abstract
Hyperbaric oxygen therapy (HBO2) is a common therapeutic modality that drives oxygen into hypoxic tissue to promote healing. Here, ten patients undergoing HBO2 underwent PA oximetry of the left radial artery and forearm pre- and post-HBO2; this cohort validated the use of PA imaging in HBO2. There was a significant increase in radial artery oxygenation after HBO2 (p = 0.002) in the validation cohort. We also include a case study: a non-diabetic male in his 50s (HB 010) presenting with bilateral ischemic and gangrenous wounds. HB 010 showed higher perfusion and oxygen saturation on the right foot than the left after HBO2 which correlated with independent surgical observations. Imaging assisted with limb salvage treatment. Hence, this work shows that PA imaging can measure changes in arterial oxygen saturation due to HBO2; it can also produce 3D maps of tissue oxygenation and evaluate response to therapy during HBO2.
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Affiliation(s)
- Yash Mantri
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - Aditya Mishra
- Materials Science Program, University of California San Diego, La Jolla, CA, USA
| | - Caesar A. Anderson
- Department of Emergency Medicine, Hyperbaric and Wound Healing Center, University of California San Diego, Encinitas, CA, USA
| | - Jesse V. Jokerst
- Materials Science Program, University of California San Diego, La Jolla, CA, USA
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
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17
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Chuter V, Quigley F, Tosenovsky P, Ritter JC, Charles J, Cheney J, Fitridge R. Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:51. [PMID: 35787293 PMCID: PMC9254685 DOI: 10.1186/s13047-022-00550-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/06/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is implicated in up to 50% of diabetes-related foot ulcers (DFU) and significantly contributes to morbidity and mortality in this population. An evidence-based guideline that is relevant to the national context including consideration of the unique geographical and health care system differences between Australia and other countries, and delivery of culturally safe care to First Nations people, is urgently required to improve outcomes for patients with PAD and DFU in Australia. We aimed to identify and adapt current international guidelines for diagnosis and management of patients with PAD and DFU to develop an updated Australian guideline. METHODS Using a panel of national content experts and the National Health and Medical Research Council procedures, the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines were adapted to the Australian context. The guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were applied to the IWGDF guideline for PAD by the expert panel. Recommendations were then adopted, adapted or excluded, and specific considerations for implementation, population subgroups, monitoring and future research in Australia were developed with accompanying clinical pathways provided to support guideline implementation. RESULTS Of the 17 recommendations from the IWGDF Guideline on diagnosis, prognosis and management of PAD in patients with diabetes with and without foot ulcers, 16 were adopted for the Australian guideline and one recommendation was adapted due to the original recommendation lacking feasibility in the Australian context. In Australia we recommend all people with diabetes and DFU undergo clinical assessment for PAD with accompanying bedside testing. Further vascular imaging and possible need for revascularisation should be considered for all patients with non-healing DFU irrespective of bedside results. All centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively, including implementation of intensive cardiovascular risk management. CONCLUSIONS A guideline containing 17 recommendations for the diagnosis and management of PAD for Australian patients with DFU was developed with accompanying clinical pathways. As part of the adaptation of the IWGDF guideline to the Australian context, recommendations are supported by considerations for implementation, monitoring, and future research priorities, and in relation to specific subgroups including Aboriginal and Torres Strait Islander people, and geographically remote people. This manuscript has been published online in full with the authorisation of Diabetes Feet Australia and can be found on the Diabetes Feet Australia website: https://www.diabetesfeetaustralia.org/new-guidelines/ .
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia.
- Discipline of Podiatry, University of Newcastle, Ourimbah, Australia.
| | | | - Patrik Tosenovsky
- Department of Vascular & Endovascular Surgery, Royal Perth Hospital, Wellington Street, Perth, Australia
| | - Jens Carsten Ritter
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia
- Curtin University, School of Medicine, Perth, Australia
| | - James Charles
- First Peoples Health Unit, Griffith University, Gold Coast, Australia
| | | | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
- Vascular and Endovascular Service, Central Adelaide Local Health Network, Adelaide, Australia
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18
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Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Ruemenapf G, Morbach S, Sigl M. Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review. J Clin Med 2022; 11:2155. [PMID: 35456247 PMCID: PMC9032488 DOI: 10.3390/jcm11082155] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible ("too late", "too sick", "no technical option"). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. METHODS The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. RESULTS If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. CONCLUSIONS Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.
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Affiliation(s)
- Gerhard Ruemenapf
- Vascular Center Oberrhein Speyer-Mannheim, Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus, 67346 Speyer, Germany
| | - Stephan Morbach
- Department of Diabetology und Angiology, Marienkrankenhaus, 59494 Soest, Germany;
| | - Martin Sigl
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site, 68199 Mannheim, Germany;
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20
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Hou X, Guo P, Cai F, Lin Y, Zhang J. Angiosome-guided endovascular revascularization for treatment of diabetic foot ulcers with peripheral artery disease. Ann Vasc Surg 2022; 86:242-250. [PMID: 35257914 DOI: 10.1016/j.avsg.2022.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Because diabetic foot ulcers (DFUs) are difficult to heal and cause huge economic losses to society, accelerating their healing has become extremely important. The purpose of this study was to evaluate the effect of revascularization based on the angiosome concept on DFU. MATERIALS AND METHODS Between January 2018 and July 2020, 112 consecutive legs with DFUs in 111 patients who were discharged from the vascular surgery department of our hospital were retrospectively evaluated. The legs were assigned to two groups depending on whether direct arterial flow to the foot ulcer based on the angiosome concept was achieved. Comparisons of the ulcer healing rate, mean time to ulcer healing, major amputation rate, survival rate, and major amputation-free survival rate between the angiosome direct revascularization (DR) and angiosome indirect revascularization (IR) groups were performed. RESULTS DR was achieved in 71 legs (63%) compared with IR in 41 legs. The ulcer healing rate (70.4% in the DR group vs. 34.1% in the IR group, P < 0.01), the mean time to ulcer healing (7.01 ± 4.26 months vs. 10.09 ± 3.24months, P < 0.01), the survival rate (90.1% vs. 53.7%, P < 0.01), and the major amputation-free survival rate (81.7% vs. 48.8%, P < 0.01) were significantly higher in the DR group than in the IR group. Undergoing DR did not significantly reduce the major amputations rate compared with IR (13.4% and 34.1%, respectively, P = 0.15), but there might be a trend. In multivariate models, DR remained a significant predictor for ulcer healing (HR, 7.07; 95% confidence interval, 6.54-7.60, P < 0.01). Opening multiple infrapopliteal arteries in the DR group compared with restoring only one infrapopliteal artery did not significantly improve the the ulcer healing rate (P = 0.59), the mean time to ulcer healing (P = 0.70), major amputation rate (P = 0.83), the survival rate (P = 0.31), and the major amputation-free survival rate(P = 0.40). CONCLUSIONS Attaining a direct arterial flow based on the angiosome concept may be important for ulcer healing, survival, and amputation-free survival in diabetic foot patients. Opening multiple infrapopliteal arteries in DR patients may not improve the ulcer healing, survival, major amputation or amputation-free survival compared with single DR vessel patency.
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Affiliation(s)
- Xinhuang Hou
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Pingfan Guo
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Fanggang Cai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Yichen Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Jinchi Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China.
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21
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Jakanov MK, Zhakiev BS, Karsakbayev UG, Kurmanbayev BA, Taishibayev KR, Sagynganov SK. Endovascular surgery for the treatment of purulent and necrotic complications in diabetic foot syndrome. Med J Islam Repub Iran 2021; 35:106. [PMID: 34956952 PMCID: PMC8683799 DOI: 10.47176/mjiri.35.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Diabetic foot syndrome (DFS) causes damage to the peripheral arteries in 50% of patients with diabetes mellitus (DM). The purpose of this study was to evaluate the efficacy of endovascular interventions, stenting, and balloon angioplasty for the treatment of patients with purulent and necrotic lesions in DFS. Methods: This was a retrospective study. During 2019-2020, stenting and balloon angioplasty were performed in 51 patients (study group) with purulent and necrotic complications of diabetic foot with limb ischemia. There were 32 women (62.7%) and 19 men (37.3%). The age of the patients varied from 45 to 81 years. Endovascular interventions were performed in combination with conservative therapy and topical treatment on 2 to 3 days after the debridement of the purulent lesions. To assess the outcomes of endovascular interventions, we studied the nature of changes in arterial circulation in the lower extremities. The mean blood flow velocity was calculated using the Doppler ultrasonography. The study was performed on the popliteal artery (PA), the posterior tibial artery (PTA), and on the dorsalis pedis artery. In this study, patients were divided into 2 groups: the study group- those who received endovascular intervention- and the control group- those who received only conservative therapy, which included local treatment without surgery. Results: The weightbearing function of the foot at discharge from the hospital was preserved in 94.2% (48 patients) of the study group and in 73.4% (22 patients) of the control group. During the next 6 months, repeated small foot surgeries were required in 7.3% (3 patients) of patients from the study group and in 20% (4 patients) of patients from the control group. Six months after discharge, the weightbearing function of the foot was preserved in all the patients from the study group available for follow-up and in 85% of the patients from the control group. Conclusion: The results of the study demonstrate the positive corrective effects of endovascular interventions, stenting, and balloon angioplasty on the clinical course of ischemic and neuroischemic forms of DFS.
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Affiliation(s)
- Murat K Jakanov
- Department of General Surgery, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Bazylbek S Zhakiev
- Department of Surgical Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Uteugaly G Karsakbayev
- Department of Surgical Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Bulat A Kurmanbayev
- Department of Surgical Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Kairat R Taishibayev
- Department of General Surgery, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Serik K Sagynganov
- Department of General Surgery, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
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22
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Li M. Guidelines and standards for comprehensive clinical diagnosis and interventional treatment for diabetic foot in China (Issue 7.0). J Interv Med 2021; 4:117-129. [PMID: 34805959 PMCID: PMC8562298 DOI: 10.1016/j.jimed.2021.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/22/2023] Open
Abstract
Diabetic foot (DF) is one of the most common complications of diabetes and is associated with high morbidity, disability, lethality and low cure-rate. The clinical diagnosis and treatment of DF need to be standardized. The Chinese Diabetic Foot Cell and Interventional Therapy Technology Alliance has released six editions of guidelines and standards for clinical diagnosis and interventional treatment of DF, which filled the gap in the domestic DF treatment standard and played an important role in improving the level of diagnosis and treatment in China. In line with the latest developments in diagnosis and treatment, the Alliance, along with other 89 institutions, developed and issued the new edition based on the sixth edition to help standardize the clinical diagnosis and treatment of DF in China.
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Affiliation(s)
- Maoquan Li
- China Alliance of Cellular and Interventional Therapy Techniques for Diabetic Foot, China.,Technical Committee on Interventional Medicine and Bioengineering of Chinese Intervention Physicians Branch, China.,National Centre for Clinical Medical Research on Radiation and Treatment, China.,Department of Interventional and Vascular Surgery, Affiliated Tenth People's Hospital of Tongji University, China.,Interventional Vascular Institute of Tongji University, Shanghai 200072, China
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23
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Bouillet B, Ahluwalia R, Iacopi E, Garcia-Klepzig JL, Lüdemann C, Manu C, Meloni M, Saenz De Buruaga VR, Vouillarmet J, Petit JM, Van Acker K, Lázaro-Martínez JL. Characteristics of new patient referrals to specialised diabetic foot units across Europe and factors influencing delays. J Wound Care 2021; 30:804-808. [PMID: 34644141 DOI: 10.12968/jowc.2021.30.10.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Foot ulcers are a common complication of diabetes and are associated with an increase in lower limb amputation and death. Early referral to a specialised unit is recommended. The aim of this study was to assess the characteristics of new-patient referrals to specialised diabetes foot care units across Europe and to determine the factors involved in delayed referral. METHOD In this prospective observational study, consecutive patients with a new foot ulcer presenting to nine diabetic foot centres in five European countries (France, Germany, Italy, Spain and the UK) were included. RESULTS Some 25% of the 332 patients included had presented with a foot ulcer >3 months before referral to the participating foot clinic. Compared with patients referred earlier, patients with a long time to referral (>3 months) were older (p=0.006) and had a less severe wound according to Infectious Diseases Society of America (IDSA) classification (p=0.003) and University of Texas classification (grade D=infection + peripheral artery disease, p=0.004). CONCLUSION The proportion of patients with a diabetic foot ulcer (DFU) referred to a specialised unit >3 months after the beginning of the ulcer remained high throughout Europe. Patients with severe DFU were, however, referred more quickly by front line health professionals. Primary care professionals need to be made aware of the importance of early referral to a specialised unit in order to improve the management of foot disease in patients with diabetes. DECLARATION OF INTEREST The authors have no conflicts of interest to declare.
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Affiliation(s)
- Benjamin Bouillet
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Dijon, France.,Unité INSERM, LNC-UMR 1231, Université de Bourgogne, Dijon, France
| | | | - Elisabetta Iacopi
- University of Pisa, Ospedale di Cisanello, via Paradisa 2, 56126 Pisa, Italy
| | | | - Claas Lüdemann
- Franziskus Krankenhaus Berlin, Budapester Strasse, 15-19, 10787 Berlin, Germany
| | - Chris Manu
- King's College Hospital, Denmark Hill, London, UK
| | - Marco Meloni
- University of Roma Tor Vergata, Viale Oxford 81, 00133 Roma, Italy
| | | | - Julien Vouillarmet
- CHU Lyon Sud, Pavillon Médical, 165 chemin du Grand Revoyet 69495 Pierre Bénite, France
| | - Jean-Michel Petit
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Dijon, France.,Unité INSERM, LNC-UMR 1231, Université de Bourgogne, Dijon, France
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24
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Yannoutsos A, Lin F, Gaisset R, Jaillette C, Lazareth I, Emmerich J, Priollet P. Characteristics and outcomes of octogenarians with revascularized critical limb ischemia: Impact of altered cardiac function for early mortality. JOURNAL DE MEDECINE VASCULAIRE 2021; 46:224-231. [PMID: 34862016 DOI: 10.1016/j.jdmv.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Patients with critical limb ischemia (CLI) present with advanced age and end-stage organ damage, in particular heart failure. The aim of the present study is to describe clinical and biological characteristics in octogenarian patients with CLI compared to their younger counterparts and to determine the peri-procedural risk and early mortality after endovascular procedure. METHODS From November 2013 to May 2019, 315 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The main outcome was total 1-year mortality. RESULTS The study included 170 octogenarians and 145 non-octogenarians. The mean age of octogenarian patients was 86.9±4.8 years, almost 20 years higher than that registered in non-octagenarians patients (67.4±8.6 years). Octogenarian patients were mostly women (59.4%), presented with lower body mass index (23.8±4.4kg/m2), lower serum albumin level (31.5±5.4g/L) and lower creatinine clearance (66.1±24.5mL/mn) than younger counterparts. They were more likely to be institutionalized in a nursing home (27.1%). In the peri-procedural period, major bleeding occurred in 40 patients (12.7%), without statistical significance between the two age groups. Peri-procedural mortality occurred in 12 patients (3.8%), of whom 10 patients (83%) were octogenarians. Cumulative mortality rate was 25.4% (80 patients) during the one-year follow-up period: 58 octogenarians died (34.1%) compared to 22 non-octogenarian patients (15.2%), P<0.001. Cardiovascular events were highly prevalent, accounting for 40% of overall mortality. Twenty-five patients (8%) experienced major amputation, without significant difference between the two age groups. In octogenarian population, institutionalized status (P=0.004) and BNP level (P=0.001) were positively correlated with mortality whereas systolic blood pressure (P<0.001), left ventricular ejection fraction (P=0.003), serum albumin (P=0.020), C-Reactive protein (P=0.020) and renin-angiotensin system inhibitors at hospital discharge were negatively correlated with mortality. In multivariate analysis for mortality, only BNP level≥500pg/mL (HR 3.27; 95% CI 1.04-10.97; P=0.04), was correlated with mortality, independently of other confounders. CONCLUSION In the present study population, octogenarians represent a rather distinct CLI population, 20 years of age older as compared to non-octogenarians, with prevalent malnutrition and institutionalized status. The present results underline a substantial one-year mortality rate of 34.1% in this elderly population following revascularization procedure with a 6% peri-procedural mortality. Decompensated heart failure is an important contributor for mortality.
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Affiliation(s)
- A Yannoutsos
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France; Inserm UMR 1153-CRESS, université Paris Descartes, Paris, France.
| | - F Lin
- Medical information department, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - R Gaisset
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - C Jaillette
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - I Lazareth
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - J Emmerich
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France; Inserm UMR 1153-CRESS, université Paris Descartes, Paris, France
| | - P Priollet
- Vascular medicine department, groupe hospitalier Paris Saint-Joseph, Paris, France
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25
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Solly EL, Psaltis PJ, Bursill CA, Tan JTM. The Role of miR-181c in Mechanisms of Diabetes-Impaired Angiogenesis: An Emerging Therapeutic Target for Diabetic Vascular Complications. Front Pharmacol 2021; 12:718679. [PMID: 34483928 PMCID: PMC8414254 DOI: 10.3389/fphar.2021.718679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/06/2021] [Indexed: 12/13/2022] Open
Abstract
Diabetes mellitus is estimated to affect up to 700 million people by the year 2045, contributing to an immense health and economic burden. People living with diabetes have a higher risk of developing numerous debilitating vascular complications, leading to an increased need for medical care, a reduced quality of life and increased risk of early death. Current treatments are not satisfactory for many patients who suffer from impaired angiogenesis in response to ischaemia, increasing their risk of ischaemic cardiovascular conditions. These vascular pathologies are characterised by endothelial dysfunction and abnormal angiogenesis, amongst a host of impaired signaling pathways. Therapeutic stimulation of angiogenesis holds promise for the treatment of diabetic vascular complications that stem from impaired ischaemic responses. However, despite significant effort and research, there are no established therapies that directly stimulate angiogenesis to improve ischaemic complications such as ischaemic heart disease and peripheral artery disease, highlighting the immense unmet need. However, despite significant effort and research, there are no established therapies that directly stimulate angiogenesis in a clinical setting, highlighting the immense unmet need. MicroRNAs (miRNAs) are emerging as powerful targets for multifaceted diseases including diabetes and cardiovascular disease. This review highlights the potential role of microRNAs as therapeutic targets for rescuing diabetes-impaired angiogenesis, with a specific focus on miR-181c, which we have previously identified as an important angiogenic regulator. Here we summarise the pathways currently known to be regulated by miR-181c, which include the classical angiogenesis pathways that are dysregulated in diabetes, mitochondrial function and axonal guidance, and describe how these relate both directly and indirectly to angiogenesis. The pleiotropic actions of miR-181c across multiple key angiogenic signaling pathways and critical cellular processes highlight its therapeutic potential as a novel target for treating diabetic vascular complications.
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Affiliation(s)
- Emma L Solly
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Christina A Bursill
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,ARC Centre of Excellence for Nanoscale BioPhotonics, The University of Adelaide, Adelaide, SA, Australia
| | - Joanne T M Tan
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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26
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The Association between Foot and Ulcer Microcirculation Measured with Laser Speckle Contrast Imaging and Healing of Diabetic Foot Ulcers. J Clin Med 2021; 10:jcm10173844. [PMID: 34501291 PMCID: PMC8432122 DOI: 10.3390/jcm10173844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/30/2022] Open
Abstract
Diagnosis of peripheral artery disease in people with diabetes and a foot ulcer using current non-invasive blood pressure measurements is challenging. Laser speckle contrast imaging (LSCI) is a promising non-invasive technique to measure cutaneous microcirculation. This study investigated the association between microcirculation (measured with both LSCI and non-invasive blood pressure measurement) and healing of diabetic foot ulcers 12 and 26 weeks after measurement. We included sixty-one patients with a diabetic foot ulcer in this prospective, single-center, observational cohort-study. LSCI scans of the foot, ulcer, and ulcer edge were conducted, during baseline and post-occlusion hyperemia. Non-invasive blood pressure measurement included arm, foot, and toe pressures and associated indices. Healing was defined as complete re-epithelialization and scored at 12 and 26 weeks. We found no significant difference between patients with healed or non-healed foot ulcers for both types of measurements (p = 0.135-0.989). ROC curves demonstrated moderate sensitivity (range of 0.636-0.971) and specificity (range of 0.464-0.889), for LSCI and non-invasive blood pressure measurements. Therefore, no association between diabetic foot ulcer healing and LSCI-measured microcirculation or non-invasive blood pressure measurements was found. The healing tendency of diabetic foot ulcers is difficult to predict based on single measurements using current blood pressure measurements or LSCI.
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27
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Frykberg RG, Attinger C, Smeets L, Koller A, Bal A, Kavarthapu V. Surgical strategies for prevention of amputation of the diabetic foot. J Clin Orthop Trauma 2021; 17:99-105. [PMID: 33738238 PMCID: PMC7944028 DOI: 10.1016/j.jcot.2021.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 12/28/2022] Open
Abstract
Prevention of amputation has become a key objective of clinicians providing care to patients with high-risk diabetic foot problems. In this regard, the multidisciplinary diabetic foot team (MDFT) has been embraced as the most effective way to manage patients with foot ulcers, infections, and Charcot feet. Importantly, such specialized teams have also integrated various surgical specialties to enable more expedient management of these often complex conditions. Experienced diabetic foot surgeons over the last three or four decades have contributed much to this discipline, whereby foot-sparing reconstructive procedures or minor amputations have become fundamental strategies for limb preservation teams. Central to limb salvage, of course, is the recognition of underlying vascular insufficiency and the importance of prompt (endo)vascular intervention. Restoration of adequate perfusion is essential to allow the podiatric, orthopaedic, or plastic surgeon to perform indicated functional reconstructive or minor amputation procedures. This evidence-based overview discusses the various indications and surgical principles inherent in modern concepts aimed at preventing amputation in the high-risk diabetic foot.
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Affiliation(s)
| | - Christopher Attinger
- Departments of Plastic and Orthopedic Surgery, Medstar Georgetown University Hospital, USA
| | | | - Armin Koller
- Department of Technical Orthopaedics, Dr. Guth Hospital, Hamburg, Germany
| | - Arun Bal
- Fortis Raheja Hospital, Mumbai, India
| | - Venu Kavarthapu
- King’s College Hospital, London, UK
- University of Southern Denmark, Denmark
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28
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Jiang X, Yuan Y, Ma Y, Zhong M, Du C, Boey J, Armstrong DG, Deng W, Duan X. Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia. J Diabetes Res 2021; 2021:6699292. [PMID: 34046505 PMCID: PMC8128546 DOI: 10.1155/2021/6699292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022] Open
Abstract
Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.
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Affiliation(s)
- Xiaoyan Jiang
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yi Yuan
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yu Ma
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Miao Zhong
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Chenzhen Du
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Johnson Boey
- Department of Podiatry, National University of Hospital Singapore, Singapore 169608
| | - David G. Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Wuquan Deng
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Xiaodong Duan
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
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29
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Wound outcomes and factors associated with wound healing after first-time femoropopliteal artery intervention in patients with ischemic tissue loss. Asian J Surg 2021; 44:649-655. [PMID: 33349551 DOI: 10.1016/j.asjsur.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/14/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/OBJECTIVE This study's goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss. METHODS A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation. RESULTS At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091-0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124-0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063-0.360, p < 0.001). CONCLUSION Wound outcome classifications showed detailed information regarding clinical outcomes in patients with ischemic tissue loss. Renal insufficiency, ischemia grade 3 and poor functional performance were independent risk factors that prevented wound healing.
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30
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Seghieri G, De Bellis A, Seghieri M, Gualdani E, Policardo L, Franconi F, Francesconi P. Gender Difference in the Risk of Adverse Outcomes After Diabetic Foot Disease: A Mini-Review. Curr Diabetes Rev 2021; 17:207-213. [PMID: 32674734 DOI: 10.2174/1573399816666200716195600] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022]
Abstract
Diabetic foot disease (DFD) is a complication of diabetes mellitus, characterized by multiple pathogenetic factors, bearing a very high burden of disability as well as of direct and indirect costs for individuals or healthcare systems. A further characteristic of DFD is that it is associated with a marked risk of subsequent hospitalizations for incident cardiovascular events, chronic renal failure or of allcause mortality. Additionally, DFD is strongly linked to the male sex, being much more prevalent among men. However, even if DFD mainly affects males, several past reports suggest that females are disadvantaged as regards the risk of subsequent adverse outcomes. This review aims to clarify this point, attempting to provide an explanation for this apparent oddity: being DFD a typically male complication of diabetes but, seemingly, with a greater load of subsequent consequences for females.
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Affiliation(s)
| | - Alessandra De Bellis
- Diabetes and Metabolic Diseases Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Marta Seghieri
- Diabetes and Metabolic Diseases Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | | | | | - Flavia Franconi
- National Laboratory of Gender Medicine and Gender Pharmacology of National Institute of Biostructures and Biosystems, University of Sassari, Italy
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31
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Meloni M, Izzo V, Da Ros V, Morosetti D, Stefanini M, Brocco E, Giurato L, Gandini R, Uccioli L. Characteristics and Outcome for Persons with Diabetic Foot Ulcer and No-Option Critical Limb Ischemia. J Clin Med 2020; 9:E3745. [PMID: 33233329 PMCID: PMC7700155 DOI: 10.3390/jcm9113745] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
The study aimed to evaluate clinical and vascular characteristics, as well as outcomes, for diabetic persons with foot ulceration and no-option critical limb ischemia (CLI). The study group included a sample of patients admitted to our diabetic foot unit because of a new diabetic foot ulcer and CLI. All subjects were managed using a limb salvage protocol which includes lower-limb revascularization. According to whether or not the revascularization procedure was a success, patients were respectively divided into two groups: successfully treated CLI patients (ST-CLI) and no-option CLI patients (NO-CLI). Failed revascularization was considered in the case of technical recanalization failure of occluded vessels (inability to overcome the obstruction) and/or absence of arterial flow to the foot. Limb salvage, major amputation, and death after 1 year of follow-up were evaluated and compared between the two groups. Overall, 239 patients were included, 74.9% belonging to ST-CLI and 25.1% to NO-CLI. NO-CLI patients reported more cases of ischemic heart disease (80 vs. 62.1, p = 0.008), heart failure (63.3 vs. 32.4%, p < 0.0001), and end-stage renal disease (ESRD) (60 vs. 25.7%) than ST-CLI patients. In addition, more vessels were affected in the NO-CLI group (5.2 ± 1.6 vs. 4 ± 1.5, p < 0.0001), and there was more involvement of tibio-peroneal trunk (50 vs. 30.2%, p = 0.006), anterior tibial (93.3 vs. 82.7, p = 0.03), posterior tibial (93.3 vs. 73.7%, p = 0.0005), peroneal (70 vs. 48%, p = 0.002), and below-the-ankle arteries (73.3 vs. 39.1%, p < 0.0001) than ST-CLI. The 1 year outcomes for the whole population were 69.9% limb salvage, 10.9% major amputation, and 19.2% death. The outcomes for NO-CLI and ST-CLI were, respectively, as follows: limb salvage (13.8 vs. 73.4%, p < 0.0001), amputation (30 vs. 4.5%, p = 0.0001), and mortality (50 vs. 8.9%, p < 0.0001). NO-CLI patients showed a more severe pattern of peripheral arterial disease (PAD) with distal arterial lesions and worse outcomes than ST-CLI.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - Valentina Izzo
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.D.R.); (D.M.)
| | - Daniele Morosetti
- Department of Biomedicine and Prevention, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.D.R.); (D.M.)
| | - Matteo Stefanini
- Department of Radiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy;
| | - Enrico Brocco
- Department of Foot and Ankle, Polyclinic Abano Terme, 35031 Abano Terme, Italy;
| | - Laura Giurato
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - Roberto Gandini
- Department of Interventional Radiology, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy;
| | - Luigi Uccioli
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
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Stoberock K, Kaschwich M, Nicolay SS, Mahmoud N, Heidemann F, Rieß HC, Debus ES, Behrendt CA. The interrelationship between diabetes mellitus and peripheral arterial disease - a systematic review. VASA 2020; 50:323-330. [PMID: 33175668 DOI: 10.1024/0301-1526/a000925] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This systematic review examined the interrelationship between concomitant diabetes mellitus (DM) and peripheral arterial disease (PAD). The objective was to determine differences in the prevalence as well as in the outcomes in diabetic vs. non-diabetic PAD patients. The current review followed a study protocol that was published online in German in 2017. The search included societal practice guidelines, consensus statements, systematic reviews, meta-analyses, and observational studies published from 2007 to 2020 reporting symptomatic PAD and concomitant DM in patients undergoing invasive open-surgical and endovascular revascularizations. German and English literature has been considered. Eligibility criteria were verified by three independent reviewers. Disagreement was resolved by discussion involving a fourth reviewer. 580 articles were identified. After exclusion of non-eligible studies, 61 papers from 30 countries remained, respectively 850,072 patients. The included studies showed that PAD prevalence differed between diabetic vs. non-diabetic populations (20-50% vs. 10-26%), and further by age, gender, ethnicity, duration of existing diabetes, and geographic region. The included studies revealed worse outcomes regarding perioperative complications, amputation rate, and mortality rate in diabetic patients when compared to non-diabetic patients. In both groups, the amputation rates decreased during the research period. This review emphasizes an interrelationship between PAD and DM. To improve the outcomes, early detection of PAD in diabetic patients, and vice versa, should be recommended. The results of this systematic review may help to update societal practice guidelines.
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Affiliation(s)
- Konstanze Stoberock
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Kaschwich
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shiva Sophia Nicolay
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nazeh Mahmoud
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik C Rieß
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wang A, Lv G, Cheng X, Ma X, Wang W, Gui J, Hu J, Lu M, Chu G, Chen J, Zhang H, Jiang Y, Chen Y, Yang W, Jiang L, Geng H, Zheng R, Li Y, Feng W, Johnson B, Wang W, Zhu D, Hu Y. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). BURNS & TRAUMA 2020; 8:tkaa017. [PMID: 32685563 PMCID: PMC7336185 DOI: 10.1093/burnst/tkaa017] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/21/2020] [Indexed: 02/07/2023]
Abstract
In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot. Registry number: IPGRP-2020cn124
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Affiliation(s)
- Aiping Wang
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Guozhong Lv
- Department of Burn and Plastic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214062, China
| | - Xingbo Cheng
- Department of endocrinology, the First Affiliated Hospital of Suzhou University, Suzhou, 215006, China
| | - Xianghua Ma
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China.,Department of endocrinology, Xuzhou Central Hospital, Xuzhou, 221009,China
| | - Wei Wang
- Vascular Surgery, Gulou Hospital, Nanjing, 210008, China
| | - Jianchao Gui
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Ji Hu
- Department of endocrinology, The Second Affiliated Hospital of Suzhou University, Suzhou, 215004, China
| | - Meng Lu
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Guoping Chu
- Department of Burn and Plastic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214062, China
| | - Jin'an Chen
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Hao Zhang
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Yiqiu Jiang
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Yuedong Chen
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Wengbo Yang
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Lin Jiang
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Houfa Geng
- Department of endocrinology, Xuzhou Central Hospital, Xuzhou, 221009,China
| | - Rendong Zheng
- Department of endocrinology, Jiangsu Province Hospital on Traditional of Chinese and Western Medicine, 210028, China
| | - Yihui Li
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Wei Feng
- Operating department, Jiangsu Medical Association, Nanjing, 210008, China
| | - Boey Johnson
- Diabetic Foot Centre, The National University Hospital, 119077, Singapore
| | - Wenjuan Wang
- Department of Chronic Non-Communicable Diseases, Chinese Center for Disease Control and Prevention, Beijing, 102206, China
| | - Dalong Zhu
- Vascular Surgery, Gulou Hospital, Nanjing, 210008, China
| | - Yin Hu
- Operating department, Jiangsu Medical Association, Nanjing, 210008, China
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Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study. Endocr Regul 2020; 54:207-216. [PMID: 32857716 DOI: 10.2478/enr-2020-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU. METHODS The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing. RESULTS The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004-0.332). This was followed by PAD (OR 0.093; 95% CI 0.028-0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030-0.395), anemia (OR 0.179; 95% CI 0.056-0.571). CONCLUSION Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.
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Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss. J Vasc Surg 2020; 71:2073-2080.e1. [DOI: 10.1016/j.jvs.2019.07.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 07/29/2019] [Indexed: 11/15/2022]
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Mills JL. The impact of organized multidisciplinary care on limb salvage in patients with mild to moderate WIfI ischemia grades. J Vasc Surg 2020; 71:2081-2082. [PMID: 32446513 DOI: 10.1016/j.jvs.2019.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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Cerqueira LDO, Duarte EG, Barros ALDS, Cerqueira JR, de Araújo WJB. WIfI classification: the Society for Vascular Surgery lower extremity threatened limb classification system, a literature review. J Vasc Bras 2020; 19:e20190070. [PMID: 34178056 PMCID: PMC8202158 DOI: 10.1590/1677-5449.190070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The Society for Vascular Surgery has proposed a new classification system for the threatened lower limb, based on the three main factors that have an impact on limb amputation risk: Wound (W), Ischemia (I) and foot Infection ("fI") - the WIfI classification. The system also covers diabetic patients, previously excluded from the concept of critical limb ischemia because of their complex clinical condition. The classification's purpose is to provide accurate and early risk stratification for patients with threatened lower limbs; assisting with clinical management, enabling comparison of alternative therapies; and predicting risk of amputation at 1 year and the need for limb revascularization. The objective of this study is to collect together the main points about the WIfI classification that have been discussed in the scientific literature. Most of the studies conducted for validation of this classification system prove its association with factors related to limb salvage, such as amputation rates, amputation-free survival, prediction of reintervention, amputation, and stenosis (RAS) events, and wound healing.
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Affiliation(s)
| | - Eliud Garcia Duarte
- Universidade Vila Velha - UVV, Cirurgia Vascular, Vila Velha, ES, Brasil.,Centro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético - PROPÉ, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.,Hospital Estadual de Urgência e Emergência do Espírito Santo - HEUE, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.,Hospital Santa Mônica de Vila Velha, Serviço de Cirurgia Vascular e Endovascular, Vila Velha, ES, Brasil
| | - André Luis de Souza Barros
- Universidade Vila Velha - UVV, Cirurgia Vascular, Vila Velha, ES, Brasil.,Centro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético - PROPÉ, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil
| | - José Roberto Cerqueira
- Hospital Santa Mônica de Vila Velha, Serviço de Cirurgia Vascular e Endovascular, Vila Velha, ES, Brasil
| | - Walter Júnior Boim de Araújo
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Serviço de Angiorradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.,Hospital Angelina Caron, Departamento de Residência Médica em Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3277. [PMID: 32176448 DOI: 10.1002/dmrr.3277] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023]
Abstract
The accurate identification of peripheral artery disease (PAD) in patients with diabetes and foot ulceration is important, in order to inform timely management and to plan intervention including revascularisation. A variety of non-invasive tests are available to diagnose PAD at the bedside, but there is no consensus as to the most useful test, or the accuracy of these bedside investigations when compared to reference imaging tests such as magnetic resonance angiography, computed tomography angiography, digital subtraction angiography or colour duplex ultrasound. Members of the International Working Group of the Diabetic Foot updated our previous systematic review, to include all eligible studies published between 1980 and 2018. Some 15 380 titles were screened, resulting in 15 eligible studies (comprising 1563 patients, of which >80% in each study had diabetes) that evaluated an index bedside test for PAD against a reference imaging test. The primary endpoints were positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We found that the most commonly evaluated test parameter was ankle brachial index (ABI) <0.9, which may be useful to suggest the presence of PAD (PLR 6.5) but an ABI value between 0.9 and 1.3 does not rule out PAD (NLR 0.31). A toe brachial index >0.75 makes the diagnosis of PAD less likely (NLR 0.14-0.24), whereas pulse oximetry may be used to suggest the presence of PAD (if toe saturation < 2% lower than finger saturation; PLR 17.23-30) or render PAD less likely (NLR 0.2-0.27). We found that the presence of triphasic tibial waveforms has the best performance value for excluding a diagnosis of PAD (NLR 0.09-0.28), but was evaluated in only two studies. In addition, we found that beside clinical examination (including palpation of foot pulses) cannot reliably exclude PAD (NLR 0.75), as evaluated in one study. Overall, the quality of data is generally poor and there is insufficient evidence to recommend one bedside test over another. While there have been six additional publications in the last 4 years that met our inclusion criteria, more robust evidence is required to achieve consensus on the most useful non-invasive bedside test to diagnose PAD.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation, University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki University Hospital, Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Seattle, Washington
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Kehagias E, Ioannou CV, Bouloukaki I, Papadaki E, Galanakis N, Kontopodis N, Tsetis D. Feasibility of ischemic leg ulcer healing using percutaneous techniques: a real-life study. Acta Radiol 2020; 61:353-360. [PMID: 31319687 DOI: 10.1177/0284185119862955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Percutaneous transluminal angioplasty is established as the first-line vascular procedure in patients with lower extremity artery disease. Purpose We aimed to evaluate the technical and clinical effectiveness of percutaneous transluminal angioplasty in the management of ischemic foot ulcers. Material and Methods All consecutive patients presenting with a foot ulcer at the outpatient vascular surgery clinic of our hospital between June 2009 and June 2015 were evaluated using foot pulse assessment, ankle-brachial index, and duplex scanning. If non-invasive parameters suggested lower extremity artery disease, CT angiography and/or digital subtraction angiography were performed and a percutaneous transluminal angioplasty was carried out when feasible during the same session. All patients were followed until healing, amputation, death, or for at least two years. Short- and long-term clinical success was evaluated based on ulcer size and appearance. Patients with worsening ulcers after percutaneous transluminal angioplasty underwent bypass grafting or amputation. Results Percutaneous transluminal angioplasty was performed in 161 patients (100%) with stenoses > 50%, including cases lesions > 10 cm and/or multiple/calcified lesions, 144 of which completed the study. In 88 (61.2%) patients, percutaneous transluminal angioplasty was performed in the suprapopliteal axis exclusively, in 10 (6.8%) patients in the infrapopliteal axis only, and in 46 (31.9%) in both levels. Percutaneous transluminal angioplasty was technically successful in 141 (98%) patients. After 3.1 years, the rate of healing was 68%, limb salvage 88%, overall survival 69.5%, and amputation-free survival 64%. Conclusion Our data suggest that percutaneous transluminal angioplasty for ischemic foot ulceration treatment is in the majority of patients feasible, effective, and safe with high rates of healing and limb salvage.
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Affiliation(s)
- Elias Kehagias
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Izolde Bouloukaki
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Evangelia Papadaki
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3278. [PMID: 32176442 DOI: 10.1002/dmrr.3278] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 11/10/2022]
Abstract
Clinical outcomes of patients with diabetes, foot ulceration, and peripheral artery disease (PAD) are difficult to predict. The prediction of important clinical outcomes, such as wound healing and major amputation, would be a valuable tool to help guide management and target interventions for limb salvage. Despite the existence of a number of classification tools, no consensus exists as to the most useful bedside tests with which to predict outcome. We here present an updated systematic review from the International Working Group of the Diabetic Foot, comprising 15 studies published between 1980 and 2018 describing almost 6800 patients with diabetes and foot ulceration. Clinical examination findings as well as six non-invasive bedside tests were evaluated for their ability to predict wound healing and amputation. The most useful tests to inform on the probability of healing were skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO2 ≥ 25 mmHg. With these thresholds, all of these tests increased the probability of healing by greater than 25% in at least one study. To predict major amputation, the most useful tests were ankle pressure < 50 mmHg, ABI < 0.5, toe pressure < 30 mmHg, and TcPO2 < 25 mmHg, which increased the probability of major amputation by greater than 25%. These indicative values may be used as a guide when deciding which patients are at highest risk for poor outcomes and should therefore be evaluated for revascularization at an early stage. However, this should always be considered within the wider context of important co-existing factors such as infection, wound characteristics, and other comorbidities.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
| | - Konstantinos Katsanos
- Department of Interventional Radiology, Patras University Hospital School of Medicine, Patras, Greece
| | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Department of Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Boyko EJ. How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3241. [PMID: 31845475 DOI: 10.1002/dmrr.3241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Abstract
Assessment of ischaemia and interventions to improve perfusion are key elements in the management of the diabetic foot ulcer to achieve wound healing. This article will review, analyse and interpret the value of clinical information in determining the likelihood of limb ischaemia and thereby the need for referral to a vascular specialist. I conducted an historical review of the genesis of several currently recommended clinical signs and their diagnostic properties in the assessment of limb ischaemia. Changes in limb ischaemia probability based on such results were calculated using Bayes theorem, and the use of such probabilities is discussed in the context of the threshold approach to clinical decision making. Some clinical signs have negligible value in altering probability of limb ischaemia, possibly because they were advocated by Buerger for the diagnosis of thromboangiitis obliterans, an occlusive vascular disease of a different pathophysiology than atherosclerosis. Pedal pulse palpation, the most widely studied clinical sign, will marginally change a pre-test probability of ischaemia of 50% to 76% if positive (abnormal pulses) and to 36% if negative (normal pulses). Higher or lower pre-test probabilities of ischaemia will change the post-test probabilities such that these are too low or high to rule in or rule out ischaemia, respectively. Individual clinical signs convey little information regarding the presence of limb ischaemia but may have some value in combination or with pre-test probability near 50% in the assessment of ischaemia and the decision to refer for a vascular consultation.
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Affiliation(s)
- Edward J Boyko
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3276. [PMID: 31958217 DOI: 10.1002/dmrr.3276] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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Affiliation(s)
| | - Rachael O Forsythe
- British Heart Foundation/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, AZ
| | - Sigrid Nikol
- Department of Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Hinchliffe RJ, Schaper NC. Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3279. [PMID: 32176439 DOI: 10.1002/dmrr.3279] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/16/2022]
Abstract
In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13 000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2 years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30 days, 10% vs 9% at 1 year and 13% vs 9% at 2 years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30 day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2 years and 47% (39-71%) at 5 years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre-Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Department of Veterans Affairs, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon P Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Washington, Seattle
| | | | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Gabel JA, Bianchi C, Possagnoli I, Oyoyo UE, Teruya TH, Kiang SC, Abou-Zamzam AM, Bishop V, Eastridge D. A conservative approach to select patients with ischemic wounds is safe and effective in the setting of deferred revascularization. J Vasc Surg 2020; 71:1286-1295. [PMID: 32085957 DOI: 10.1016/j.jvs.2019.06.199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 06/19/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The Wound, Ischemia, and foot Infection classification system has been validated to predict benefit from inmediate revascularization and major amputation risk among patients with peripheral arterial disease. Our primary goal was to evaluate wound healing, limb salvage, and survival among patients with ischemic wounds undergoing revascularization when intervention was deferred by a trial of conservative wound therapy. METHODS All patients with peripheral arterial disease and tissue loss are prospectively enrolled into our Prevention of Amputation in Veterans Everywhere limb preservation program. Limbs are stratified into a validated pathway of care based on predetermined criteria (immediate revascularization, conservative treatment, primary amputation, and palliative care). Limbs allocated to the conservative strategy that failed to demonstrate adequate wound healing and were candidates, underwent deferred revascularization. Rates of wound healing, freedom from major amputation, and survival were compared between patients who underwent deferred revascularization with those who received immediate revascularization by univariate and multivariate analysis. RESULTS Between January 2008 and December 2017, 855 limbs were prospectively enrolled into the Prevention of Amputation in Veterans Everywhere program. A total of 203 limbs underwent immediate revascularization. Of 236 limbs stratified to a conservative approach, 185 (78.4%) healed and 33 (14.0%) underwent deferred revascularization (mean, 2.7 ± 2.6 months). The mean long-term follow-up was 51.7 ± 37.0 months. Deferred compared with immediate revascularization demonstrated similar rates of wound healing (66.7% vs 57.6%; P = .33), freedom from major amputation (81.8% vs 74.9%; P = .39), and survival (54.5% vs 50.7%; P = .69). After adjustment for overall Wound, Ischemia, and foot Infection stratification stages, deferred revascularization remained similar to immediate revascularization for wound healing (hazard ratio [HR], 1.5; 95% confidence interval [CI], 0.7-3.2), freedom from major amputation (HR, 0.7; 95% CI, 0.3-1.7) and survival (HR, 1.2; 95% CI, 0.6-2.4). CONCLUSIONS Limbs with mild to moderate ischemia that fail a trial of conservative wound therapy and undergo deferred revascularization achieve similar rates of wound healing, limb salvage, and survival compared with limbs undergoing immediate revascularization. A stratified approach to critical limb ischemia is safe and can avoid unnecessary procedures in selected patients.
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Affiliation(s)
- Joshua A Gabel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, Calif
| | - Christian Bianchi
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, Calif; Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif.
| | - Isabella Possagnoli
- Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif
| | - Udochukwu E Oyoyo
- Department of Radiology, Loma Linda University Health, Loma Linda, Calif
| | - Theodore H Teruya
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, Calif; Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif
| | - Sharon C Kiang
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, Calif; Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif
| | - Ahmed M Abou-Zamzam
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, Calif
| | - Vicki Bishop
- Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif
| | - Diana Eastridge
- Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, Calif
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Zhang S, Wang S, Xu L, He Y, Xiang J, Tang Z. Clinical Outcomes of Transmetatarsal Amputation in Patients with Diabetic Foot Ulcers Treated without Revascularization. Diabetes Ther 2019; 10:1465-1472. [PMID: 31243732 PMCID: PMC6612342 DOI: 10.1007/s13300-019-0653-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Most studies on outcomes of transmetatarsal amputation (TMA) have been for patients who underwent revascularization. This study was performed to evaluate the outcomes of TMA in diabetic patients without revascularization. METHODS One hundred two diabetic patients who were not candidates for revascularization underwent TMA and received a multidisciplinary treatment. These patients were followed up for a mean period of 38 months to observe the outcomes, including wound healing, above-the-ankle amputation and death. The associations between variables and the outcomes were analyzed by Cox regression analysis. RESULTS By the end of the follow-up, 97 patients with full data were analyzed. Sixty-three (64.9%) patients had wounds healed completely after a median interval of 8 months, 16 (16.5%) patients underwent above-the-ankle amputation, and 26 (26.8%) died. Cox regression analysis showed that patients with higher ABI (RR = 3.097, 95% CI: 1.587-6.043) and serum albumin (RR = 2.755, 95% CI: 1.335-5.687) exhibited a higher probability of wound healing. CONCLUSIONS Diabetic patients who were not candidates for revascularization who underwent TMA could achieve a satisfactory wound healing rate with a multidisciplinary treatment. ABI and serum albumin were significant predictors of wound healing.
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Affiliation(s)
- Shanshan Zhang
- Department of Endocrine and Metabolic Diseases, Shengli Oilfield Central Hospital, Dongying, 257034, China
| | - Shumin Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Lei Xu
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yang He
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Jiali Xiang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Zhengyi Tang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
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Mennes OA, van Netten JJ, van Baal JG, Steenbergen W. Assessment of microcirculation in the diabetic foot with laser speckle contrast imaging. Physiol Meas 2019; 40:065002. [DOI: 10.1088/1361-6579/ab2058] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 756] [Impact Index Per Article: 151.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 719] [Impact Index Per Article: 143.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Nattero-Chávez L, Redondo López S, Alonso Díaz S, Garnica Ureña M, Fernández-Durán E, Escobar-Morreale HF, Luque-Ramírez M. The peripheral atherosclerotic profile in patients with type 1 diabetes warrants a thorough vascular assessment of asymptomatic patients. Diabetes Metab Res Rev 2019; 35:e3088. [PMID: 30338903 DOI: 10.1002/dmrr.3088] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 01/22/2023]
Abstract
AIMS Epidemiological data on subclinical atherosclerotic disease in type 1 diabetes mellitus (DM1) are scarce. We aimed to estimate the subclinical atherosclerosis profile of asymptomatic patients with DM1 and an abnormal ankle-brachial index (ABI). MATERIAL AND METHODS In a cross-sectional design (ClinicalTrials.gov Identifier: NCT02910271), we estimated ABI in 289 consecutive asymptomatic patients with DM1. An abnormal ABI led to measurements of toe-brachial index (TBI) and peripheral doppler ultrasound (DUS) to diagnose peripheral artery disease (PAD) and/or atherosclerotic carotid plaques (ACP). RESULTS A reduced (≤0.9) or increased (>1.2) ABI was detected in 17 (6%) and 75 (26%) patients, respectively. PAD was confirmed by TBI and DUS in 9 (53%) patients with a reduced ABI and 28 (37%) patients with an increased ABI, resulting in a 12.8% (9.4-17.2) prevalence of asymptomatic PAD. Fourteen patients with an abnormal ABI also exhibited ACP [4.8% (2.9-7.9)], with 64% of these patients showing bilateral disease. Artery stenosis was mild or moderate in 21% and 29% of patients, respectively. Thus, 46 [16% (12-21)] patients showed asymptomatic PAD, ACP, or both. According to our data, we would have to explore three asymptomatic patients with DM1 and normal pulses to unmask one case of PAD, and seven asymptomatic patients showing abnormal ABI values to detect one carotid disease. CONCLUSIONS Peripheral artery disease is often undiagnosed in asymptomatic patients with DM1. However, its presence may change medical management in a substantial percentage of cases, highlighting the potential benefit of a thorough vascular assessment on these patients.
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Affiliation(s)
- Lía Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain
| | - Sandra Redondo López
- Department of Vascular Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sara Alonso Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Marta Garnica Ureña
- Department of Vascular Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Elena Fernández-Durán
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain
- University of Alcalá, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain
- University of Alcalá, Spain
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Liu C, You JX, Chen YX, Zhu WF, Wang Y, Lv PP, Zhao F, Li HY, Li L. Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible. J Diabetes Res 2019; 2019:2429136. [PMID: 31828156 PMCID: PMC6885796 DOI: 10.1155/2019/2429136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/22/2019] [Indexed: 01/04/2023] Open
Abstract
No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ 2 or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = -2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.
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Affiliation(s)
- Chao Liu
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Jia-Xing You
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Yi-Xin Chen
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Wei-Fen Zhu
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Ying Wang
- Wound and Ostomy Care Clinic, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Pan-Pan Lv
- Department of Ultrasound, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Feng Zhao
- Department of Clinical Laboratory, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Hong-Ye Li
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Lin Li
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
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