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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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2
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Tanaka R, Fujimura S, Kado M, Fukuta T, Arita K, Hirano-Ito R, Mita T, Watada H, Kato Y, Miyauchi K, Mizuno H. Phase I/IIa Feasibility Trial of Autologous Quality- and Quantity-Cultured Peripheral Blood Mononuclear Cell Therapy for Non-Healing Extremity Ulcers. Stem Cells Transl Med 2022; 11:146-158. [PMID: 35298656 PMCID: PMC8929435 DOI: 10.1093/stcltm/szab018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022] Open
Abstract
Non-healing wounds are among the main causes of morbidity and mortality. We recently described a novel, serum-free ex vivo expansion system, the quantity and quality culture system (QQc), which uses peripheral blood mononuclear cells (PBMNCs) for effective and noninvasive regeneration of tissue and vasculature in murine and porcine models. In this prospective clinical study, we investigated the safety and efficacy of QQ-cultured peripheral blood mononuclear cell (MNC-QQ) therapy for chronic non-healing ischemic extremity wounds. Peripheral blood was collected from 9 patients with 10 chronic (>1 month) non-healing wounds (8 males, 1 female; 64-74 years) corresponding to ischemic extremity ulcers. PBMNCs were isolated and cultured using QQc. Within a 20-cm area surrounding the ulcer, 2 × 107 cells were injected under local anesthesia. Wound healing was monitored photometrically every 2 weeks. The primary endpoint was safety, whereas the secondary endpoint was efficacy at 12-week post-injection. All patients remained ambulant, and no deaths, other serious adverse events, or major amputations were observed for 12 weeks after cell transplantation. Six of the 10 cases showed complete wound closure with an average wound closure rate of 73.2% ± 40.1% at 12 weeks. MNC-QQ therapy increased vascular perfusion, skin perfusion pressure, and decreased pain intensity in all patients. These results indicate the feasibility and safety of MNC-QQ therapy in patients with chronic non-healing ischemic extremity wounds. As the therapy involves transplanting highly vasculogenic cells obtained from a small blood sample, it may be an effective and highly vasculogenic strategy for limb salvage.
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Affiliation(s)
- Rica Tanaka
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Intractable Disease Research Center, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Fujimura
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Intractable Disease Research Center, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makiko Kado
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Taro Fukuta
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kayo Arita
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Intractable Disease Research Center, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Rie Hirano-Ito
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Center for Genomic and Regenerative Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomoya Mita
- Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hirotaka Watada
- Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoshiteru Kato
- Department of Internal Medicine, Division of Cardiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Katsumi Miyauchi
- Department of Internal Medicine, Division of Cardiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Mizuno
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Intractable Disease Research Center, Juntendo University Graduate School of Medicine, Tokyo, Japan
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3
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Meloni M, Giurato L, Panunzi A, Bellia A, Bohbot S, Lauro D, Uccioli L. Effectiveness of Sucrose Octasulfate Dressing in the Treatment of Neuro-Ischaemic Diabetic Foot Heel Ulcers: A Retrospective Single arm Study. INT J LOW EXTR WOUND 2022:15347346221087499. [PMID: 35287510 DOI: 10.1177/15347346221087499] [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: 11/17/2022]
Abstract
The study aimed to evaluate the effectiveness of the use of sucrose octasulfate impregnated dressing (TLC-NOSF [Technology Lipido-Colloid-Nano-OligoSaccharide Factor]) in the management of persons with neuro-ischaemic heel diabetic foot ulcers (DFUs). Consecutive patients who referred for an active non-infected neuro-ischaemic heel DFU belonging to grade IC (superficial) or IIC (deep to tendons, muscle or capsule) according to Texas University Classification were included. All patients were managed by a pre-set limb salvage protocol in the respect of International guidelines and the TLC-NOSF dressing was used as primary and specific dressing. Patients were evaluated any 2 to 4 weeks until wound healing or different outcomes. Primary outcome was the rate of complete wound healing after 24 weeks of follow-up. The secondary outcomes assessed the healing time, the rate of wound regression, the re-ulceration in the case of complete healing and the safety. Thirty patients were included. The mean age was 67 ± 11 years, 17 (56.7%) were male, all of them were affected by type 2 diabetes with a mean duration of 18 ± 7 years. Twenty patients (66.7%) showed deep ulcers (grade 2 of Texas University Classification); the mean TcPO2 at the inclusion was 42 ± 7 mm Hg. Twenty-two patients (73.3%) healed by Week 24. The mean time of healing was 84 ± 32 days, 2 (6.7%) patients had ulcer relapse after healing, 28 (93.3%) had wound regression >50%, 2 (6.7%) had mild infection, 1 (3.3%) reported major amputation. No serious adverse events related to TLC-NOSF dressing or local reactions were reported. This current study showed the potential benefit of sucrose octasulfate for treating neuro-ischaemic heel DFUs in addition to the standard of care.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Andrea Panunzi
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | | | - Davide Lauro
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
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4
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Biscetti F, Cecchini AL, Rando MM, Nardella E, Gasbarrini A, Massetti M, Flex A. Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review. ATHEROSCLEROSIS PLUS 2021; 46:1-14. [PMID: 36643723 PMCID: PMC9833249 DOI: 10.1016/j.athplu.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/10/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Abstract
Background and aims The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease. Methods Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors. Results In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease. Conclusion We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.
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Affiliation(s)
- Federico Biscetti
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy,Corresponding author. Internal and Cardiovascular Medicine Unit. Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | | | - Maria Margherita Rando
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elisabetta Nardella
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Flex
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
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Lilja E, Gottsäter A, Miftaraj M, Ekelund J, Eliasson B, Svensson AM, Zarrouk M, Acosta S. Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia - A nationwide propensity score adjusted analysis. Vasc Med 2021; 26:507-514. [PMID: 34004125 PMCID: PMC8493412 DOI: 10.1177/1358863x211008249] [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] [Indexed: 11/17/2022]
Abstract
The risk of major amputation is higher after urgently planned endovascular
therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes
mellitus (DM). The aim of this nationwide cohort study was to compare outcomes
between patients with and without DM following urgently planned open
revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered
in the Swedish Vascular Registry, 569 were registered in the National Diabetes
Register. A propensity score adjusted Cox regression analysis was conducted to
compare outcome between the groups with and without DM. Median follow-up was 4.3
years and 4.5 years for patients with and without DM, respectively. Patients
with DM more often had foot ulcers (p = 0.034) and had
undergone more previous amputations (p = 0.001) at baseline. No
differences in mortality, cardiovascular death, major adverse cardiovascular
events (MACE), or major amputation were observed between groups. The incidence
rate of stroke was 70% higher (95% CI: 1.11–2.59; p = 0.0137)
and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI:
1.00–1.92; p = 0.0472) among patients with DM in comparison to
those without. Open vascular surgery remains a first-line option for a
substantial number of patients with CLTI, especially for limb salvage in
patients with DM. The higher incidence rates of stroke and AMI among patients
with DM following open vascular surgery for infrainguinal CLTI require specific
consideration preoperatively with the aim of optimizing medical treatment to
improve cardiovascular outcome postoperatively.
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Affiliation(s)
- Erika Lilja
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Mervete Miftaraj
- Centre of Registers, National Diabetes Register, Göteborg, Sweden
| | - Jan Ekelund
- Centre of Registers, National Diabetes Register, Göteborg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Ann-Marie Svensson
- Centre of Registers, National Diabetes Register, Göteborg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
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6
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Lilja E, Gottsäter A, Miftaraj M, Ekelund J, Eliasson B, Svensson AM, Zarrouk M, Nilsson P, Acosta S. The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis. J Diabetes Complications 2021; 35:107675. [PMID: 32828647 DOI: 10.1016/j.jdiacomp.2020.107675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 01/13/2023]
Abstract
AIM To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM). METHODS In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively. RESULTS The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14). CONCLUSIONS Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.
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Affiliation(s)
- Erika Lilja
- Department of Clinical Sciences, Malmö, Lund University, Sweden.
| | - Anders Gottsäter
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Peter Nilsson
- Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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8
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Demarchi A, Somaschini A, Cornara S, Androulakis E. Peripheral Artery Disease in Diabetes Mellitus: Focus on Novel Treatment Options. Curr Pharm Des 2020; 26:5953-5968. [PMID: 33243109 DOI: 10.2174/1389201021666201126143217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/09/2020] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus (DM) and peripheral artery disease (PAD) are two clinical entities closely associated. They share many pathophysiological pathways such as inflammation, endothelial dysfunction, oxidative stress and pro-coagulative unbalance. Emerging data focusing on agents targeting these pathways may be promising. Moreover, due to the increased cardiovascular risk, there is a growing interest in cardiovascular and "pleiotropic" effects of novel glucose lowering drugs. This review summarizes the main clinical features of PAD in patients, the diagnostic process and current medical/interventional approaches, ranging from "classical treatment" to novel agents.
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Affiliation(s)
| | - Alberto Somaschini
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Emmanuel Androulakis
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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9
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Linn YL, Chan SL, Soon SXY, Yap CJQ, Lim MNHH, Lee QWS, Chong TT, Tang TY. Heal or no heel: Outcomes of ischaemic heel ulcers following lower limb revascularization from a multi-ethnic Asian Cohort in Singapore. Int Wound J 2020; 17:2010-2018. [PMID: 32840061 PMCID: PMC7949176 DOI: 10.1111/iwj.13493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 11/30/2022] Open
Abstract
Ischaemic diabetic heel ulcers are difficult to treat and prognosis is often guarded. The aim was to document our outcome of treating heel ulcers following revascularization in a predominantly diabetic Asian cohort presenting with chronic limb threatening ischaemia from Singapore. Retrospective cohort study (n = 66, 66 limbs) over a 5‐year period. Data were collected from hospital electronic health records. Outcomes included time to healing, amputation free survival (AFS), and mortality. Minimum follow‐up period was 6 months. Multivariate regression analysis was performed to look for factors associated with poor outcome. Mean age was 67.4 ± 8.8 years. 62/66 (93.9%) were diabetics. Mean wound size at presentation was 3.6 ± 2.3 cm. Mean Wound, Ischaemia, Foot Infection (WIFI) score was 5 ± 1.6. 12/66 (18%) patients had a patent posterior tibial artery pre‐operatively. Straight line flow was restored in only 31/66 (46.9) patients but 47/66 (71.2%) had successful limb salvage. Median time to wound healing was 90.0 (IQR 60‐180) days. A median of 1 (IQR 0‐2) wound debridement was required. Patients who underwent negative pressure dressing (23/66; 34.8%) required a median of 26 (IQR 13‐33) cycles to achieve healing. Amputation free survival (AFS) was 72% and 68% at 6‐ and 12‐months, respectively. Mortality rate was 16.7% and 19.7% at 6‐ and 12‐months, respectively. Low albumin level and initial Rutherford class were independent predictors of worse 6‐month AFS. Outcomes of heel ulcers post revascularisation may not be as poor as previously described. Persistent attention to wound care with multidisciplinary effort is needed for optimal healing.
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Affiliation(s)
- Yun Le Linn
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Sze Ling Chan
- Health Services Research Center, SingHealth, Singapore, Singapore
| | | | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | | | | | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore
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10
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Butt T, Lilja E, Elgzyri T, Apelqvist J, Gottsäter A, Engström G, Acosta S. Amputation-free survival in patients with diabetic foot ulcer and peripheral arterial disease: Endovascular versus open surgery in a propensity score adjusted analysis. J Diabetes Complications 2020; 34:107551. [PMID: 32061519 DOI: 10.1016/j.jdiacomp.2020.107551] [Citation(s) in RCA: 8] [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: 11/26/2019] [Revised: 01/16/2020] [Accepted: 01/24/2020] [Indexed: 12/27/2022]
Abstract
AIMS The aim of the present study was to compare outcomes of endovascular surgery versus open vascular surgery in patients with diabetic foot ulcer (DFU) and peripheral arterial disease (PAD). METHODS Between 1984 and 2006, 1151 patients with DFU were admitted to the diabetic foot care team. Three hundred seventy-six patients with 408 limbs were consecutively included at a multidisciplinary foot center, 289 limbs were treated with endovascular surgery and 119 limbs with open vascular surgery first strategy. A propensity score adjusted analysis was performed to compare outcomes for type of revascularization. RESULTS Major amputation rates at 3 years were 17.0% and 16.8% (p = 0.97) and mortality at 3 years were 43.1% and 46.5% (p = 0.55) after endovascular surgery and open vascular surgery, respectively. In the propensity score adjusted analysis, patients undergoing endovascular surgery first had similar outcomes in terms of major amputation, mortality, combined major amputation/mortality compared to those undergoing open vascular surgery. Longer time to intervention (p = 0.003) was associated with increased major amputation rate in the multivariable Cox regression analysis. CONCLUSION The endovascular surgery first and open vascular surgery first strategies were associated with similar long-term results in a large cohort of patients with DFU and PAD undergoing revascularization. Rapid revascularization reduces the risk of amputation.
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Affiliation(s)
- Talha Butt
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden.
| | - Erika Lilja
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden
| | - Targ Elgzyri
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden; Department of Endocrinology, Skåne University Hospital, Sweden
| | - Jan Apelqvist
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden; Department of Endocrinology, Skåne University Hospital, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
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11
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Giannopoulos S, Armstrong EJ. Diabetes mellitus: an important risk factor for peripheral vascular disease. Expert Rev Cardiovasc Ther 2020; 18:131-137. [PMID: 32129693 DOI: 10.1080/14779072.2020.1736562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Meloni M, Izzo V, Giurato L, Brocco E, Gandini R, Uccioli L. Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers. INT J LOW EXTR WOUND 2019; 19:275-281. [DOI: 10.1177/1534734619884438] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.
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