Current opinion on the role of the foot perfusion in limb amputation risk assessment

Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients

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.

Treatment of end-stage peripheral artery disease by Neuromodulation

BACKGROUND: Neuromodulation is a therapeutic option to improve limb salvage in end-stage peripheral arterial disease (PAD), but there is no consensus on indication for spinal cord stimulation (SCS) in PAD patients. OBJECTIVE: The aim of this study was to present end-stage PAD patient outcomes treated with SCS. METHODS: This study is a retrospective analysis based on a local prospective registry. Neuromodulation was performed there was: [1] no revascularisation option, [2) no septicaemia, [3) Rutherford stage 4–6. The primary endpoint of the study was limb salvage. Secondary endpoints were improvement in pain symptoms (assessed using a visual anlog scale/VAS) and improvement in walking distance. RESULTS: Limb salvage was reached in 30/34 patients (88%). Patients reported a significant reduction in pain on the 10-point VAS scale from baseline (median = 7.5, IQR = 7–8) to follow-up at 2 years (median = 0, IQR 0–2.75), p <  0.001. Walking distance also improved from preoperative (median = 50 m, IQR = 20–50 m) to follow-up at 2 years (median = 150 m, IQR 50–272 m), p <  0.001. RESULTS: SCS implantation in patients with end-stage PAD can enable limb salvage in a high percentage of cases and increase mobility due to pain reduction. The role of microcirculation in these improvements needs to be investigated in further studies.

The effect of rheopheresis treatment on the cytokine profile in diabetic foot syndrome with hyperviscosity in the aspect of clinical changes: A preliminary study

BACKGROUND

Rheopheresis is a selective extracorporal double cascade filtration treatment, which can extract high molecular weight proteins being responsible for hyperviscosity. As the whole blood and plasma viscosity decrease microcirculation improves.

OBJECTIVE

In this preliminary study we aimed to analyze additional beneficial effects of rheopheresis treatment with changes of pro-inflammantory cytokine levels in diabetic foot syndrome patients.

METHODS

Two rheopheresis treatments were performed for 6 patients with diabetic foot ulcer and/or neuropathy on consecutive days. Before and after the treatments whole blood and plasma viscosity, as well as IL-6, IL-8, and TNF-alpha serum levels were determined, and complex angiological and ENG examinations were performed.

RESULTS

Rheopheresis decreased the whole blood and plasma viscosity, and the serum levels of IL-6, IL-8, and TNF-alpha were markedly reduced. The life quality of the patients improved, the ulcers healed, the pain decreased. Daily dose of analgesics decreased in the follow-up period (6 months). The ENG showed improving amplitude and/or normalizing conduction speed.

CONCLUSION

Application of rheopheresis in patients with diabetic foot syndrome has a beneficial effect, providing favorable rheological condition, normalizing cytokine profile and reducing the sensorineural symptoms.