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Assessment and management of peripheral vascular disease in the diabetic patient. Francis Dix Consultant vascular and endovascular surgeon. Peripheral vascular disease with diabetes. diabetes team clinical effects of combined disease pathophysiology assessment treatment – cases.

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assessment and management of peripheral vascular disease in the diabetic patient

Assessment and management of peripheral vascular disease in the diabetic patient

Francis Dix

Consultant vascular and endovascular surgeon

peripheral vascular disease with diabetes
Peripheral vascular disease with diabetes
  • diabetes team
  • clinical effects of combined disease
  • pathophysiology
  • assessment
  • treatment – cases
multidisciplinary teamwork with holistic approach
Multidisciplinary teamwork with holistic approach

GP and community services

Hospital services

slide5
Diabetes may cause first fall in life expectancy for 200 yearsJeremy Laurance, health editor, The Independent October 2008

The World Health Organisation has predicted that deaths from diabetes

in Britain would rise from 33,000 a year in 2005 to 41,000 by 2015 but

Professor Alberti said that figure underestimated its true impact. More

than 80 per cent of sufferers die from heart attacks or strokes and more

than 1,000 a year suffer kidney failure requiring dialysis.

"The WHO figure [for deaths] was very conservative," he said. "Large

numbers die from heart disease and strokes [linked with diabetes] and

they do not include those.“

It costs the NHS £1m an hour to treat. One pound in every £10 spent

on the hospital service is for diabetes and its complications.

pvd in diabetics has a poor prognosis
PVD in diabetics has a poor prognosis
  • PVD is 20 x more common in diabetics than non diabetics
  • lower limb amputation is 15 x more common in diabetics
  • ten year cumulative incidence of lower limb amputation is 5.4% in

type I diabetes and 7.3% in type II

  • 10% of diabetics get an ulcer (10% are purely ischaemic, 45% are ischaemic with associated neuropathy, infection, biomechanical abnormalities and Charcot deformity)

Increased risk of CVD, CAD, nephropathy,

retinopathy and death

atherosclerosis in diabetes
Atherosclerosis in diabetes
  • same atherosclerosis - endothelial damage

- platelet aggregation

- lipid deposition

- plaque formation

  • same risk factors
  • distribution is different - mainly below knee disease

and profunda femoris artery disease

macrocirculation and microcirculation
Macrocirculation and microcirculation

Macrocirculation

- large vessel calcification

- atherosclerotic plaque

Microcirculation

- thickening of capillary basement membrane

- increased microvascular flow (hence warm foot)

- oedema secondary to impaired postural vasoconstriction

- increased metabolic requirement

- impaired ability to respond to trauma

- platelet degranulation increased

slide10
Assessment of the

peripheral circulation

assessment for pvd
Assessment for PVD
  • Clinical assessment
  • ABPI and waveform
  • Duplex
  • Angiography (CTA, MRA, catheter angiogram)
clinical assessment
Clinical assessment
  • symptoms and signs

may be obvious or subtle

- history of rest pain at night

- gangrene

  • colour

- white

- red (hyperaemic skin)

  • temperature

- cool

  • Pulses and ABPI
slide14
ABPI

Diabetes

treatment options
Treatment options
  • risk factor management and modification
  • training, education and counselling
  • wound debridement
  • angioplasty
  • vascular reconstruction
  • amputation
medical treatment
Medical treatment
  • good diabetic control
  • stop smoking
  • regular exercise
  • antiplatelets
  • statins
  • ACE inhibitor
surgery for the infected diabetic foot
Surgery for the infected diabetic foot
  • be aggressive
  • be thorough
  • don`t suture the wound
  • appropriate antibiotics
  • post-operative TNP
  • MRI?
  • regular wound review
vascular reconstruction
Vascular reconstruction
  • for salvageable limbs where angioplasty will fail (long occlusions, multiple stenoses)
  • use autologous vein where possible

The long-term results of the Bypass

versus Angioplasty in Severe

Ischaemia of the Leg (BASIL) trial

favour surgery rather than

angioplasty if there is a good vein

and the patient is fit. Some patients

with critical lower limb ischemia are

best treated by analgesia or primary

amputation

reconstruction
Reconstruction

similar long term outcomes of revascularisation in patients with and without diabetes

Karacagil S et al. Diabet Med 1995; 12: 537-541

amputation
Amputation
  • can be a very positive end point after months of hospitalisation and chronic ill health
  • don`t try to salvage unsalvageable limbs
  • level of amputation depends on degree of tissue disease, level of arterial occlusion and expected postoperative mobility (general health and motivation)
  • discuss the possibility of amputation as early as possible
diabetes and pvd
Diabetes and PVD
  • common but complications often preventable
  • holistic approach through multidisciplinary team
  • good community diabetic care
  • clinical assessment is easy (don`t worry about a high ABPI in the absence of symptoms)
  • early referral of symptomatic patients