Peripheral vascular

disease in diabetics
Dr. Hossam Hassan, MD, FRCS
NWAFH

PAD: A Call to Action

-

What is peripheral arterial disease

(PAD)? and why is it so dangerous?

Diagnosing PAD in the primary care

setting

The importance of aggressive risk

management of PAD

Evidence
base
patients with PAD

for

protecting

most commonly manifests in men older than

50 years

Atherosclerosis affects up to 10% of the

Western population older than 65 years
12.2% required amputation
Predicted mortality rates for patients with
claudication at 5, 10, and 15 years of follow-up
are approximately 30%, 50%, and 70%,
respectively.

The risk factors for PAOD

diabetes, hypertension, hyperlipidemia,
family history, sedentary lifestyle, and tobacco use

Smoking
Greatest of all the cardiovascular risk factors
Damage is directly related to the amount of used.
Counseling patients on the importance of smoking
cessation is paramount in management.

Diabetes
epidemic
Incidence of diabetes in the world in
2000 was 171,000,000
Projected incidence in 2030 is
366,000,000
In 2010, 12.3% of adults in the United
States had diabetes

Incidence by
Country

Society in
Transition

Cost in Developed
Countries
25% of diabetic patients develop a foot problem
in their lifetime
2008: estimated 20.8 million with DM in USA
Total of $19bn spent on diabetic foot ulcers
$11bn spent on amputation
Up to $21bn could be saved annually with
practical and effective preventative foot-care
education
Rogers et al, JAPMA, 2008;98:166

Cost in
Undeveloped
Countries

2010: estimated 51 million with DM in India

Population-based study from Chennai

Cost of illness study: 4677 subjects screened: 1050

with DM, 718 agreed to take part
Median direct cost for DM $526, indirect $103
Costs increased according to complications
Extrapolated to all India annual cost of Diabetes in
India US$32bn.
Tharkar et al, DRCP 2010;89:334

Metabolic syndrome is more common

in PAD than in CHD or stroke
Cross-Sectional survey of 1,045 vascular disease patients
60

57%
Prevalence
of metabolic 40
syndrome in
each patient
group (%)

40%

43%

45%

20

0
CHD

Olijhoek JK et al. Eur Heart J 2004; 25: 342-348.

Stroke

AAA
AAA = Abdominal Aortic Aneurysm

PAD

Prevalence of PAD increases

with age
San Diego Study (PAD by noninvasive tests)2

Patients with PAD (%)

Rotterdam Study (ABI Test <0.9)1

Figure adapted from Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000.
1 Meijer WT et al. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.
2.Criqui MH et al. Circulation 1985; 71: 510-515.

Mortality is very high in patients with

severe PAD

Patients (%)

Relative 5-year mortality

50
45
40
35
30
25
20
15
10
5
0

3
8

4
4

4
8

15

Breast
cancer1

Colon/rectal
cancer1

Severe
PAD2

1. Criqui MH. Vasc Med 2001; 6 (suppl 1): 37.

2. McKenna M et al.
al. Atherosclerosis 1991; 87:
87: 11928.
3. Ries LAG et al.
.
(eds).
SEER
Cancer
Statistics
Review,
al
Review, 19731997. US: National Cancer Institute; 2000.

Non-Hodgkins
lymphoma3

There is a strong two-way

association between decreased
ABI and increased risk for
70
1
cardiovascular
death
60
All-cause mortality

Percent

50

CVD Mortality

40
30
20
10
0
.6
<0

(n

)
25

6
0.

7
0.
<
-

21
=
(n
7
0.

.8
0
-<

=
(n

8
0.

)
40

9
0.
<
-

)
30
1
n=
9
0.

1.
-<

95
1
n=
0
1.

1
1.
<
-

Baseline ABI*
Resnick HE et al. Circulation 2004; 109: 733-739.

*Mean participant follow-up 8.3 years

(n

0)
8
9

Only 1 in 10 patients with

PAD has classical symptoms
of intermittent claudication
1 in 5 people over 65

has PAD

Only 1 in 10 of these
patients has classical
symptoms of intermittent
claudication (IC)

ABI<0.9

Diehm C et al. Atherosclerosis 2004; 172; 95-105.

Association recommends
screening for PAD in patients with
diabetes
A screening ABI should be performed in patients with diabetes

Those >50 years of age

If normal an exercise
test should be
carried out
The ABI test
should be repeated
every 5 years

Those <50 years of age who

have other risk factors
associated with PAD
Smoking
Hypertension
Hyperlipidaemia
Duration of diabetes
>10 years

Foot care is also important in diabetic patients as PAD is

a major contributor to diabetic foot problems2

1. American Diabetes Association. Diabetes Care 2003; 26: 3333-3341.

2. Estes JM, Pomposelli FB Jr. Diabet Med 1996: 13: S43- S57.

Risk factor management

approach
Smoking cessation
Weight reduction
Total cholesterol <175 mg/dL / <4.5 mmol/L
LDL cholesterol <100 mg/dL / <2.6 mmol/L
Glycosylated haemoglobin <7.0%
Blood pressure (BP) <140/90 mm Hg

For patients with diabetes BP < 130/80mm Hg

Platelet inhibition

Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

Key learning points

REMEMBER
Only 1 in 10 patients with
PAD have typical
claudication1
Patients with diabetes are
at high risk of PAD
It is important to improve
the management of PAD to
protect patients from an
increased risk of ischaemic
events

1. Diehm C et al. Atherosclerosis 2004; 172: 95-105.

ACTION
Ensure aggressive and early
risk management of patients
who are at high risk but may
be asymptomatic
Screen patients with diabetes
>50 years of age, and those
<50 years of age who have
additional risk factors
associated with PAD

Diabetic Foot
Ulcers
63% of all diabetic ulcers are due to a
combination of:
Neuropathy
Trauma
Deformity

Many are further complicated by

Peripheral Arterial Disease (PAD) and
infection

How do we screen
patients?
Comprehensive foot exam
HgA1C
History reviewing risk factor

Development of
Ulcers
Typically painless, even with severe
infection
Often just report soiled socks

A diabetic foot ulcer

should heal if:
There is adequate arterial inflow
Any infection is appropriately managed
Pressure is removed from the wound and its
margins

Diabetic Lower Extremity

Ulcers
Cascade of Events:
Neuropathy
Ischemic changes
Injury
Massive tissue disruption
(tunneling, undermining, cavity formation)

Cellular dysfunction leukocytes /

macrophages
Infection

Neuropathy
Incorporates metabolic and vascular
defects
Results in neuronal demyelination and
atrophy

Motor muscle atrophy

Autonomic decrease in perspiration
Sensory loss of protective sensation

Structural
Deformity
Leads for focal area of high pressure
Due to atrophy of the intrinsic
musculature responsible for stabilizing
the toes

Trauma Resulting from

Neuropathic Changes
Motor neuropathy
Altered gait and foot
deformities

Autonomic neuropathy
Dry skin and fissures

Sensory neuropathy
Unrecognized trauma
Ill fitting shoes
Stepping on pins,
pebbles, etc

Deformity Resulting from

Neuropathic Changes
Cause high compressive
& frictional forces
around area of deformity
= skin breakdown
Directly related to ill
fitting footwear

Prevention in
Patients with
Neuropathy
Need to screen patient for
neuropathy

Test with Semmes-Weinstein

Monofilament

Uses touch pressure sensation by

utilizing a 10 gram monofilament
Defines level of loss-of-protective
sensation
Failed monofilament test defined as
inability to sense 4 of 10 locations per
plantar aspect of the foot

Peripheral
Arterial Disease
Diabetes Mellitus increases the risk of lower
extremity PAD
PAD leads to additional healing complications
and increased risk for infection
One in three patients with diabetes over the age
of 50 has PAD
The American Diabetes Association recommends
screening for PAD in all diabetic patients older
than 50 years

Clinical
classification

Claudication, defined as reproducible ischemic

muscle pain relieved with rest , is one of the
most common manifestations of peripheral
vascular disease

Ulcer on the toes, web spaces

Ischemic gangrenes of the toes, web

spaces,

General Physical Examination

Atrophy of calf muscles, loss of extremity hair,
and thickened toenails are clues to underlying
peripheral arterial occlusive disease (PAOD).

Pulses
Palpation of pulses from the abdominal aorta to the foot,
Auscultation for bruits in the abdominal and pelvic regions
Absence of a pulse signifies arterial obstruction proximal
to the area palpated.

Screening for PAD

When pulses are not present, further assessment of

with a handheld Doppler device.
An audible Doppler signal assures some blood flow
No Doppler signals, a vascular surgeon should be
immediately consulted

Ankle-brachial index (ABI),

ratio of systolic blood pressure at the ankle to the arm.

Ankle-Brachial
Index

Duplex ultrasound scanning

Contrast
Angiography

Despite
recent
advances in the noninvasive evaluation of
lower extremity PAD,
contrast angiography
remains
the
gold
standard.
Vasc Endovascular Surg. 2002;36:439445

Angiography

Angiography

Conservative medical management

Risk factors modification

(strict control of HTN, DM and
Lipids)

Smoking cessation counselling

Exercise Program is the most effective

Exercise pyramid for Healthy life

Pharmacological therapy (Aspirin, clopidogril, pentoxfylline)

Physician
Responsibilities
Inspect patients shoes for areas of
inadequate support or improper
Most patients are okay with athletic
shoes and thick absorbent socks
Patients with deformities or special
support needs benefit from custom shoes
Provide education about proper care and
follow up
Control blood sugars

Patient Education
Daily foot inspection by the patient or
caregiver
Gentle cleansing with soap and water,
followed by topical moisturizers
Minor foot injuries and infections can be
unintentionally exacerbated by home
remedies that impede healing
Avoid hot soaks, heating pads, hydrogen
peroxide, betadine
Cleanse minor wound and apply topical
antibiotic to maintain a moist wound
environment

How Should Diabetic

Foot Ulcers Be
Treated?
Multidisciplinary Approach to Treatment
May involve a number of the following:
General surgery
Vascular surgery
Dieticians
Infectious disease
Endocrinology
Diabetes Educators
Radiology
Physical Therapy
Orthotist
Nursing

Care Plan Objectives

Determine and Manage Etiologies
Comprehensive History and Physical
Assessment
Non-invasive studies
Management of etiologies

Laboratory Evaluation

Nutrition status
Glucose control
Co-morbid disease management

Ulcer management
Off-loading
Patient Education

Determine and Manage

Etiologies
History and Physical
Patient and their family medical history
History of the ulcer
Thorough assessment of the patient

Lower Extremity Assessment

Semmes Weinstein and Tuning Fork Assesses for neuropathy
Hand-held Doppler - Dorsalis pedis and
posterior tibial pulse signals

Non-invasive studies
Vascular studies
Radiographic studies

Vascular Studies
Transcutaneous Oximetry (TcPO2) measures the
oxygenation of the tissues around the ulcer
Skin Perfusion Pressure (SPP) - measures the
pressure at which blood flow first returns to the
capillaries following a controlled release of
occlusion from a blood pressure cuff.
Arterial Duplex Ultrasound - Duplex
ultrasonography of the arteries
Ankle-Brachial Index (ABI)/Segmental
Pressures/Toe Pressures - Assess pressure at
multiple levels on the limb or digit
Angiography invasive study providing detailed
imaging of the arteries

Radiographic
Studies
X-ray should be performed on all diabetic
foot ulcerations to rule out foreign body
presence

MRI recommended by ADA as best noninvasive diagnostic imaging for osteomyelitis

Bone Biopsy - the definitive diagnostic study

for osteomyelitis allowing for culture and
sensitivity of the specimen

Management of
Etiologies
PAD and Osteomyelitis are two common
secondary etiologies affecting healing of the
diabetic ulcer
Both must be identified and
corrected/optimized for successful ulcer
healing to occur
Other etiologies also need to be identified and
corrected/optimized for successful ulcer
healing

Ulcer Management
Diagnose and treat underlying
etiologies
Adequate debridement
Dressing choice based on ulcer needs
Treatments that stimulate healing

Negative Pressure Wound Therapy (NPWT)

Biologic products
Bioengineered tissues
Growth factors

Hyperbaric Oxygen Therapy (HBOT)

Offload!!!!

Adequate Debridement
Serial sharp ulcer bed
preparation
Removes senescent
cells, necrotic tissue,
converts a chronic ulcer
to an acute wound,
re-initiates healing
cascade
Centers that utilize sharp
debridement exhibit the
highest degree of
healing.

T.K. Carlson

Approaches to ulcer
Care For the Diabetic
Patient
Simple dressings that meet the needs of the ulcer
Antimicrobial therapy topically and systemically
Advanced Treatment Modalities
Growth Factors
Bio-engineered Tissue
Negative Pressure Wound Therapy
Hyperbaric Oxygen Therapy

Plastic surgery skin grafts/flaps

Advanced Treatment
Modalities
Advanced dressings can reduce costs up to
50% particularly when you consider the
cost of an infection
Utilizing the wrong dressing can increase
the cost of treating ulcers and cause
further complications for the patient
Thoroughly assess the state of the ulcer
bed before prescribing treatment
plan/dressings
Nothing works well on the DFU without
proper offloading

Off-Loading: A
Standard of Care
Proper off-loading:
Reduces pressure
Reduces shear
Reduces shock
Transfers weigh from sensitive or painful areas
Corrects or supports flexible deformities
Accommodates fixed deformities

Off-Loading: A
Standard of Care
Off-loading includes:
Rest/elevation
Felt/foam
Multi- podus splint/boot
Removable cast walker/walking boot
Total contact casting (TCC)
Wedge shoe
Surgical shoe with pressure relief insole

Other assistive devices used in addition

Crutches
Wheelchairs
Walkers

Orthotic For Ulcers

That Dont Heal

Orthotics For Ulcers That

Do Heal
Therapeutic
footwear should be
placed upon healing
Prevents recurrence
Accommodates
deformities
Distributes the
pressure equally
throughout the foot
(The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

Patient Education
Must take an active role in their care
Ulcer management
Routine nail care
Disease management

Decreases the chance of reoccurrence

Foot hygiene
Daily inspection
Proper footwear
Prompt treatment of new lesions

Elective surgery to correct structural

deformities before ulcerations occur

(The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

Summary
PAD is a reliable warning sign that a patient is at high
risk for life threatening cardiovascular and
cerebrovascular events
PAD is easily overlooked by both patients and
physicians assess whether patients presenting with
symptoms or associated risk factors have PAD
Treatments are available to protect the patients with
PAD from future MI or stroke

Summary
With the increase in diabetes in both the
younger and aging population, we are at risk
for greater complications
Common causes of Diabetic Foot Ulcers
include: neuropathy, trauma, deformity, high
plantar pressures
Common
secondary
etiologies
include:
peripheral
arterial
disease
(PAD)
and
osteomyelitis

Summary
Treatment Objectives of Diabetic foot
ulcers
Determine and manage the etiologies
Establish blood supply
Off-loading followed by therapeutic footwear
upon healing
Patient education

Off-loading the pressure at the site of the

ulcer is a standard of care

Summary
Treating the diabetic foot often includes:
Debridement (clinical and/or surgical)
Advanced treatment options
HBO
NPWT
Biologic products:
Growth factors
Bio-engineered tissues

Diabetic
patients
must
be
active
participants in their care to decrease the
chance of reoccurrence

Thank You