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An Evaluation of the Efficacy of Methods Used in Screening for Lower-Limb Arterial Disease in Diabetes.
Perspect Vasc Surg Endovasc Ther. 2006 Mar;18(1):81
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Lower-limb peripheral arterial occlusive disease (PAOD) is a common cause of hospital admission among patients with diabetes. The authors conducted a study of 130 limbs in 68 patients with and without diabetes mellitus to evaluate the accuracy of methods used to screen for PAOD and peripheral neuropathy, including foot pulses and the ankle-brachial or toe-brachial pressure index, and Doppler waveform analysis. They determined that the screening tools of foot pulses, toe-brachial pressure index and qualitative waveform analysis were highly sensitive screening methods in patients as long as peripheral neuropathy was not present. Qualitative waveform analysis and the toe-brachial index were more effective in high-risk limbs with detectable peripheral neuropathy.
The influence of diabetes and lower limb arterial disease on cutaneous foot perfusion. J Vasc Surg. 2006 Aug 22;
Williams DT, Price P, Harding KG
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OBJECTIVE: Peripheral arterial occlusive disease and peripheral neuropathy are major risk factors in diabetic foot disease. We evaluated the relative influences of noncritical lower limb arterial disease and peripheral neuropathy on cutaneous foot perfusion in diabetes.
METHOD: Toe-brachial pressure indices, transcutaneous oxygen, and carbon dioxide tensions at foot and chest sites were measured in individuals with diabetes, with or without detectable peripheral neuropathy and with or without significant arterial disease on color duplex imaging. Subjects without diabetes, with and without arterial disease, were used as controls.
RESULTS: A total of 130 limbs were studied during an 8-month period. Toe-brachial pressure indices reflected the presence of arterial disease in all groups. Foot transcutaneous oxygen values were reduced in diabetes and correlated with chest transcutaneous oxygen values. Low foot transcutaneous oxygen with elevated transcutaneous carbon dioxide values were only demonstrated in individuals with diabetes, arterial disease, and peripheral neuropathy. Toe-brachial pressure indices demonstrated a positive correlation with foot transcutaneous oxygen values, but values >1.2 demonstrated a negative correlation.
CONCLUSIONS: We demonstrated two influences on cutaneous foot perfusion in diabetes: (1) a global microcirculatory dysfunction, reflected in low chest and foot transcutaneous oxygen values, and (2) macrovascular disease as indicated by reduced toe-brachial pressure indices and foot transcutaneous oxygen values. Further, the results demonstrated that in diabetic individuals without critical limb ischemia, impaired foot perfusion secondary to arterial disease is amplified significantly by coexisting microcirculatory disease.
any one know ........ are tbi's potentially as invasive as abi's in dislodging emboli from thrombi (re. use of cuffs) ie can digital arteries be atherosclerotic? and do the sound waves of doppler u/s have invasive properties, again dislodging emboli (also relevant to performing lower leg arterial waveform analyses)? ... thanks, mark c
any one know ........ are tbi's potentially as invasive as abi's in dislodging emboli from thrombi (re. use of cuffs) ie can digital arteries be atherosclerotic? and do the sound waves of doppler u/s have invasive properties, again dislodging emboli (also relevant to performing lower leg arterial waveform analyses)? ... thanks, mark c
I've been reading the archives. I'm interested in the answer to your question also.
It seems the ABI is the test that podiatrists can do in detecting the degree of peripheral arterial disease (PAD). How much of a risk is the use of the cuff to embolism? I have read quite a bit on the subject of ABI recently and I have not come across any mention of it.
Impact of peripheral arterial disease in patients with diabetes-Results from PROactive (PROactive 11).
Dormandy JA, Betteridge DJ, Schernthaner G, Pirags V, Norgren L; on behalf of the PROactive investigators. Atherosclerosis. 2008 Mar 18. [Epub ahead of print]
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We compared cardiovascular disease outcomes according to the presence of peripheral arterial disease (PAD) at baseline in a post hoc analysis from the PROactive study. Of the 5238 patients in PROactive (a study of pioglitazone versus placebo in patients with type 2 diabetes and macrovascular disease; mean follow-up=34.5 months), 1274 had PAD at baseline (619=pioglitazone; 655=placebo). Patients with PAD at baseline showed significantly higher rates of the primary endpoint, main secondary endpoint, all-cause mortality (all P<0.0001), and stroke (P=0.0175) than those with no PAD at baseline. The risk of PAD alone was similar to that of myocardial infarction alone. In patients with no PAD at baseline, the event rates of the primary endpoint (P=0.0160), main secondary endpoint (P=0.0453), and acute coronary syndrome (P=0.0287) were significantly lower with pioglitazone than with placebo. This beneficial effect of pioglitazone was not seen in patients with PAD at baseline. In the total population, there was a higher frequency of leg revascularizations with pioglitazone than placebo-this was wholly due to first events that occurred within the initial 12 months of treatment. The presence of PAD increased the risk of all major cardiovascular events. Those without PAD at baseline seemed to benefit more from pioglitazone treatment than the overall PROactive population.
and do the sound waves of doppler u/s have invasive properties, again dislodging emboli (also relevant to performing lower leg arterial waveform analyses)? ... thanks, mark c
My understanding of the potentialy harmful tissue effects of US are that it is less to do with the vibrational effects of the sound waves but more the effects of cavitation (creation of gas bubbles created within body fluids). Diagnostic US equipement is designed to limit energy output below body tissue cavitation levels as opposed to therapeutic US which is designed to allow this. When you use your US cleaner for your instruments or tissue debridement it is the bubbles created by the vibrations which do the work not the sound waves themselves.
cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918 www.winnipegfootclinic.com
Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and the presence of cardiovascular disease risk factors.
Mostaza JM, Suarez C, Manzano L, Cairols M, López-Fernández F, Aguilar I, Diz Lois F, Sampedro JL, Sánchez-Huelva H, Sanchez-Zamorano MA, Eur J Intern Med. 2008 Jun;19(4):255-60
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BACKGROUND: We evaluated the association between a low ankle-brachial index (ABI), chronic complications of diabetes, and the presence of traditional cardiovascular disease risk factors in subjects with type 2 diabetes but without known cardiovascular disease.
METHODS: We included diabetic subjects (n=923; 52% male; age range 50-85 years) without clinical evidence of coronary, cerebrovascular, or peripheral artery disease (PAD). A history of nephropathy, retinopathy, or neuropathy was collected from the medical records. A 12-lead electrocardiogram and ABI measurements were conducted on all study participants.
RESULTS: The mean duration of diabetes was 9.6 years. Prevalence of a low ABI (<0.9) was 26.2%. Multivariate analysis indicated that factors significantly associated with a low ABI were age (OR: 1.06; 95%CI: 1.033-1.084; p<0.001), plasma triglyceride concentration (OR: 1.002; 95%CI: 1.001-1.004; p=0.006), duration of diabetes (OR: 1.029; 95%CI: 1.008-1.051; p=0.007), and smoking habit (OR: 1.755; 95%CI: 1.053-2.925; p=0.03). The presence of nephropathy, neuropathy, retinopathy, left ventricular hypertrophy, left bundle branch block, and atrial fibrillation were all associated with a low ABI, but only renal disease remained significant after adjusting for age, duration of diabetes, and cardiovascular risk factors.
CONCLUSION: A low ABI is highly prevalent in subjects with diabetes and is related to age, duration of diabetes, smoking habit, and hypertriglyceridemia. Although chronic complications are frequently associated with a low ABI, only renal damage is independently associated with peripheral artery disease.
Prevalence of peripheral arterial disease in patients with diabetes mellitus in a primary care setting.
Rabia K, Khoo EM. Med J Malaysia. 2007 Jun;62(2):130-3.
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The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
The association between diabetes mellitus and the prevalence of intermittent claudication: the HUNT study.
Jensen SA, Vatten LJ, Myhre HO. Vasc Med. 2008 Nov;13(4):239-44.
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The objective of this study was to investigate the association between diabetes mellitus (DM) and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway were mailed an invitation to participate in a health survey (HUNT 2). A total of 19,712 participants aged 40-69 years old completed and returned the questionnaire included with the invitation. They also attended an examination where brachial blood pressure was measured and non-fasting venous blood was collected. The venous blood sample was subsequently analysed for concentrations of blood lipids. Responses to 12 questions on IC were previously tested against ankle blood pressure measurements (ABPI < 0.9) and the algorithm with the best test properties was used to identify individuals with IC. Participants reported a history of DM by simple questions in the questionnaire. Logistic regression analysis was then used to compute age-adjusted prevalence odds ratios for the association between exposure variables and the prevalence of IC. Potential confounding by smoking, blood lipids and brachial blood pressure was investigated in multivariate analyses. For both sexes IC was more common in individuals with DM (OR(women) = 3.8, CI, 1.9-7.6; OR(men) = 2.8, CI, 1.4-5.8) compared to participants without DM. Adjustment for smoking, blood lipids and brachial blood pressure did not substantially change these results. In conclusion, the prevalence of IC was more than three times higher in patients with DM compared to non-diabetic participants.
The vascular and biochemical effects of cilostazol in diabetic patients with peripheral arterial disease.
O'Donnell ME, Badger SA, Sharif MA, Makar RR, Young IS, Lee B, Soong CV. Vasc Endovascular Surg. 2009 Apr-May;43(2):132-43.
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OBJECTIVES: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. METHODS: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. RESULTS: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. CONCLUSIONS: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.
Polydeoxyribonucleotide (PDRN): A Safe Approach to Induce Therapeutic Angiogenesis in Peripheral Artery Occlusive Disease and in Diabetic Foot Ulcers.
Altavilla D, Bitto A, Polito F, Marini H, Minutoli L, Di Stefano V, Irrera N, Cattarini G, Squadrito F. Cardiovasc Hematol Agents Med Chem. 2009 Oct;7(4):313-21.
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Peripheral arterial occlusive disease (PAOD) of lower extremities is becoming more prevalent worldwide. The general prognosis is particularly negative with a high prevalence of coronary heart disease and cerebrovascular disease. Diabetic foot ulcers occur in 15% of all the patients with diabetes and proceed to lower-leg amputations. In diabetic ulcers, wound healing is impaired because of delayed angiogenesis. In both pathological conditions, therapeutic angiogenesis using angiogenic growth factors, particularly Vascular Endothelial Growth Factor VEGF, is expected to be a valuable treatment. The most used approaches are based on VEGF local delivery or gene therapy, but they failed to meet the expected primary goals of therapy. Adenosine receptor stimulation can induce VEGF expression in many types of cells and this may be achieved by stimulating the A(2A) or A(2B) receptor or both, following the signalling pathways activated by hypoxia. Polideoxyribonucleotide (PDRN) is obtained from sperm trout by an extraction process. The compounds hold a mixture of deoxyribonucleotides polymers with chain lengths ranging between 50 and 2000 bp. PDRN is able to stimulate VEGF production during pathological conditions of low tissue perfusion. It likely acts through the stimulation of A(2A) receptors. Furthermore, acute and chronic toxicity studies showed a good safety profile. PDRN has been shown to be effective in an experimental model of PAOD, hind limb ischemia, impaired wound healing and burn injury. Preliminary studies and ongoing clinical trials predict a significant therapeutic efficacy in patients. These data lead to hypothesize a role for PDRN in therapeutic angiogenesis.
PVD in diabetes
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