Diabetes and Critical limb ischemia

1. Diabetes & Critical Limb ischemia
Dr.Elamaran.E M.S.,MCh(CTVS)
Vascular & Thoracic surgeon
Mahatma Gandhi Medical College & Research Institute
Pondicherry

3. Critical Limb Ischemia
• Severe form of PAD(Chronic)
• Ischemic ulcers,Gangrene and rest pain
• Severe limb ischemic symptoms for more than 2
weeks
• Blood flow : Tissue requirement
• CLI recognition - clinical picture, anatomical
stratification and hemodynamic assessment of
flow disturbances
Alexandrescu VA, Letawe A. Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges.Curre Res Diabetes & Obes J. 2015

4. Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74
CLI -Natural history &Prognosis

5. • Presentation - Pain syndrome
• Vessel involvement -Tibio-peronneal trunk
• Chronicity
• Associated co-morbidities
• Cost
DM and CLI

6. Diabetic foot ulcers
• Diabetic foot ulcers- Complex problem(Leading cause of hospitalisation and
amputation).
• Triad - Neuropathy, Ischemia and Infection
• Neuropathy & Ischemia (sign of abnormal loading and impaired perfusion)-
Initiating factor
• Infection - Consequence

7. Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74

8. Ischemia & Neuroischemia of Diabetic foot
• Ischemia - Important factor preventing healing
• Contributing factor for amputations in diabetes- 90%
• Decreased perfusion - Macrovascular and Microvascular dysfunction
Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74

9. Macrovascular dysfunction
• Diffuse multi-segmental
• Predominant Infra-Popliteal disease
• Poor collateralisation
• Distal patent pedal vessels

10. Diabetic vessels

11. Microvascular dysfunction
• Neuropathy
• Decreased nutritive and non-nutritive blood flow
• altered thermoregulation with opening of AV shunting
• Pre capillary sphincter malfunction
• Capillary ischemia ,leak and venous pooling
• Vessel wall inflammation

13. Diabetic foot ulcer
Akbari CM, LoGerfo FW. Diabetes and peripheral vascular diseaseJ Vasc Surg 1999; 30: 373–84

14. Clinical examination
• Foot examination:
• Both DPA and PTA are palpable - No significant PVD
• But in diabetes - AV shunting - Impaired perfusion
• Neuropathy assessment
• Infection - increased exudation rate
Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74

15. • CLI is a clinical diagnosis but should be supported by objective tests

16. Diagnostic Methods
• Physiologic:
• ABI
• Toe Pressure
• tcPO2
• Anatomical:
• Doppler
• CTA
• MRA
• DSA

17. • Need for revascularisation to improve perfusion and wound healing should be
identified by clinical examination and non-invasive vascular testing.
• Detailed Visualisations of infrapopliteal arteries is necessary for a complete
evaluation of diabetic foot.

18. Limb salvage strategies
• Integrated medical care concept
• Urgent evaluation of lower limb circulation.
• Treatment of life threatening limb infections - immediate hospitalisation,
intravenous antibiotics and immobilisation.
• Surgical procedures - Debridement and revascularisations towards tissue
healing.
• Management of cardio-respiratory problems
Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74

19. Revascularisation
• Timing of intervention
• Limb threatening deep infection
• Debridement first and revascularisation thereafter
• Distal bypass-2to5days or endovascular simultaneously
• No limb threatening infection
• Optimise blood supply before debridement
Lepäntalo M et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg.2011 Dec;42 Suppl 2:S60-74

20. Endovascular techniques
• Antegrade or Retrograde /Safari
• Subintimal or parallel wire
• Pedal -plantar arch technique
Alexandrescu VA, Letawe A. Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges.Curre Res Diabetes & Obes J. 2015

21. Antegrade technique

22. Retrograde

24. Open bypass
• Distal vein bypass - tibial, pedal or plantar vessels
• More physiological, high flow and pulsatile distal flow
• Prevent collateral stress towards arteriogenesis and
tissue cicatrization.
Alexandrescu VA, Letawe A. Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges.Curre Res Diabetes & Obes J. 2015

25. • Medical adjuvants - Prostaglandin E1,Stem cells(marrow),Gene
therapy,Growth factors

26. Current concepts - Diabetic foot syndrome
• Multifaceted pattern of disease with varied clinical presentation.
• Macro and Micro vascular assessment with angiographic information while treating
CLI
• Specific arterial flow ,reconstruction policies and result stratification -difficult in
tissue damage management
• Prevention -Early identification and referral
• Goal-Relieve pain, healing ulcer ,prevent limb loss and improve quality of life
• Wound targeted revascularisation /Angiosome concept.
Alexandrescu VA, Letawe A. Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges.Curre Res Diabetes & Obes J. 2015

27. Key factors - choice of revasularisation

28. Our stats - 3 years

29. Study Variables No of patients Percentage
Age of the patient
(years)
30 - 45 2 7.4
46 - 60 22 81.5
61 - 75 3 11.11
Gender male 18 66.67
female 9 33.33
Risk factors No of patients
(out of 27)
Percentage (%)
Diabetes mellitus 22 81.5
Hypertension 17 63
Smoking 15 55.6
Chronic renal failure 2 7.4
H/O CAD 2 7.4
H/O CVA 1 3.7

30. Limb perfusion (flow in one of
the three vessel No of patients Percentage
End of 30 days 21 84.0
End of 6 months 17 68.0
1 year 12 48.0
Outcomes No of patients (out
of 27)
Percentage
Procedural
complication
Thrombus 2 7.4
Perforation 1 3.7
calcifications 2 7.4
Amputation level 20 80.0
Pain score improved < 5 /10 22 88.0
> 5 / 10 3 12.0

31. Thank you
Special thanks
Dr.Harivadan Lukka
Dr.V.S.Bedi
Dr.K.R.Suresh