This document discusses DFU (diabetic foot ulcer) vs PAD (peripheral arterial disease) and their treatment. It notes that PAD is more common in diabetics and is a risk factor for DFU. The stages of PAD are described from asymptomatic to critical limb ischemia. Examination involves checking pulses and ABSI. Treatment depends on severity and may include risk factor control, exercise, medication, endovascular or open revascularization procedures, wound care, or amputation. A multidisciplinary team approach is emphasized along with rehabilitation and follow up.

1. DFU vs PVD
in
Kursus Pendekatan Holistik Pesakit Diabetik Dalam Pengurusan Diabetic Foot dan
Penjagaan Luka
DR Ahmad Fais Mukriz bin Alwi
Pakar Klinikal UD52
Department of Surgery, HSNZ K. Terengganu

2. Diabetes Mellitus1
• Metabolic disease
• Hyperglycaemia
• Impairment of Insulin secretion, action or
both
• Chronic hyperglycaemia associated with long
term damage, dysfunction or damage of
target/ end organ i.e. BLOOD VESSELS,
NERVES, brain, eyes, kidney
1. https://doi.org/10.2337/diacare.27.2007.S5

3. DFU vs PAD: Overview
• Foot ulcer – common presentation
• Diagnosis
• PAD, CLI, CVI, DFU, DFI
• Referral to General Surgery / Vascular services
– Primary setting / Tertiary setting
• Treatment : Revascularization / Amputation

4. Magnitude of problem
• Diabetics Statistic
• Malaysia
– current prevalence of DM in 2015 is 17.5%, over
double since 19962
• Terengganu
– 18.6% of population (2015)3
• Financial implications
– USD 60 (2013) HSNZ KT 4 per patient (on average)
2. Tee, E. S. & Yap, R. W. K. (2017). Type 2 diabetes mellitus in Malaysia: current trends and risk factors. Eur J Clin Nutr, 71(7), 844-849.
3. National Health and Morbidity Survey 2015
4. Lam, A., Zaim, M., Helmy,, H., & Ramdhan, I. (2014). Economic Impact of Managing Acute Diabetic Foot Infection in a Tertiary Hospital in
Malaysia. Malaysian Orthopaedic Journal, 8(1), 46–49. http://doi.org/10.5704/MOJ.1403.018

5. Diabetic Foot Ulcer
• Ulcer - break of epithelium
• Poor healing - diabetic factors
• Infection – local swelling / sepsis
• Ischaemia - element of PAD
• Classification – Wagner / Univ of Texas ,
Threatened Limb Classification (Wifl)-vascular
• Treatment – antibiotic, debridement, amputation,
Revascularization

8. Relationship of DM and PAD
• PAD 2-4 times more common in diabetics5
• 12% asymptomatic PAD in Type 1 DM and
young patients6
• 11% had PAD 6 years after DM7
• 25-28% relative risk of PAD in increased HbA1c
7
5.Beckman, J. A., Creager, M. A. & Libby, P. (2002). Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. Jama,
287(19), 2570-81.
6.Forrest, K. Y., Becker, D. J., Kuller, L. H., Wolfson, S. K. & Orchard, T. J. (2000). Are predictors of coronary heart disease and lower-extremity
arterial disease in type 1 diabetes the same? A prospective study. Atherosclerosis, 148(1), 159-69.
7. Adler, A. I., Stevens, R. J., Neil, A., Stratton, I. M., Boulton, A. J. & Holman, R. R. (2002). UKPDS 59: hyperglycemia and other potentially
modifiable risk factors for peripheral vascular disease in type 2 diabetes. Diabetes Care, 25(5), 894-9.

9. Peripheral Arterial Disease
• General term of non coronary arterial disease
• Arterial insufficiency
• Atherosclerosis
• Risk factors:
– Age: 70 years old, 50 years old (high risk eg DM)
– Male gender
– Ethnic
– Family history
– Smoking
– Hypertension
– DM
– Hyperlipidaemia
– Metabolic syndrome

10. Pathophysiology
• PAD /CLI
–Atheroclerosis
• DM (one of risk
factor)
• DFU
–Neuropathy
–PAD
–Microvascular
disturbance

11. Natural history of PAD
Asymptomatic
Intermittent claudication
Critical Limb ischaemia
Diabetes mellitus with
ulcer

12. History
• Asymptomatic – symptoms related to physical
activity or exercise
• Intermittent claudication
• Rest pain
• Non healing ulcer
• Gangrene
• + risk factors , Past Medical History
PROGRESSION
OF
DISEASE

13. • INTERMITTENT CLAUDICATION:
• Reproducible leg pain at fix distance of
walking that required patient to rest
• Distance may shortened in disease progress
• Differentiate from other causes such as
neuropathic pain, musculoskeletal pain
• Unable to get history – bedridden, pre existing
joint or muscle pain

14. Critical Limb Ischaemia
Limb at risk / threatened limb
• Rest pain – persistent, recurring ischaemic pain
required regular analgesia for more than 2 weeks
or
• Tissue Loss - leg ulceration or gangrene of the
foot or toes
With
• Ankle systolic pressure <50 mmHg or toe systolic
pressure <30mmHg

18. Physical examination
• Examination of pulses
• Normal (++)
• Weak (+)
• Absent (-)
Femoral
artery
Popliteal
artery
Posterior
tibial artery Dorsalis
pedis
artery
+
+
+
+

19. Hand Held doppler
• Wave form
• ABSI (Ankle/ Brachial systolic index)
• = Ankle SBP / Brachial SBP

20. ABSI INTEPRETATION
>1.1 NORMAL
HARDENED / NON COMPRESSIBLE VESSEL
0.9 – 1.1 NORMAL
0.7-0.89 MILD TO MODERATE DISEASE
(ASYMPTOMATIC TO MILD)
<0.7 MODERATE TO SEVERE DISEASE
<0.3 CRITICAL LIMB ISCHAEMIA

21. • Toe pressure examination
• Photo plethysmography
• Distal perfusion in diabetic patient

22. • Blood:
– FBC
– RBS / FBS /HbA1c
– RFT
– Lipid profile
• Wound swab for C & S
• Imaging:
– Foot X ray – osteomyelitis
– MRI foot - soft tissue infection /OM

23. Investigations
• Imaging
– Level of stenosis / occlusion
– Distal run-off
– Plan for intervention / revascularization
• Endovascular
• Open Surgery

24. • Options:
– Duplex scan
– CT angiography
– MRA
– DS angiography

26. Treatment
• Multidisciplinary team approach
– Vascular surgeon
– Orthopaedic surgeon
– Intervention rediologist
– Physician / Endocrinologist
– Nurse
– Dietician
– Physiotherapist
– Occupational therapist

27. • Intermittent claudication
– Non-debilitating claudication
• Not affecting lifestyle / mobility / daily activity / work
– Regular follow up
• Monitor symptoms progression
• Monitor co-morbid
• Pharmacotherapy

28. • Chronic Limb ischaemia
• Risk factor modification
– Stop smoking
– Diabetic control
– Anti platelet
– Lipid lowering agents
– Regular exercise program
• 30-60 minutes , 3x/week , 3 months
– Analgesia – opiods, NSAIDs, Cox-2-inhibitor

29. • Indication for intervention:
• Debilitaitng claudication
• Chronic limb ischaemia
• Options:
• Endovascular – angioplasty / stenting
• Open bypass surgery
• Hybrid

30. Endovascular
• Short segment lesion
• Not suitable for bypass/GA
– Age
– Co morbid
• With / out stenting
Bypass surgry
• Long segment lesion
• Lesions at origin
• Configurations
• Aorto-bifemoral
• Ilio-femoral
• Femoro-popliteal
• Distal bypass
• Native vein graft / prosthetic
graft

31. • Local treatment:
• Debridement
• Wound care / dressing
• Minor amputation
– Removal of necrotic tissue
– Reduce septic focus
– Promote granulation

32. • Primary amputation
• Non salvagable foot
• Poor revascularization outcome
– Poor distal run-off
– Severe calcified vessel
• Patient selection:
– Poor cardiac function
– Poor pre-morbid condition
• Not failure of treatment – to regain mobility

33. Rehabilitation & follow up
• Rehabilitation
• Mobilization
• Prosthesis
• Foot wear
• Follow up
• Control risk factor
• Medication
• Surveillance
– Recurring stenosis
– Bypass Graft failure

34. THANK YOU
Take home message:
Early diagnosis
Examine pulses
Early referal