This document compares angiographic findings between patients with non-healing diabetic foot ulcers (DFUs) with and without Charcot foot (CF). It found that patients with CF and DFUs had less severe peripheral arterial disease (PAD) based on angiographic findings compared to DFU patients without CF, however revascularization rates were equal between the two groups. The study assessed 29 CF patients and 48 non-CF patients with DFUs who underwent lower limb angiography. It found patients without CF had significantly more frequent presence of severe PAD (Graziani class 4 and higher) versus the CF group.

1. COMPARISON OF ANGIOGRAPHIC
FINDINGS BETWEEN PATIENTS WITH
NON-HEALING DIABETIC FOOT ULCERS
WITH AND WITHOUT CHARCOT FOOT
Robert Bem, Alexandra Jirkovská, Michal Dubský, Andrea Němcová,
Veronika Wosková, Vladimíra Fejfarová, Jelena Skibová
Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague
Backround
• Association between Charcot foot (CF) and peripheral arterial
disease (PAD) is not fully understood
• The pathogenesis of CF is mainly based on diabetic
neuropathy
• In clinical practice, it is frequently observed that CF patients
treated for non-healing diabetic foot ulcers (DFU) are under
clinical suspicion on PAD as well
Aims
• The aim of our study was to assess the role of lower limb
angiography in patients with non-healing DFU with and
without CF with the respect to pathological findings and
possibility of vascularization
Rajbhandari et al, Diabetologia, 2002
International Consensus on the Diabetic Foot, 2007
Molines et al, J Diabetes Metabolism, 2010
Palena LM et al, Cardioavasc Intervent Radiol, 2013

2. Patients and methods
Characteristics CF group Controls P
n 29 48 -
Age (years) 64±9.6 66.4±9.5 NS
Sex (M/F) 22/7 40/8 NS
Duration of DM (years) 23.9±9.4 18.5±10 0.02
Type 2 Diabetes n (%) 21 (72) 36(75) NS
HbA1C (%) 8.32±1.19 8.03±1.38 NS
VPT (%) 100 83.3 NS
Data are mean ± SDVPT= vibration perception treshold
The presence of PAD was compared between:
- 29 diabetic patients with ulcerated Charcot foot (CF group)
- 48 consecutive patients presenting with a new DFU, but without
CF (Controls)
The diagnosis of PAD
Clinical suspicion
(e.g. nonhealing ulcer,
gangrene, ...)
TcpO2 < 40mm Hg
Angiography
The presence of PAD was defined as an
abnormal angiographic findings on lower
limb arteries (stenosis >70% or oclusion)
Diagnosis of Charcot
foot
Active:
- Clinical - hot, swollen foot with/without
redness and skin temperatures ≥2 0C
compared to the contralateral foot
- Radiological examination (positive three
phase technetium-99m-labelled
bisphosphonate bone scan)
Inactive:
- Active CNO in history
- Reduction of clinical signs and
temperature difference below 2°C, typical
deformity
Graziani L et al, Eur J Vasc Endovasc Surg, 2007
Graziani classification
Characteristics of the study subjects

3. Results
The distribution of PAD by Graziani classification
Class Angiographic Finding CF group (%) Controls (%) p
1
Isolated, one vessel tibial or peroneal artery
obstruction
0 0 NS
2a
Isolated femoral/popliteal artery or two below
knee arteries obstructed but with patency of
one of the two tibial arteries
6.9 0 NS
2b
Isolated femoral/popliteal artery or two below
knee tibial arteries obstructed but with patency
of the peroneal artery
31.1 6.3 0.01
3
Isolated, one artery occluded and multiple
stenosis of tibial/peroneal and/or femoral/
popliteal arteries
27.6 25 NS
4
Two arteries occluded and multiple stenosis of
tibial/peroneal and/or femoral/popliteal vessels
27.6 41.6 0.04
5
Occlusion of all tibial and peroneal arteries
(below knee cross-sectional occlusion)
3.4 12.5 NS
6
Three arteries occluded and multiple stenosis of
tibial/peroneal and/or femoral/popliteal arteries
3.4 14.6 NS
7
Multiple femoro-popliteal obstructions with no
visible below the knee arterial segments
0 0 NS
Revascularization rates based on angiographic findings
in patients with non-healing DFU
Charcot group (n=29) Controls (n=48)
NS
■ PTA= percutaneous transluminal angioplasty ■ bypass ■ revascularization was not possible
72.4% 68.8%
17.3% 18.7%
10.3% 12.5%
Patients without CNO had significant more frequent presence of most severe findings (Graziani class 4 and
higher – 68.7%) in comparison with CF group (34.4%; p<0.001).
Conclusions
Our results indicate that patients with CF and non-healing DFU
had lower grade of PAD impairment than patients without CF,
nevertheless angiographic findings led to equally frequent
revascularization as in non-CF patients.