Introduction

Prevalence:

  • 4.8 Million UK pop.
  • 5 Million by 2025

Issue:

  • Glucose management issue

Types:

  • Type 1: Genetic
  • Type 2: Bad diet and lack of exercise
  • Other



Body Vascular Anatomy

Body Vascular Anatomy



Foot Vascular Anatomy

Foot Vascular Anatomy



Diabetes Mellitus

Diabetes Mellitus Flowchart



Diabetes Neuropathy

  • Neuropathy = nerve damage

  • NCS = nerve conduction

  • Vibration, Pressure/Touch and Motor/Reflex are the most common tests

Diabetes Neuropathy



PVD

  • What is PVD?
    • Arterial
    • Venous
    • Lymphatic
    • Peripheral Arterial Disease (PAD)
    • Intermittent Claudication
    • Critical Limb Ischaemia
    • Gangrene
What is PVD?
Progressive Luminal Occlusion?
Transfer of Glucose in the Body

Effects of PVD

  • Pain
  • Callus
  • Numbness
  • Deformity
  • Ulcers
  • Gangrene
  • Neuropathy (nerve damage)
  • Ischemia (reduced blood supply)



Diagnosis

Signs and Symptoms

  • Intermittent Claudication
  • Rest Pain
  • Numbed/dull leg

Method 1: Pedal Pulse Palpitation

  • Regularity
  • Symmetry
  • Strength
  • Is this subjective?



Method 2: Doppler Ultrasound

  • Regularity
  • Symmetry
  • Strength
  • Is this objective?
Doppler Ultrasound: How it works

Doppler Ultrasound Probe Positioning

Doppler Ultrasound: Where to Position the Probe

Which Pulses should be assessed

  • All guidelines concur that at least 2 pulses should be assessed for each foot.

  • Normally these are:

    • posterior tibial,
    • dorsalis pedis
    • anterior tibial.

  • However, NICE guidance recommends that they should always include the peroneal pulse as this may be the only one present in some people, particularly those with diabetes (NICE, 2012).

Arteries of the Foot



Method 3: ABPI

Ankle-brachial Pressure Index (ABPI) Calculation

ABI Calculation

ABPI Interpretation

ABPI Diagnosis
< 0.5 Severe PAD
0.5 - 0.7 Moderate PAD
0.7 - 0.9 Mild PAD
0.9 - 1.3 Normal
> 1.3 Calcification?

ABPI in Diabetes

ABI in Diabetes



Method 4: Toe Pressure

  • Regularity
  • Symmetry
  • Strength
  • Is this objective?

Toe Brachial Index (TBI)

  • TBI > 0.7 = normal

  • Rest pain

    • often in patients with TBI < 0.15
    • absolute pressure in the toes of 20-30 mmHg



Method 5: Transcutaneous Oxygen

  • Microcirculation
  • Very localised
  • TcPO2 > 50 mmHg = normal
  • Determine Amputation Level
  • Determine Healing Potential
    • Poor chances if <30mmHG
Transcutaneous Oxygen



Diagnosis - Gold Standard Transcutaneous Oxygen

Arterial Duplex

  • Regularity
  • Symmetry
  • Strength
  • Is this objective?

CT Angiography

  • Regularity
  • Symmetry
  • Strength
  • Is this objective?

Toe Brachial Index (TBI)

  • Regularity
  • Symmetry
  • Strength
  • Is this objective?



NHS Integrated Care Pathway

PAD Integrated Care Pathway

Referral Pathway

NHS Urgent Referral Pathway



Treatments for PVDS

Conservative Medical Surgical
Method Exercise Peripheral Vasodilators Angioplasty/Stent
Treatment Managing your risk factors Anti-Platelet medication, Statins Bypass
Details - High BP - Smoking Cessation - Diet - Diabetes Control - cilostazol, nifedipine, naftidrofuryl oxalate (vasodilators) - aspirin or clopidogrel (antiplatelet) - Art/Rosuv/Simv STATINS



Critical Limb Ischemia (CLI)

Only method of treatment is amputation - feet are black - muscle death due to lack of blood supply



P & 0 Consideration

  • Materials
  • Aims and Objectives
    • Short term
    • Long term



References

  1. Soyoye, D. O., Ikem, R. T., Kolawole, B. A., Oluwadiya, K. S., Bolarinwa, R. A., & Adebayo, O. J. (2016). Prevalence and Correlates of Peripheral Arterial Disease in Nigerians with Type 2 Diabetes. Adv Med, 2016, 3529419. https://doi.org/10.1155/2016/3529419

  2. Wang, Z., Wang, X., Hao, G., Chen, Z., Zhang, L., Shao, L.,… China hypertension survey, investigators. (2019). A national study of the prevalence and risk factors associated with peripheral arterial disease from China: The China Hypertension Survey, 2012-2015. Int J Cardiol, 275, 165–170. https://doi.org/10.1016/j.ijcard.2018.10.047

  3. Pradeepa, R., Chella, S., Surendar, J., Indulekha, K., Anjana, R. M., & Mohan, V. (2014). Prevalence of peripheral vascular disease and its association with carotid intima-media thickness and arterial stiffness in type 2 diabetes: the Chennai urban rural epidemiology study (CURES 111). Diab Vasc Dis Res, 11(3), 190–200. https://doi.org/10.1177/1479164114524584

  4. Felício, J. S., Koury, C. C., Abdallah Zahalan, N., de Souza Resende, F., Nascimento de Lemos, M., Jardim da Motta Corrêa Pinto, R., … Abrahão Neto, J. F. (2019). Ankle-brachial index and peripheral arterial disease: An evaluation including a type 2 diabetes mellitus drug-naive patients cohort. Diab Vasc Dis Res, 1479164119829385. https://doi.org/10.1177/1479164119829385

  5. Urbano, L., Portilla, E., Munoz, W., Hofman, A., Sierra-Torres, C. H., Muñoz, W., … Sierra-Torres, C. H. (2018). Prevalence and risk factors associated with peripheral arterial disease in an adult population from Colombia. Arch Cardiol Mex, 88(2), 107–115. https://doi.org/10.1016/j.acmx.2017.02.002

  6. Okello, S., Millard, A., Owori, R., Asiimwe, S. B., Siedner, M. J., Rwebembera, J., … Annex, B. H. (2014). Prevalence of lower extremity peripheral artery disease among adult diabetes patients in southwestern Uganda. BMC Cardiovasc Disord 14 75 https://doi org/10 1186⁄1471-2261-14-75