The fate of the ischaemic limb in diabetes: it is neuropathy that makes the difference

Evidence is presented of the deleterious effects of sensory and autonomic polyneuropathy on coexisting peripheral arterial occlusive disease (PAOD) in diabetes mellitus. Autonomic neuropathy triggers medial arterial calcification in the lower leg, which affects arterial haemodynamics, and aggravates preexisting PAOD. Calcificated arteries are incompressible and give false blood pressure readings by sphygmomanometry, with subsequent underestimation of PAOD. Sensory neuropathy leads to loss of protective pain sensation, and precludes the timely diagnosis and treatment of limb ischaemia (no claudication, no rest pain). Absent pain perception is also critical for the outcome of surgical interventions, as wound infections and other complications will occur unnoticed. These features have consequences for the detection of high-risk patients, and for the safety of surgery as well.

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Aortoiliac and femoropopliteal lesions in patients with concomitant peripheral arterial disease and medial arterial calcification

Ultraschall in der Medizin - European Journal of Ultrasound ◽

10.1055/s-2007-988963 ◽

2007 ◽

Vol 28 (S 1) ◽

Author(s):

S Crisan ◽

D Crisan ◽

S Vesa ◽

M Chirila ◽

C Pestrea ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Arterial Disease ◽

Arterial Calcification ◽

Peripheral Arterial ◽

Medial Arterial Calcification

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Association of infrapopliteal medial arterial calcification with lower-limb amputations in high-risk patients: A systematic review and meta-analysis

Vascular Medicine ◽

10.1177/1358863x20979738 ◽

2020 ◽

pp. 1358863X2097973

Author(s):

Fabrizio Losurdo ◽

Roberto Ferraresi ◽

Alessandro Ucci ◽

Anna Zanetti ◽

Giacomo Clerici ◽

...

Keyword(s):

Risk Factor ◽

High Risk ◽

Lower Limb ◽

Fixed Effects ◽

Meta Analysis ◽

Arterial Calcification ◽

High Risk Patients ◽

Patients With Diabetes ◽

Risk Patients ◽

Medial Arterial Calcification

Medial arterial calcification (MAC) is a known risk factor for cardiovascular morbidity. The association between vascular calcifications and poor outcome in several vascular districts suggest that infrapopliteal MAC could be a risk factor for lower-limb amputation (LLA). This study’s objective is to review the available literature focusing on the association between infrapopliteal MAC and LLA in high-risk patients. The PubMed and Embase databases were systematically searched. We selected original studies reporting the association between infrapopliteal MAC and LLAs in patients with diabetes and/or peripheral artery disease (PAD). Estimates were pooled using either a fixed-effects or a random-effects model meta-analysis. Heterogeneity was evaluated using the Q and I2 statistics. Publication bias was investigated with a funnel plot and Egger test. The trim-and-fill method was designed to estimate the possibly missing studies. Influence analysis was conducted to search studies influencing the final result. Test of moderators was used to compare estimates in good versus non-good-quality studies. Fifteen articles satisfied the selection criteria ( n = 6489; median follow-up: 36 months). MAC was significantly associated with LLAs (pooled adjusted risk ratio (RR): 2.27; 95% CI: 1.89–2.74; I2 = 25.3%, Q-test: p = 0.17). This association was kept in the subgroup of patients with diabetes (RR: 2.37; 95% CI: 1.76–3.20) and patients with PAD (RR: 2.48; 95% CI: 1.72–3.58). The association was maintained if considering as outcome only major amputations (RR: 2.11; 95% CI: 1.46–3.06). Our results show that infrapopliteal MAC is associated with LLAs, thus suggesting MAC as a possible new marker of the at-risk limb.

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Pulsatility index is better than ankle-brachial Doppler index for non-invasive detection of critical limb ischaemia in diabetes

VASA ◽

10.1024/0301-1526.34.4.235 ◽

2005 ◽

Vol 34 (4) ◽

pp. 235-241 ◽

Cited By ~ 13

Author(s):

Janssen

Keyword(s):

Pulsatility Index ◽

Diabetic Polyneuropathy ◽

Critical Limb Ischaemia ◽

Arterial Calcification ◽

Invasive Technique ◽

Diabetic Patients ◽

Limb Ischaemia ◽

Non Invasive ◽

Ankle Pressure ◽

Medial Arterial Calcification

Background: Diabetic polyneuropathy of the feet and legs obscures the diagnosis of critical limb ischaemia (CLI) because of lack of pain sensation. Hence, the Fontaine classification does not apply to these patients. Furthermore, many of them will exhibit medial arterial calcification, which invalidates the application of sphygmomanometry. This study was done to evaluate the pulsatility index (PI) assessed at the ankle arteries by colour Doppler ultrasonography as a non-invasive method to diagnose CLI in diabetic polyneuropathy. Patients and methods: 140 legs of 106 diabetic patients were studied who presented with polyneuropathy and painlessness of the feet; of these, 117 feet displayed an ulcer or gangrene. CLI was defined as the need for arterial revascularisation, as indicated by the physicians in charge on the basis of a) a foot lesion Wagner grade 1–5, and b) a positive arteriography. All patients were subjected to 4 vascular assessment techniques: digital subtraction arteriography, ankle-brachial Doppler index, systolic ankle blood pressure, and PI. Results: Of the 140 legs, 61 (44%) were affected by CLI, and 76 (54%) by medial arterial calcification. A PI < 1.2 indicated CLI with a sensitivity of 0.87 and a specificity of 0.62. The sensitivity and specificity of ankle-brachial index < 0.9, and of systolic ankle pressure < 70 mm Hg to predict CLI was 0.71 and 0.42, and 0.30 and 0.89, respectively. Conclusions: The pulsatility index is a better non-invasive technique than the ankle-brachial Doppler index or the systolic ankle pressure to assess critical limb ischaemia in diabetic polyneuropathy. A pulsatility index < 1.2 at the ankle arteries is a reliable criterion for diagnosis of CLI in diabetic patients with polyneuropathy.

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Different Lower Extremity Arterial Calcification Patterns in Patients with Chronic Limb-Threatening Ischemia Compared with Asymptomatic Controls

10.20944/preprints202104.0205.v1 ◽

2021 ◽

Author(s):

Louise CD Konijn ◽

Richard AP Takx ◽

Willem PThM Mali ◽

Hugo TC Veger ◽

Hendrik van Overhagen

Keyword(s):

Vessel Wall ◽

Arterial Disease ◽

Critical Limb Ischaemia ◽

Arterial Calcification ◽

Limb Ischaemia ◽

Multiple Logistic Regression ◽

Therapeutic Consequences ◽

Peripheral Arterial ◽

Crural Arteries ◽

Severe Type

Objectives The most severe type of peripheral arterial disease (PAD) is critical limb ischaemia (CLI). In CLI, calcification of the vessel wall plays an important role in symptoms, amputation rate and mortality. However, calcified arteries are also found in asymptomatic persons (non-PAD patients). We investigated whether the calcification pattern in CLI patients and non- PAD patients are different and could possibly explain the symptoms in CLI patients. Materials and Methods 130 CLI and 204 non-PAD patients underwent a CT of the lower extremities. This resulted in 118 CLI patients (mean age 72±12, 70.3% male) that were age-matched with 118 non-PAD patients (mean age 71±11, 51.7% male). The characteristics severity, annularity, thickness and continuity were assessed in the femoral and crural arteries and analysed by binary multiple logistic regression. Results Nearly all CLI patients have calcifications and these are equally frequent in the femoropopliteal (98.3%) and crural arteries (97.5%), while the non-PAD patients had in just 67% any calcifications with more calcifications in the femoropopliteal (70.3%) than in the crural arteries (55.9%, p<0.005). The crural arteries of the CLI patients had significantly more complete annular calcifications (OR 2.92, p=0.001.) while in the non-PAD patients dot-like calcifications dominated. In CLI patients, the femoropopliteal arteries had more severe, irregular / patchy and thick calcifications (OR 2.40, 3.27, 1.81, p≤0.05, respectively) while in non-PAD patients, thin continuous calcifications prevailed. Conclusions Compared with non-PAD patients CLI patients are more frequently and extensively calcified. Annular calcifications were found in the crural arteries of CLI patients while dot-like calcifications were mostly present in the non-PAD patients. These different patterns of calcifications in CLI point at different etiology and can have prognostic and eventually therapeutic consequences.

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Assessment of Diabetic Foot through the Developmental Stages of Lower Limb Abnormalities Using Ultrasound

The Eye and Foot in Diabetes ◽

10.5772/intechopen.92431 ◽

2020 ◽

Author(s):

Suresh K.S. ◽

Sukesh Kumar A.

Keyword(s):

Blood Pressure ◽

Lower Limb ◽

Diabetic Foot ◽

Developmental Stages ◽

Systolic Pressure ◽

Arterial Calcification ◽

Velocity Spectrum ◽

Transcutaneous Oxygen ◽

Peripheral Arterial ◽

Medial Arterial Calcification

A diabetic foot is one of the most serious complications of diabetes mellitus. This causes large number of lower leg amputations worldwide. Usually this disease is getting diagnosed in a very later stage. Ankle-arm index, diastolic blood pressure, fasting plasma glucose, hemoglobin A1C, high blood pressure, medial arterial calcification, nerve conduction velocity, peripheral vascular disease, systolic blood pressure, transcutaneous oxygen tension, etc. are some of the major indicators of a diabetic foot. Among these peripheral arterial abnormalities and neuropathy are the most dominant visible factors. Detection and monitoring of diabetic foot help to demonstrate the feet at risk of ulceration positively. This study reveals the various assessment methodologies of lower limb abnormalities leading to diabetic foot using ultrasound. Ultrasound is being used in various cases related to diabetic foot, from the identification of systolic pressure for the ankle brachial pressure index to the velocity analysis of hemodynamic studies. The study analyses the lower limb abnormalities and extracts the features of diabetic foot from the velocity spectrum of ultrasound Doppler scan.

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The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: Requirements for diagnostics

American Journal of Kidney Diseases ◽

10.1053/ajkd.2002.34885 ◽

2002 ◽

Vol 40 (3) ◽

pp. 472-479 ◽

Cited By ~ 172

Author(s):

Yrjö Leskinen ◽

Juha P. Salenius ◽

Terho Lehtimäki ◽

Heini Huhtala ◽

Heikki Saha

Keyword(s):

Renal Failure ◽

Chronic Renal Failure ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Arterial Calcification ◽

Peripheral Arterial ◽

Medial Arterial Calcification

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Overview of Treatment Options for Critical Limb Ischaemia Patients

European Cardiology Review ◽

10.15420/ecr.2011.7.1.51 ◽

2011 ◽

Vol 7 (1) ◽

pp. 51 ◽

Cited By ~ 1

Author(s):

Frederic Baumann ◽

Nicolas Diehm ◽

◽

Keyword(s):

Treatment Options ◽

Critical Limb Ischaemia ◽

Treatment Modalities ◽

High Morbidity ◽

Limb Ischaemia ◽

Arterial Revascularisation ◽

Planning Treatment ◽

Treatment Concepts ◽

Peripheral Arterial ◽

Renal Origin

Patients with critical limb ischaemia (CLI) constitute a subgroup of patients with particularly severe peripheral arterial occlusive disease (PAD). Treatment modalities for these patients that often exhibit multilevel lesions and severe vascular calcifications are complicated due to multiple comorbidities, i.e. of cardiac and vascular but also of renal origin. These need to be taken into consideration while planning treatment options. Although CLI is associated with considerably high morbidity and mortality rates, the clinical outcome of patients being subjected to revascularisation has improved substantially in recent years. This is mainly due to improved secondary prevention strategies as well as dedicated endovascular innovations for this most challenging patient cohort. The aim of this article is to provide a discussion of the contemporary treatment concepts for CLI patients with a focus on arterial revascularisation.

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