Degrees of Arterial Stenosis and Other Factors Related with Diabetic Foot Wound Severity

Background: Few studies have addressed which blood vessels are affected by arterial stenosis in patients with diabetic foot (DF) and the severity thereof. Furthermore, whether the severity of arterial stenosis is significantly correlated to DF severity was yet to be established. We analyzed the association between the severity of arterial stenosis and DF wound severity, along with a variety of relevant factors.Methods: Seventy-one cases hospitalized with DF were evaluated. To assess the degree of arterial stenosis of the five major arteries of the lower extremity (femoral, popliteal, anterior tibial, posterior tibial and peroneal artery), we performed computed tomography angiography, and quantified arterial stenosis using Bollinger scores. We then assessed DF severity and calculated self-reported wound scores. We also analyzed factors that can affect DF severity and the degree of arterial stenosis in the lower extremities.Results: There was no significant association between the mean total Bollinger score and wound severity. Albumin, protein, and Bollinger scores of femoral arteries showed significant association with wound severity, and age and ankle-brachial index (ABI) showed significant association with mean total Bollinger scores (P<0.05). Albumin and Bollinger scores of femoral arteries had significant association with wound severity, and age and ABI showed significant association with mean total Bollinger scores (P<0.05).Conclusion: There was no significant association between the degree of vascular obstruction and the severity of DF. Our results indicate that surgeons should consider the other factors above to ensure appropriate management of patients with DF and assess the prognosis.

Download Full-text

Initial Clinical Experience with Percutaneous Atherectomy in the Infragenicular Arteries

Journal of Endovascular Therapy ◽

10.1177/152660280301000523 ◽

2003 ◽

Vol 10 (5) ◽

pp. 987-993 ◽

Cited By ~ 14

Author(s):

Thomas Zeller ◽

Ulrich Frank ◽

Karlheinz Bürgelin ◽

Uwe Schwarzwälder ◽

Peter-Christian Flügel ◽

...

Keyword(s):

Balloon Angioplasty ◽

Ankle Brachial Index ◽

Peroneal Artery ◽

Lesion Length ◽

Anterior Tibial Artery ◽

Tibial Artery ◽

Below The Knee ◽

Directional Atherectomy ◽

Mean Diameter ◽

The Mean

Purpose: To evaluate the efficacy and safety of a new atherectomy device for the treatment of infragenicular lesions in arteries with a reference diameter of at least 2.5 mm. Methods: Twenty-seven below-the-knee lesions in 17 patients (12 men; mean age 69±12 years) with chronic peripheral arterial occlusive disease were treated with directional atherectomy. The target lesion was in the popliteal artery (segment 3) in 2 (7%) cases, the tibioperoneal trunk in 12 (44%), the peroneal artery in 8 (30%), the anterior tibial artery in 2 (7%), and the posterior tibial artery in 3 (11%). Six (22%) of the lesions were in-stent stenoses. The mean diameter stenosis was 87%±9%, and the mean lesion length was 34±24 mm. Results: All but 2 (7%) of the lesions could be treated successfully (residual stenosis <30%) with the atherectomy catheter (93% technical success) using an average of 5±2 (range 1–10) passes of the device. Six lesions (22%) were treated after predilation and 21 (78%) with primary atherectomy. In 8 (30%) lesions, additional balloon angioplasty was performed. The 2 failures were in heavily calcified lesions through which the device could not pass despite predilation. The mean diameter stenosis after atherectomy was 14%±22% (range 0%–90%); after additional balloon angioplasty, the mean residual stenoses reduced to 12%±21% (range 0%–100%). One (6%) of the 2 patients who failed atherectomy sustained a thrombotic occlusion of the target vessel. This complication was treated successfully with local lysis, but the vessel reoccluded 3 days later; a stent was implanted. The mean ankle-brachial index increased from 0.50±0.27 to 0.86±0.40 before discharge. Conclusions: Below-the-knee native vessel lesions and in-stent restenoses with a diameter of at least 2.5 mm can be treated successfully and safely with this new atherectomy catheter. Additional balloon angioplasty was necessary in only a few cases.

Download Full-text

Anatomical Consideration of Deep Calf Veins: Application to Catheter-Directed Thrombolysis

10.21203/rs.3.rs-130379/v1 ◽

2021 ◽

Author(s):

Kyu-Ho Yi ◽

Hee-Jin Kim

Keyword(s):

Anatomical Variations ◽

Venous Access ◽

Vein Thrombosis ◽

Posterior Tibial ◽

Surface Areas ◽

Antegrade Approach ◽

Catheter Directed Thrombolysis ◽

Anterior Tibial ◽

The Mean ◽

Deep Vein

Abstract An antegrade approach is frequently used in catheter-directed thrombolysis to remove deep-vein thrombosis. However, the antegrade approach is difficult when accessing veins with small diameters, therefore, understanding the variation of deep calf vein is important. This study measured the diameters and surface areas of the proximal and distal posterior tibial vein, peroneal vein, and anterior tibial vein in order to determine which are preferable for venous access. This study dissected 132 legs from Korean and Thai cadavers. The proximal and distal posterior tibial vein, peroneal vein, and anterior tibial vein were scanned and measured. The mean diameter and surface area were largest for the proximal tibial vein, at 6.34 mm and 0.312 cm2, respectively, followed by the anterior tibial vein (5.22 mm and 0.213 cm2), distal posterior tibial vein (3.29 mm and 0.091 cm2), and peroneal vein (3.43 mm and 0.081 cm2). The proximal posterior tibial vein and anterior tibial vein have large diameters and surface areas, which make them ideal for applying an antegrade approach in catheter-directed thrombolysis. The distal posterior tibial vein and peroneal vein are not recommended due to their smaller surface areas and also the anatomical variations therein.

Download Full-text

Ultrasound in diagnosis of anatomical variation of anterior and posterior tibial arteries.

Medical Ultrasonography ◽

10.11152/mu.2013.2066.181.mzh ◽

2016 ◽

Vol 18 (1) ◽

pp. 64 ◽

Cited By ~ 4

Author(s):

Miao Zheng ◽

Chuang Chen ◽

Qianyi Qiu ◽

Changjun Wu

Keyword(s):

Anatomical Variation ◽

Posterior Tibial Artery ◽

Peroneal Artery ◽

Medial Malleolus ◽

Anterior Tibial Artery ◽

Tarsal Tunnel ◽

Posterior Tibial ◽

Tibial Artery ◽

Tibial Arteries ◽

Anterior Tibial

Aims: Knowledge about branching pattern of the popliteal artery is very important in any clinical settings involving the anterior and posterior tibial arteries. This study aims to elucidate the anatomical variation patterns and common types of anterior tibial artery (ATA) and posterior tibial arteries (PTA) in the general population in China. Material and methods: Anatomical variations of ATA, PTA, and peroneal artery were evaluated with ultrasound in a total of 942 lower extremity arteries in 471 patients. Results: Three patterns of course in the PTA were ultrasonographically identified: 1) PTA1: normal anatomy with posterior tibial artery entering tarsal tunnel to perfuse the foot (91.5%), 2) PTA2: tibial artery agenetic, and replaced by communicating branches of peroneal artery entering tarsal tunnel above the medial malleolus to perfuse the foot (5.9%), and 3) PTA3: hypoplastic or aplastic posterior tibial artery communicating above the medial malleolus with thick branches of peroneal artery to form a common trunk entering into the tarsal tunnel (2.4%). In cases where ATA was hypoplastic or aplastic, thick branches of the peroneal artery replaced the anterior tibial artery to give rise to dorsalis pedis artery, with a total incidence of 3.2 % in patients, and were observed more commonly in females than in males. Hypoplastic or aplastic termini of ATA and PTA, with perfusion of the foot solely by the peroneal artery, was identified in 1 case. In another case, both communicating branches of the peroneal artery and PTA entered the tarsal tunnel to form lateral and medial plantar arteries.Conclusions: Anatomical variation of ATA and PTA is relatively common in the normal population. Caution should be exercised with these variations when preparing a peroneal artery vascular pedicle flap grafting. Ultrasound evaluation provides accurate and reliable information on the variations.

Download Full-text

Pseudoaneurysm of the Perforating Peroneal Artery following Ankle Arthroscopy

Case Reports in Orthopedics ◽

10.1155/2018/9821738 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6

Author(s):

Ichiro Tonogai ◽

Eiki Fujimoto ◽

Koichi Sairyo

Keyword(s):

Ankle Joint ◽

Vascular Complications ◽

Posterior Tibial Artery ◽

Ankle Arthroscopy ◽

Peroneal Artery ◽

Anterior Tibial Artery ◽

Foot And Ankle ◽

Posterior Tibial ◽

Tibial Artery ◽

Anterior Tibial

The use of standard anterolateral and anteromedial portals in ankle arthroscopy results in reduced risk of vascular complications. Anatomical variations of the arterial network of the foot and ankle might render the vessels more susceptible to injury during procedures involving the anterior ankle joint. The literature, to our knowledge, reports only one case of a pseudoaneurysm involving the peroneal artery after ankle arthroscopy. Here, we report the unusual case of a 48-year-old man in general good health with the absence of the anterior tibial artery and posterior tibial artery. The patient presented with a pseudoaneurysm of the perforating peroneal artery following ankle arthroscopy for traumatic osteoarthritis associated with nonunion of the medial malleolus. The perforating peroneal artery injury was repaired by performing end-to-end anastomosis. The perforating peroneal artery is at higher risk for iatrogenic injury during ankle arthroscopy in the presence of abnormal arterial variations of the foot and ankle, particularly the absence of the anterior tibial artery and posterior tibial artery. Before ankle arthroscopy, surgeons should therefore carefully observe the course of the perforating peroneal artery on enhanced 3-dimensional computed tomography, especially in patients with a history of trauma to the ankle joint.

Download Full-text

Correlation of Ankle-Brachial Index and Ultrasound Findings on Dorsalis Pedis Artery and Posterior Tibial Artery in Patients with Diabetic Foot Ulcer

Journal of Indonesian Society for Vascular and Endovascular Surgery ◽

10.36864/jinasvs.2020.2.002 ◽

2020 ◽

Vol 1 (2) ◽

pp. 1-5

Author(s):

Dedy Pratama ◽

Mulawardi Mulawardi ◽

Patrianef Darwis

Keyword(s):

Diabetic Foot ◽

Ankle Brachial Index ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Posterior Tibial Artery ◽

Test Results ◽

Posterior Tibial ◽

Tibial Artery ◽

Dorsalis Pedis Artery ◽

Insignificant Correlation

Introduction: In patients with diabetic foot ulcers, atherosclerosis, and endothelial dysfunction can worsen the patient’s vascular condition. Atherosclerosis is one of which is assessed by the ankle-brachial index (ABI). The occurrence of endothelial dysfunction can be identified indirectly from the examination of flow-mediated dilatation (FMD) via doppler ultrasound. This study was conducted to determine whether there is a correlation between the ankle-brachial index examination with ultrasound examinations of the dorsalis pedis artery and posterior tibial arteries in diabetic foot sufferers. Method: The study design was a cross-sectional prospective conducted on 11th November – 15th December 2014 at Cipto Mangungkusumo National Hospital, Fatmawati National Hospital, and Tangerang Hospital. The inclusion criteria used were diabetics and allow for ABI examination and ultrasonography. Patients who did not have a precise diagnosis and had undergone a major amputation of the leg examined were excluded from the study. Results: From the Spearman non-parametric correlation analysis test results obtained significant results on the correlation between ABI and posterior tibial artery volume flow (VF) (p=0.021). In contrast, insignificant results were obtained on the correlation between peak systolic velocity (PSV) dorsalis pedis artery with ABI (p=0.561), as well as an insignificant correlation between VF of dorsalis pedis artery with ABI (p=0.143), as well as insignificant correlation on PSV of posterior tibial artery with ABI (p=0.231) The results of Spearman’s non-parametric correlation analysis test results obtained significant results on the correlation between ABI and ABI spectral picture (p=0,000) in the diabetic foot. Conclusion: There was a significant correlation between the posterior tibial artery VF with ABI and the Doppler ultrasound spectral picture with ABI. Keywords: ultrasound doppler, ankle-brachial index, diabetic foot ulcer, dorsalis pedis artery, popliteal artery

Download Full-text

Quantitative and Qualitative Assessment of the Relative Arterial Contributions to the Calcaneus

Foot & Ankle International ◽

10.1177/1071100717749229 ◽

2018 ◽

Vol 39 (5) ◽

pp. 604-612 ◽

Cited By ~ 2

Author(s):

Johanna C. E. Donders ◽

Craig E. Klinger ◽

Andre D. Shaffer ◽

Lionel E. Lazaro ◽

Ryan R. Thacher ◽

...

Keyword(s):

Posterior Tibial Artery ◽

Quantitative Mri ◽

Peroneal Artery ◽

Anterior Tibial Artery ◽

Soft Tissue Envelope ◽

Posterior Tibial ◽

Tibial Artery ◽

Contrast Enhanced ◽

Entry Points ◽

Anterior Tibial

Background: The purpose of this study was to quantitatively and qualitatively assess relative arterial contributions to the calcaneus. Method: Fourteen cadaveric ankle pairs were used. In each specimen, the posterior tibial artery, peroneal artery, and anterior tibial artery were cannulated and used for contrast-enhanced magnetic resonance imaging (MRI) and computed tomography (CT). Quantitative MRI analysis of the pre- and postcontrast MRI scans facilitated assessment of relative arterial contributions. In addition, postcontrast MRIs were used to measure all perfused arterial entry points and scaled to a 3-dimensional calcaneus model. Contrast-enhanced CT imaging was assessed to further delineate the extraosseous arterial course. Two pairs underwent infusion of diluted BaSO4 through a constant-pressure pump using extended infusion duration. Results: Quantitative MRI findings indicated the peroneal artery provided 52.6% of the calcaneal arterial supply, 31.6% from the posterior tibial artery, and 15.8% from the anterior tibial artery. The cortical entry points were found in fairly consistent patterns along calcaneal cortical surfaces. All specimens demonstrated intraosseous anastomoses between lateral and medial entry points at common locations. Conclusions: The peroneal artery was found to provide the largest calcaneal arterial contribution, followed by the posterior tibial artery and anterior tibial artery. A rich anastomotic arterial network was found supplying the calcaneus. Clinical Relevance: This study provides quantitative and qualitative findings of the relative arterial contribution of the calcaneus. This knowledge can help expand our understanding of calcaneal vascularization, demonstrate the vascular impact of calcaneal fracture and surgery, and facilitate future research on the arterial anatomy of the calcaneal soft tissue envelope.

Download Full-text

Collateral circulation between angiosomes in the feet of diabetic patients

Vascular ◽

10.1177/1708538118759250 ◽

2018 ◽

Vol 26 (4) ◽

pp. 432-439 ◽

Cited By ~ 2

Author(s):

Erkan Orhan ◽

Ömer Özçağlayan

Keyword(s):

Collateral Circulation ◽

Posterior Tibial Artery ◽

Artery Occlusion ◽

Peroneal Artery ◽

Diabetic Patients ◽

Anterior Tibial Artery ◽

Posterior Tibial ◽

Tibial Artery ◽

Anterior Tibial ◽

Tibial Artery Occlusion

Objectives The main factor in the healing of foot ulcers in diabetic patients is adequate perfusion. There is no consensus on whether direct or indirect revascularization is more effective in leg revascularization. At the centre of that debate, there is a disagreement about whether collateral circulation is sufficient or not. Our aim is to evaluate collateral circulation activity between angiosomes in the feet of diabetic patients by evaluating the level of occlusion in leg arteries and comparing the angiosome regions that have necrosis. Methods The study included 61 patients. All had undergone CT angiography to the lower extremity prior to any revascularization of the leg arteries between September 2014 and September 2016. Stenosis was evaluated on the anterior tibial artery, the posterior tibial artery and the peroneal artery up to the level of the ankle. The opening of the vessel wall at the narrowest part of the vessel was determined as a percentage. The areas with necrosis were determined according to the angiosomes of the posterior tibial artery, anterior tibial artery and peroneal artery vessels. Results Necrosis of the foot was most common in the posterior tibial artery angiosome. Necrosis in the posterior tibial artery angiosome was independent of the level of posterior tibial artery occlusion; however, it was associated with the occlusion of the anterior tibial artery ( p < 0.05). It was found that anterior tibial artery occlusion over 15% resulted in necrosis in the posterior tibial artery angiosome. Conclusions Collateral circulation between the anterior tibial artery and posterior tibial artery is active and there is almost always occlusion in the posterior tibial artery branches. The posterior tibial artery angiosome is fed by the collateral arteries of the anterior tibial artery even if there is no occlusion of posterior tibial artery at the level of the leg, so indirect revascularization on the anterior tibial artery is sufficient to provide foot circulation.

Download Full-text

Treatment of Diabetic Foot Ulcers With Necrotizing Fasciitis in the Lower Leg Using the STAGE Principles: A Report of 9 Cases With a Literature Review

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734620943021 ◽

2020 ◽

pp. 153473462094302

Author(s):

Ying Tian ◽

Xu Sun ◽

Chaojun Zhu ◽

Hanchi Sun ◽

Yue Shi ◽

...

Keyword(s):

Necrotizing Fasciitis ◽

Diabetic Foot ◽

Ankle Brachial Index ◽

Rapid Onset ◽

Lower Leg ◽

Foot Ulcers ◽

Layer By Layer ◽

Diabetic Foot Ulcers ◽

Wide Range ◽

The Mean

Diabetic foot ulcers (DFUs) combined with necrotizing fasciitis (NF) has rapid onset, involves a wide range of lesions, is difficult to treat, and has a high mortality rate. It has become a clinically critical disease. DFU patients are at high risk for NF. The STAGE principles guide surgical intervention in the treatment of DFU wounds and emphasizes that “based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound.” This work reports the application of the STAGE principles for the treatment of 9 cases of DFUs combined with NF in the lower leg (Wagner grade 3-5). The mean ankle-brachial index was 0.55 (0-0.91, standard deviation [SD] = 0.33), the mean years of smoking were 19.56 years (0-50, SD = 17.83), and the mean cigarette consumption was 9.11 cigarettes/day (0-20, SD = 7.77). The mean duration of ulcers was 45.56 days (3-103, SD = 35.44). Among the 9 patients, only patient no. 9 died, and the mean follow-up time for the other 8 patients was 12 months (3-36, SD = 13.42). In short, the STAGE principles are also applicable to the treatment of DFUs combined with NF in the lower leg.

Download Full-text

HUBUNGAN ANKLE BRACHIAL INDEX DENGAN KEPARAHAN ULKUS PADA PENDERITA KAKI DIABETIK

JURNAL BIOMEDIK (JBM) ◽

10.35790/jbm.7.3.2015.9488 ◽

2015 ◽

Vol 7 (3) ◽

Author(s):

Amelia L. Kristiani ◽

Richard M. Sumangkut ◽

Hilman P. Limpeleh

Keyword(s):

Diabetic Foot ◽

Ankle Brachial Index ◽

P Value ◽

Diabetic Foot Ulcers ◽

Cross Sectional ◽

Grade 5 ◽

Cross Sectional Design ◽

Vascular Obstruction ◽

Spearman Test ◽

The Relationship

Abstract: This study aimed to determine the relationship between ankle brachial index (ABI) and the severity of ulcer using Wagner classification among patients with diabetic foot in Prof. Dr. R. D. Kandou Hospital Manado. This was an observational study with a cross-sectional design conducted at the Department of Surgery and Department of Internal Medicine of Prof. Dr. R.D. Kandou Manado Hospital from January to June 2015. The results showed that there were 38 patients with diabetic foot ulcers. The highest proportion was the group of patients with Wagner grade 4 (10 patients - 26.3%), followed by grade 1 (9 patients - 23.7%), grade 2 and 3 (each of 8 patients - 21.05%), and grade 5 (3 patients - 7.9%). There were 22 patients (57.9%) with normal ABI values, followed by moderate ischemia in 8 patients (21.1%), mild ischemia in 7 patients (18.4%), and only 1 patient (2.6%) with severe vascular obstruction. The Spearman test showed a P value of 0.008 which meant that there was a significant correlation between ABI and the severity of ulcer. The lower the ABI value, the more severe the ulcer of diabetic foot cases Conclusion: ABI value had a significant relationship with the severity of ulcers of diabetic foot patients.Keywords: ABI, diabetic footAbstrak: Penelitian ini bertujuan untuk mengetahui hubungan Ankle Brachial Index (ABI) dengan derajat keparahan ulkus pada penderita dengan kaki diabetik yang dirawat di RSUP Prof. Dr. R. D. Kandou Manado. Penelitian berupa studi observasional dengan desain potong lintang yang dilakukan di Bagian Bedah dan Bagian Penyakit Dalam RSUP Prof. Dr. R. D. Kandou Manado selama periode Januari sampai Juni 2015. Hasil penelitian mendapatkan 38 penderita kaki diabetik dengan proporsi terbanyak yaitu penderita dengan ulkus Wagner grade 4 sebanyak 10 pasien (26,3%), diikuti grade 1 sebanyak 9 pasien (23,7%), grade 2 dan 3 masing-masing sebanyak 8 pasien (21,05%), dan terakhir ulkus Wagner grade 5 sebanyak 3 pasien (7,9%). Nilai ABI normal didapatkan paling banyak yaitu pada 22 pasien (57,9%), diikuti oleh obstruksi vaskular sedang sebanyak 8 pasien (21,1%) dan iskemi ringan sebanyak 7 pasien (18,4%), dan hanya 1 pasien (2,6%) dengan obstruksi vaskular berat. Hubungan ABI dan keparahan ulkus diuji dengan analisis koefisien koreksi Spearman dan mendapatkan nilai P = 0,008 yang menunjukkan makin rendah nilai ABI maka nilai keparahan ulkus semakin besar. Simpulan: Nilai ABI memiliki hubungan bermakna dengan keparahan ulkus penderita kaki diabetik.Kata kunci: ABI, kaki diabetik

Download Full-text

High tolerance of progressive elastic compression in peripheral arterial disease

VASA ◽

10.1024/0301-1526/a000799 ◽

2019 ◽

Vol 48 (5) ◽

pp. 413-417 ◽

Cited By ~ 2

Author(s):

Serge Couzan ◽

Jean-François Pouget ◽

Claire Le Hello ◽

Céline Chapelle ◽

Silvy Laporte ◽

...

Keyword(s):

Venous Insufficiency ◽

Ankle Brachial Index ◽

Arterial Disease ◽

Return Flow ◽

High Tolerance ◽

Compression Stockings ◽

Short Term ◽

Poor Tolerance ◽

The Mean ◽

Peripheral Arterial

Summary. Background: Theoretically progressive compression stockings, which produce a higher compression at the calf than at the ankle level, improve venous return flow without exacerbating peripheral arterial insufficiency (PAD). We aimed to evaluate the short-term tolerance of elastic progressive compression stockings on peripheral arterial vascularisation in patients with symptomatic PAD and associated mild venous insufficiency. Patients and methods: Monocentric, prospective, open pilot study of 18 patients (acceptability study, 6 x 6 plan) evaluating the short-term tolerance of progressive compression stockings (18 ± 2 mmHg at calf and 8 ± 2 mmHg at ankle level) in patients with PAD (ankle brachial index ABI > 0.60 < 0.75) and chronic venous insufficiency (C1s–C4 stages of the CEAP classification). Day 15 tolerance was evaluated by a composite primary criteria comprising: no decrease > 15 % of ABI on each side, no decrease > 15 % of toe brachial index (TBI) on each side and no decrease > 25 % of the number of active plantar flexions performed while standing. Results: The proportion of men was 77.8 %, mean age was 77.3 ± 7.5 years and no patient were diabetic. At inclusion, the mean low ABI was 0.60 ± 0.04 and the mean high ABI was 0.77 ± 0.18. The mean low TBI was 0.32 ± 0.09 and the mean high TBI 0.46 ± 0.15. The mean number of active standing plantar flexions was 33.0 ± 5.0. The majority of the patients were classified in CEAP C2s and C3 classes (class 2: 16.7 %, class C2s: 27.8 %, class C3: 44.4 %, class C4: 5.6 % and class C4s: 5.6 %). Poor tolerance occurred in no patient. By day 30, no patient had worsening of their arterial and venous symptoms. No adverse events occurred during the study. Conclusions: These results suggest a high tolerance of progressive elastic stockings (18 ± 2 mmHg at calf and 8 ± 2 mmHg at ankle level) in symptomatic PAD.

Download Full-text