The Study On The Diabetic Foot With Severe Peripheral Arterial Occlusive Disease

Backgroud: The diabetic foot is a kind of pathological conditions of foot or lower limbs of tissue destruction in diabetes mellitus (DM) patients, lower vascular lesions and neuropathy and the common infections, From the skin to the bone and joint of organizations are involved, the most common is serious ulcers, need amputation. Amputation affect not only the quality of life of the patients, and increases the risk of serious side amputation, can be disabled, and even death. According to statistics, the amputation rate of diabetic foot is 15 times. There is more than 50% of DM patients in patients with traumatic amputation each year, and amputation at least 50% of patients with DM is avoided. Research shows that the lifetime risk of developing a foot ulcer in diabetic patients may be as high as 25%. Foot ulceration requires long and intensive treatment, and is associated with major healthcare costs.PAD is present in approximately more than one-half of all patients with foot ulcers,and have close relations with the occurrence and prognosis of the diabetic foot, the DM PAD incidence is higher 20 times than the non-DM patients,8% of patients diagnosed DM exist the PAD, and with the age and duration increase, the incidence of DM is 45% after 20 years. The patients with serious PAD not only faced the danger of limb amputations but also increased the risk of death 4-7 times.The macrovascular basic lesions of DM has the following features: (1) onset fast, progress quickly, without apparent sex differences. (2) clotting activity increaseing, easy thrombosis. (3) the DM macrovascular lesions distribution was different with the non-DM patients. The former macrovascular lesions mainly involved the tibialis peroneal artery below knee,the relative incidence is 90%, so called DM "tibial arterial disease;" While the latter only 10%.(4)the lower limbs arteries calcification is outstanding, and have to do with the distribution characteristics of DM macrovascular lesions.With imaging technology development and application, we can be more clear examine the PAD condition of diabetes patients. The ultrasonic examination have the advantages of direct-viewing, without trauma, duplicating an operation, especially the color doppler flow imaging technology and high resolution ultrasonic technology unceasing enhancement, applied in blood test, not only can clearly show the domestic change of blood streem, but also measure the blood wall thickening of the Intima-Media Thickness, the size of the lumen,and observe the scope of arteriosclerosis,the position and types of plaque formation, and can also provide plaques internal structure and hemodynamic parameters.Three-dimensional CT angiography was an angiographic method that applied spiral CT scan on a 3D reconstruction, all process was accomplished by computer, data obtained by continuous cross-sectional CT through special processing, reconstruction 3D object-relievo. Its superiority displays in: (1) the examination time is short;(2)lesions stereo image clear and the relationship of the surrounding tissues observed easily;(3) a scan can omni-directional observation;(4)major vascular can simultaneous display. At the present time, the application of this method in lower limb artery disease is less reported.Percutaneous balloon angioplasty (PTA) is used to expand the site of artery occlusion by special balloon compression with certain pressure, will oppress and tighten the atherosclerotic plaques, tear endarterium and mesolamella, extend and expand middle elastic fiber, collagen and smooth muscle fiber, thus make arterial lumen expansion. Due to the below-knee arterial lumen is thin, the balloon to less than 4mm in diameter, and the materials demand of balloon,catheter,Guidewire is very high. Therefore, in the 1990s in abroad the PTA begin to be used in below-knee arteriostenosis and occlusion, but in domestic we attempt to use after 2005. Because of the characteristic of diabetic PAD lesion, the rate of restenosis after PTA was higher,the application of surgery in patients with diabetes foot is controversial.At present,In diabetic crowd,the accurate information of PAD is shortage, for the treatment of PAD,especially the efficacy of PTA to diabetes foot remains to be further research, the purpose of this study focused on the following four aspects:The first part: The study on the relationship between severe peripheral arterial disease diagnosing by the Doppler Ultrasonic examination and diabetic foot in patients with type 2 diabetes.The second part: The application of slice spiral CT angiography in diagnosing diseases of diabetic lower-limb artery, and The consistency study of the CTA technology and the DSA check. The third part: the relationship between the evaluation of the CTA technical inspection in arterial lesions of lower limb diabetes and the recent amputation rate of diabetes foot.The fourth part: the application of percutaneous transluminal angioplasty in arterial lesions of lower limb diabetes in patients with diabetic foot.Part 1Objective The study is to determine the prevalence of peripheral arterial occlusive disease in diabetes population with or without diabetic foot; meanwhile, we hope to estimate the relationship between the PAD and the diabetic foot.Methods firstly, to determine the prevalence of PAD in diabetes, and secondly, to evaluate the predictive value of PAD in relation to diabetic foot. A total of 523 patients with type 2 diabetes, in provincial hospital affiliated to Shandong University, were enrolled in the study and underwent PAD test by Doppler Ultrasonic examination. The diabetic patients were interviewed about duration, treatment profile, presence or absence of chronic DM complications, blood pressure, Height ,Body mass index (BMI). Fasting blood samples were taken to assess lipid profile, blood sugar and glycated hemoglobin (HbA1C) levels, total lipid profile (high density lipoprotein (HDL),low density lipoprotein (LDL)) and Urinary the profunda femoral artery, the popliteal artery, the anterior tibial artery, the posterior tibial artery, and the peroneal artery. Determined by Ultrasonic examination, patients were divided into three groups: group A had not peripheral artery disease, group B had moderate peripheral artery disease whose peripheral artery's stenoses involved a reduction in the vessel lumen of 50%, and group C had severe peripheral artery disease whose peripheral artery's stenoses involved 50 to 100%. The diagnosis of diabetic foot accorded to Wagner classification.Results and conclusion (1) Among the 523 patients, 95 patients were afflicted with diabetic foot, 311 patients were PAD and 131 patients were critical PAD, There were 55 patients with critical PAD among 95 patients with diabetic foot. (2) The multivariate logistic regression analysis revealed that severe PAD was significantly associated with diabetic foot, (OR=5.00), other risk factors included Smoking habit, prevalence of nephropath and Hypertension.Conclusion severe PAD, Smoking habit, prevalence of nephropath and Hypertension were significantly associated with diabetic foot, (OR=5.00)Part 2Objective: To assess the role of slice spiral CT angiography for lower limb arterial diseases in diabetic foot.Methods: 30 cases of diabetic feet with lower limb arteries were studied ,the helical scans cover abdominal aorta to the artery of the lower extremity. We used Siemens Wizard workstation for 3D reconstruction. While all the cases underwent digital subtraction angiography (DSA) in a week. All the observed arteries were divided into two groups,group A included common femoral artery,the superficial femoral artery and the popliteal artery, while group B include the anterior tibial artery, the posterior tibial artery, the peroneal artery and the dorsal pedal artery.Results: the kappa value is 0.787 of group A and 0.649 of group B. With regard to segments that had more than moderate stenosis , the sensitivity , specificity and accuracy of MIP were 93.3%,94.8%,95.5% in group A, while in group B the sensitivity,specificity and accuracy of MIP were 91.9%,90.6%,91.7% .Conclusion: The assessment of angiography of diseases of lower limb arteries with slice spiral CT is equal to DSA basically in diebetic foot patients, which can be used in the evaluation before and behind the reconstitution of the lower limb arteries.Part 3Objective To determine the relationship between angiographic evaluation of peripheral arterial occlusive disease and amputation in diabetic foot.Methods There were 95 patients involved in this study. All the patients were divided into two groups after 1 year's observasion according to with or without amputation. The diabetic patients were interviewed about duration, treatment profile, presence or absence of chronic DM complications, prior amputation, blood pressure, height, and body mass index (BMI). Fasting blood samples were taken to assess lipid profile, blood sugar and glycated hemoglobin (HbA1C) levels, total lipid profile (high density lipoprotein (HDL), low density lipoprotein (LDL)) and urinary albumin concentration. Lower limb arterial diseases were assessed in all the diabetic foot by slice spiral CT angiography(CTA). All the patients underwent CTA examination on the common iliac artery, the external iliac artery, the femoral artery, the popliteal artery, the anterior tibial artery, the posterior tibial artery, the peroneal artery and the dorsal artery of foot. Diagnosis of diabetic foot accorded with Wagner classification.Results: Amputation was carried out in 23.2% of the patients afflicted with diabetic foot. Multivariate logistic regression analysis revealed that angiographic score(OR=1.2 , p=0.012), complicated Infection(OR=4.2 , p=0.027) and Prior amputation(OR=5.8, p=0.017) were independent risk factors for amputation.Conclusion: Angiographic score, complicated infection and prior amputation are independent risk factors for amputation.Part 4Objective: To explore the efect of percutaneous transluminal angioplasty(PTA) on diabetic foot with infrapopliteal arteries disease. Methods From June 2006 to May 2008.62 patients with lower limb ischemia induced wound were analysed and evaluated. Among them,22 patients with lower limb ischemia were treated by lower arterial vascular reconstruction. The patients with lower limb ischemia were examined by slice spiral CT angiography (CTA)and colour Doppler, percutaneous transluminal angioplasty(PTA) as a primary treatment of the infrapopliteal arteries in critical limb ischemia of diabetic foot. The time of wound repair and the rate of recur rence and the rate of amputation of patients with lower limb ischemia were analysed. Results (1) The colour Doppler were performed in 62 patients with lower limb ischemia, Among them, all critical stonesis occurred in infrapopliteal artery (2) the average . angiographic score is 7. (3)The percutaneous transluminal angioplasty(PTA) with 'deep' balloon was performed in 22 patients with lower limb ischemia of diabetic foot,and 18 patients(82%) were successful, Among them, (4)The shortened days of wound repair of patients with lower limb ischemia between the group of lower arterial vascular reconstruction and the group of control was 20±5(P<0. 05). The rate of amputation of patients with lower limb ischemia of two groups of reconstructing of lower arterial vascular reconstruction and no lower arterial reconstruction was 6%(1 / 18)and 16% (7 / 44), respectively. The rate of recurrence of diabetic foot of the two groups was 8% (1 / 13)and 17.6%(6 / 34), respectively.Conclusion: The infrapopliteal arteries vascular reconstruction could accelerate wound repair of diabetic patients,and deduce the recurrence of diabetic foot.