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Minicorso GISE: Interventistica per gli arti inferiori e per il piede diabetico. EPIDEMIOLOGY, PATHOPHYSIOLOGY AND NATURAL HISTORY OF ARTERIOPATHY OF THE LOWER LIMB & ISCHEMIC DIABETIC FOOT. Giuseppe Biondi Zoccai Ospedale San Giovanni Battista “Molinette” Università di Torino - PowerPoint PPT Presentation
Citation preview
EPIDEMIOLOGY PATHOPHYSIOLOGY AND EPIDEMIOLOGY PATHOPHYSIOLOGY AND
NATURAL HISTORY OF ARTERIOPATHY OF THE NATURAL HISTORY OF ARTERIOPATHY OF THE
LOWER LIMB amp ISCHEMIC DIABETIC FOOTLOWER LIMB amp ISCHEMIC DIABETIC FOOT
Giuseppe Biondi ZoccaiGiuseppe Biondi Zoccai
Ospedale San Giovanni Battista ldquoMolinetterdquoOspedale San Giovanni Battista ldquoMolinetterdquoUniversitagrave di TorinoUniversitagrave di Torino
gbiondizoccaigmailcomgbiondizoccaigmailcom
Minicorso GISEInterventistica per gli arti inferiori
e per il piede diabetico
Genova martedigrave 2 ottobre 2007 ndash 1320-1335
DISCLOSURE
bull Consultant Boston Scientific Cordis Mediolanum Cardio Research
bull Lecture fees Bristol-Myers Squibb
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE
ACCAHA Circulation 2005
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DISCLOSURE
bull Consultant Boston Scientific Cordis Mediolanum Cardio Research
bull Lecture fees Bristol-Myers Squibb
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE
ACCAHA Circulation 2005
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE
ACCAHA Circulation 2005
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE
ACCAHA Circulation 2005
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE
ACCAHA Circulation 2005
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CLINICAL PRESENTATION OF PAD PATIENTS
Chronic Limb Ischemia
Acute Limb Ischemia
AsymptomaticPAD
StableClaudication
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
THE TIP OF THE ICEBERG
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
BURDEN OF PAD
Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)
Myocardial infarctionMyocardial infarction
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia
claudication claudication gangrene necrosisgangrene necrosis
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CLASSIFICATION
Mukherjee et al AHJ 2005
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CASE FATALITY OF PAD
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
LONG-TERM PROGNOSIS
16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and
1995 with follow-up complete to March 1998
Caro et al BMC Cardiovasc Dis 2005
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
OVERLAP IN ATHEROTHROMBOSIS
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PAD IN ITALY
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
COMPARING SEVERITY
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ATHEROSCLEROSIS
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
LARGE VS SMALL VESSELS
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
RISK FACTORS FOR PAD
TASC EJVES 2007
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
LEARNING GOALS
bull Epidemiology
bull Pathophysiology
bull Natural history
of lower limb atherosclerotic disease and ischemic diabetic foot
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CRITICAL LIMB ISCHEMIA
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CLASSIFICATION
Mukherjee et al AHJ 2005
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CRITICAL LIMB ISCHEMIA
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DIABETES AND ULCER
bull Diabetes is 1st cause of lower extremity amputation in Europe
bull Lifetime risk of ulcer 15 (up to 25)
bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES
bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral
sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma
bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia
bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular
bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT
bull Older agebull Male genderbull Diabetes (especially diabetes duration
HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CLAUDICATION IN DIABETICS
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
CAUSES OF FOOT ULCERS
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CAUSES OF ULCERS Causal Pathways
NEUROPATHY Neuropathy 78
Minor trauma 79
DEFORMITY Deformity 63
Behavioral issues
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical
ULCER Diabetes Care 1999 22157
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DIABETIC NEUROPATHY
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
NEUROPATHY VS ISCHEMIA
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
CHARCOT FOOT
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
FOOT TRAUMA
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DIABETIC FOOT TRIAD
TRAUMATRAUMAN
euro
path
y
Neu
ropa
thy
IschemiaIschemia
ULCERULCER
Infection
Infection
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
BILATERAL INVOLVEMENT
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
RISK FACTORS FOR CLI
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection
bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing
bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS
bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Peripheral sensory neuropathy
bull Structural foot deformitybull Trauma and improperly
fitted shoesbull Callusbull History prior
ulcersamputationsbull Prolonged elevated
pressures on foot
bull Limited joint mobilitybull Uncontrolled
hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
RISK FACTORS FOR DIABETIC FOOT ULCERS
bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world
bull It is characterised by multiple long-term complications affecting almost every system in the body
bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients
bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
WOUND CLASSIFICATION
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DIABETIC VASCULOPATHY
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
FOOT ULCERS IN DIABETES
Precipitate 85 of amputations ldquoRule of 15rdquo
bull 15 of diabetes patients Foot ulcer in lifetime
bull 15 of foot ulcers Osteomyelitis
bull 15 of foot ulcers Amputation
Clinical Care of the Diabetic Foot 2005
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
AMPUTATIONS IN DIABETES
Tragic ldquoRules of 50rdquo
bull 50 of amputations transfemoraltranstibial level
bull 50 of patients 2nd amputation in 5y
bull 50 of patients Die in 5y
Clinical Care of the Diabetic Foot 2005
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
RISK FACTORS FOR AMPUTATION
bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TASC EJVES 2007
PROGNOSIS OF CLI
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PROBABILITY OF HEALING
Documento di Consenso internazionale sul Piede Diabetico 1999
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
QUESTIONS
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TAKE HOME MESSAGES
bull PAD prevalence and incidence are increasing in developed countries
bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia
bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI
bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
THE RISK OF PROGRESSION IS HIGH
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
SHOULD WE TREAT OR PREVENT
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ALGORITHM FOR FOOT ULCER
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PAD in patients with CAD
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PULSE PALPATION
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ABI
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ABI
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
PVR
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
TcPO2
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
OSSIMETRIA TRANSCUTANEA
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DOPPLER ECHOGRAPHY
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ALGORITMO STANDARD
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
APPROPRIATE SHOES
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
ALGORITHM
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
DEBRIDEMENT
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
VASCULAR SURGERY
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml
For further slides on these topics please feel free to visit the metcardioorg website
httpwwwmetcardioorgslideshtml