Oral session 5: Peripheral arterial disease O5.1 The ABCDE classification of perfusion in the diabetic foot Chris Manu, King's College Hospital, London, United Kingdom Victoria Morris, King's College Hospital, London, United Kingdom Maureen Bates, King's College Hospital, London, United Kingdom Nina Petrova, King's College Hospital, London, United Kingdom Marcus Simmgen, King's College Hospital, London, United Kingdom Prashanth Vas, King's College Hospital, London, United Kingdom Hisham Rashid, King's College Hospital, London, United Kingdom Michael Edmonds, King's College Hospital, London, United Kingdom Aim: A new classification that grades the varying degrees of perfusion in the diabetic foot is needed to match the most appropriate intervention. The aim was to create a new classification that reflects the spectrum of impairment of perfusion. Method: Recruited consecutive clinic patients with an ulcer in one or both feet. We measured brachial and toe blood pressure (TBP) and derived the toe brachial index (TBPI) in both feet. We then measured transcutaneous oxygen tension (TcP02), at the dorsum of both feet in supine position and the forearm, and derived the TcP02 Index as a ratio of TcP02 on the foot/arm. If foot TcP02 was ≥40mmHg, we then measured it after a provocation test of 30o leg elevation for 5 minutes. If supine TcP02 was <40mmHg, we then measured it after an oxygen challenge (inhalation of 100% oxygen for 10min). All measurements were done with PeriFlux System 5000 Results: We studied 194 limbs in 102 patients. Ninety limbs had a TBPI of ≥0.7 and TcP02 Index of 0.84±0.19 (Mean±SD), indicating limbs with good perfusion and were graded as Group A. There were 104 limbs with TBPI <0.7 of which 68 had TcPO2 ≥40mmHg; 39 of the 68 limbs had a sustained TcPO2 that did not fall on leg elevation and were graded as Group B, but 29/68 had a fall of >10mmHg and were graded as Group C. TBP was significantly greater at 70±22mmHg in Group B compared with 55±19mmHg in Group C [p=0.004]. Thirty six of the 104 limbs with TBPI <0.7 had TcPO2 <40mmHg. It was possible to perform oxygen challenge on 21; 7 responded normally, with restoration of TcPO2 Index and were graded as Group D, but 14 did not respond, and were graded as Group E. Baseline TcPO2 was significantly greater at 31±12mmHg in Group D vs 17±13mmHg in Group E [p=0.028] Conclusion: We have classified 5 grades of perfusion using a 3 step approach of TBPI, TcPO2 and a provocation test. Group A: TBPI ≥0.7, Group B: TBPI <0.7 TcPO2 ≥40mmHg sustained on elevation, Group C: TBPI <0.7, TcPO2 ≥40mmHg falling on elevation, Group D: TBPI <0.7, TcPO2 <40mmHg with restoration of TcPO2 Index on oxygen challenge, and Group E: TBPI <0.7, TcPO2 <40mmHg with failure to restore TcPO2 Index. The ABCDE classification grades the spectrum of perfusion to aid appropriate intervention in the diabetic foot. No external funding www.diabeticfoot.nl Page 1 of 5 O5.2 Predictors of poor outcome in non-revascularized patients with a diabetic foot ulcer and peripheral arterial disease Jack Brownrigg, St George's Vascular Institute, London, United Kingdom Kristy Pickwell, University Hospital Maastricht, Maastricht, Netherlands Eurodiale Consortium, University Hospital Maastricht, Maastricht, Netherlands Robert Hinchliffe, St. George's Vascular Institute, London, United Kingdom Nicolaas Schaper, University Hospital Maastricht, Maastricht, Netherlands Aim:, The decision to perform complex and invasive revascularization procedures in patients with a diabetic foot ulcer (DFU) and peripheral arterial disease (PAD) is challenging., To identify patients who should be considered a priority for revascularization, we determined factors associated with major amputation and failure of the ulcer to heal in patients who did not undergo revascularization Methods: We analyzed the characteristics and outcomes of a cohort of 503 patients with newly presenting DFU and PAD in a large multicentre European study (Eurodiale). Results: Twenty-eight percent of patients with PAD were revascularized. Outcome with regards to healing, major amputation and death was comparable between revascularized and non-revascularized patients, although revascularized patients had more characteristics associated with poor outcome. Ankle-brachial index (ABI) < 0.9 was associated with failure to heal, major amputation and death in, the univariate analyses, but did not independently predict failure to heal or major amputation in those with PAD who were not revascularized.In patients who were not revascularized, a previous contralateral amputation, ulcer duration > 3 months, rest pain, the presence of multiple and large ulcers, osteomyelitis and ulcer location on the posterior heel were predictors of failure to heal and major amputation. These variables did not predict poor outcome in revascularized patients. Conclusions: Although not an independent predictor of poor outcome, lower ABI at presentation was associated with failure to heal and major amputation in patients with DFU and PAD. A history of amputation, rest pain and certain ulcer characteristics were important predictors of poor outcome in those patients with DFU and PAD who were not revascularized; therefore these patients should be considered a priority for revascularization. www.diabeticfoot.nl Page 2 of 5 O5.3 Angiosome-driven revascularization prevents major amputations and increases life expectancy in, patients with critical limb, ischemia (CLI) Alberto Coppelli, University of Pisa, Pisa, Italy Elisabetta Iacopi, University of Pisa, Pisa, Italy Irene Bargellini, University of Pisa, Pisa, Italy Chiara Goretti, University of Pisa, Pisa, Italy Antonello Cicorelli, University of Pisa, Pisa, Italy Alessandro Lunardi, University of Pisa, Pisa, Italy Roberto Cioni, University of Pisa, Pisa, Italy Alberto Piaggesi, University of Pisa, Pisa, Italy Aim: The role of the angiosome model (AM) as a guide for revascularization procedures is debated. We evaluated whether direct or indirect revascularization, according to AM, affects clinical outcomes in type 2 diabetic patients (T2DM) with CLI undergoing percutaneous trans-luminal angioplasty (PTA). Methods: We retrospectively evaluated 445 consecutive successful lower limb PTA performed in 370 T2DM (M/F: 257/113; age: 73.5±9.3 yrs; BMI: 27.4±4.8 Kg/m2; diabetes duration: 21.4±12.8 yrs; HbA1c 7.8±1.6%) admitted to our department for CLI and diabetic foot ulceration (DFU). Patients were divided into 2 groups: direct (DG - 266 pts, 72%) or indirect (IG - 104 pts, 28%) depending on whether the flow to the artery directly feeding the site of ulceration, according to the AM, was successfully aquired or not. No significant differences were observed between the two groups regarding, main clinical characteristics. Ulcer healing (HR), major amputation (MA) and death (D) rates were compared in the two groups during a follow-up of 18.9±12.4 months (range 1.7-43.2 months). Results: HR was 68% in DG vs 52% in IG (χ2 = 9.6; p<0.05). MA rate was 11% in DG vs 4% in IG (χ2 = 9.4; p<0.02). Cumulative mortality rate during follow-up was 14% in DG and 27% in IG (χ2 = 8.7; p<0.02). Conclusions: Our data show that direct revascularization of arteries supplying the DFU site results in higher healing rates and lower amputation and mortality rates compared to the indirect one. Thus, AM should be pursued in diabetic patients with DFU whenever PTA, is chosen as revascularization procedure. www.diabeticfoot.nl Page 3 of 5 O5.4 Two-year mortality and amputation rates in diabetic patients with critical limb ischemia treated by cell therapy or angioplasty Michal Dubsky, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Alexandra Jirkovska, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Robert Bem, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Andrea Nemcova, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Vladimira Fejfarova, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Veronika Woskova, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Aim: Autologous stem cell therapy (SCT) is a new therapeutic approach for patients with critical limb ischemia (CLI) not eligible for standard revascularization. However, data on the long-term effects of this procedure are lacking. The aim of our study was to compare the mortality and amputation rates of diabetic patients with CLI treated by SCT, repeated percutaneous transluminal angioplasty (re-PTA) or conservatively. Methods: We included and retrospectively analysed 198 diabetic patients with CLI (defined as transcutaneous oxygen pressure [TcPO2]<30 mm Hg with ulcers or gangrene) after unsuccessful PTA or bypass treated in our foot clinic over 6 years. Ninety-nine patients were indicated for re-PTA. Of the 99 patients who were ineligible for standard revascularization, 45 were treated by autologous stem cells (SCT group) and 44 patients were treated conservatively (because of transient changes in the laws regarding SCT in our country) and formed the control group. Mortality and rates of major amputation were assessed over 24 months; TcPO2 was assessed after 12 and 24 months. Results: There was no significant difference in mortality rates among the SCT, PTA, and control groups (26.7 vs. 18.2 vs. 25%). The rate of major amputation after 24 months was significantly lower in the SCT and PTA groups in comparison with controls (31.4 vs. 23.4 vs. 51.1%; p=0.04 and p=0.01), but with no significant differences between the active treatment groups. Frequency of cardiovascular diseases (myocardial infarction, stroke, ischemic heart disease) was significantly higher in the SCT group (73.3%) in comparison with the PTA and control groups (56.6 vs. 59.1%; p=0.032). Increases in TcPO2 did not differ between the SCT and PTA groups till 24 months (both p<0.05 compared to baseline); TcPO2 in the control group did not change during the follow-up period., Conclusion: Our study showed a comparable 2-year mortality in patients with CLI treated by SCT, PTA or conservatively. The rate of major amputation was lower in both active treatment groups compared to conservative therapy. Our results suggest that SCT has the potential to be a promising treatment in diabetic patients with CLI, even with significantly more prevalent cardiovascular disease. Supported by MZO 00023001. www.diabeticfoot.nl Page 4 of 5 O5.5 Management of diabetic patients on dialysis affected by peripheral arterial disease and foot ulcer: outcomes after endovascular treatment Marco Meloni, University of Tor Vergata, Rome, Italy Luigi Uccioli, University of Tor Vergata, Rome, Italy Valentina Izzo, University of Tor Vergata, Rome, RM, Italy Erika Vainieri, University of Tor Vergata, Rome, Italy Valeria Ruotolo, University of Tor Vergata, Rome, Italy Laura Giurato, University of Tor Vergata, Rome, Italy Roberto Gandini, University of Tor Vergata, Rome, Italy Aim: Nowadays the increased prevalence of dialysed patients among diabetics is a burden. Dialysis is a strong risk factor for peripheral arterial disease (PAD) and independently predicts nonhealing of ischaemic foot lesion (FL) and major amputation. It is documented that primary amputation rate can reach the 44% in case of PAD and FL in dialysed patients.¹ The treatment of these patients is still an unmet clinical need. The aim of this study was to evaluate the outcomes after percutaneous transluminal angioplasty (PTA) in diabetic patients on dialysis affected by PAD and FL. Methods: The study cohort included 577 diabetic patients with FL and PAD who underwent PTA. According to dialysis therapy patients were divided into, two groups: dialysed subjects (DS) (n=91) and not dialysed subjects (NDS) (n=486). After revascularization patients were observed with a close follow-up. Periodically debridement, infection control e TcPO2 were performed. We reported the outcomes in terms of limb salvage, major amputation and death at 12 months of follow-up. Results: In the overall analysis DS had more cardiovascular risk factor (5 risk factors 13 6 vs 5 5% p=0 03), more ischemic heart disease (55 7 vs 41 5% p=0.02) and more control of LDL levels (LDL < 70 mg/dl 41 3 vs 26 7% p=0.04) than NDS. Outcomes for DS and NDS were respectively : limb salvage(67 vs 79%), major amputation (14 2 vs 11 3%), death (18 8 vs 9 7%) (χ2=0.03)., Conclusions: Our data confirmed the worse outcome in dialysed patients as yet described in literature. However, these results are interesting when compared to the average of published data; in fact we found a reduced rate of mortality (19% vs 38%) and major amputation (14 vs 22%) at 1-year follow-up. Further, comparing these results to our previous data, we have found a sensible improvement in the rate of limb salvage (67 vs 60%).² We retain that it could be explained by the current greater carefulness to dialysed subject, the better knowledge of PAD dialysis-related, the improvement of techniques in the endovascular treatment and the close monitoring after revascularization. www.diabeticfoot.nl Page 5 of 5
© Copyright 2024