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