1. health and fitness
2. disease

Poster session 6: Peripheral arterial disease
P6.01
The prevalence of asymptomatic peripheral arterial disease in diabetic patients at
Siriraj Hospital
Navaporn Chadchavalpanichaya, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Aim: To study the prevalence of asymptomatic peripheral arterial disease in diabetic patients
at Siriraj Hospital.
Study design: A cross-sectional descriptive study
Setting: Outpatient Diabetes Mellitus Clinic, Siriraj Hospital, Thailand
Methods: Diabetic patients were randomly sampling from Outpatient Diabetes Mellitus Clinic
between February and April 2014. All participants were interviewed about the background
information, co-morbid diseases and current medications and were evaluated the vascular
claudication symptom by using the Edinburgh Claudication Questionnaire. Ankle-brachial
index (ABI) and foot protective sensation were also examined and recorded.
Results: Two hundred and fifty diabetic patients were studied. Most of the patients were
female (57.6 %) with an average age of 61.79 years. Most of them were diagnosed diabetes
more than 10 years (56%). The Majority of the patients had hypertension as co-morbid
disease (70%). Twenty- four percent of the patients had history of smoking or current
smoking. Forty-three patients had loss protective sensation (17.2%)., The prevalence of
peripheral arterial disease (PAD) was 6% and the prevalence of asymptomatic PAD or
atypical symptomatic PAD was 5.2%. The factor associated with PAD was age equal or
older than 70 years old (odds ratio=4.68, 95% CI 1.50-14.68). Furthermore, the factor
associated with asymptomatic or atypical symptomatic PAD was losing protective sensation
(odds ratio=14.27, 95% CI 4.15-49.09).
Conclusions: The prevalence of PAD at Outpatient Diabetes Mellitus Clinic, Siriraj Hospital
was 6% and the prevalence of asymptomatic or atypical symptomatic PAD was 5.2%. The
factor associated with PAD was age equal or older than 70 years old and the factor
associated with asymptomatic or atypical symptomatic PAD was losing protective sensation.
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P6.02
Prevalence of asymptomatic peripheral arterial disease in type 2 diabetic patients
Mona Mohamed Abdelsalam, Ain Shams University, Cairo, Egypt
Mohamed Reda Halawa, Ain Shams University, Cairo, Egypt
Yara Mohamed Eid, Ain Shams University, Cairo, Egypt
Haitham Ahmed Hamid, Ain Shams University Hospital, Cairo, Egypt
Aim of the work: Study the prevalence of asymptomatic peripheral arterial disease (PAD) in
a cohort of patients with type 2 diabetes attending a tertiary care hospital using Ankle
Brachial Index (ABI).
Patients and methods: 150 patients with type 2 Diabetes mellitus participated. Those with
PAD were excluded. All patients underwent the following: History taking and thorough
physical examination. FBS, HbA1c, Fasting Lipid profile. Ankle Brachial Index (ABI) was
done using standered 8 Mhz hand Doppler following Rumwell et al. (1996) steps.
Results: 49 patients showed abnormal ABI (33%), 36 patients with ABI <0.9(24%), 10
patients with ABI <0.8 (6.6%) and 3 patients with ABI>1.3 (2%).
Those with ABI <0.9 had lost monofilament test in 69.44% of cases in comparison to those
with ABI >0.9 (34.51%) with P value <0.001. Those with ABI <0.9 had trophic changes in 50
% of cases in comparison to those with ABI >0.9 (23.89%) with P value 0.003. Family history
of PAD was positive in 36.11% of subject with ABI <0.9 in comparison to 18.58% of subject
with ABI >0.9 with P value <0.02. There were significant difference as regard BMI (P <0.001)
and duration of diabetes (P <0.01). In addition, there was no significant difference between
both groups as regard gender, smoking, and history of hypertension, cerebrovascular stroke
and coronary artery disease. No significant difference in glycemic and lipid profile.
Conclusion: The Prevalence of asymptomatic PAD in the studied group of patients with
type 2 diabetes was about 33%. Lost protective sensations and trophic changes and positive
family history of PAD, longer duration of diabetes and higher BMI were more common in
those with ABI<0.9.
ABBREVIATION: ABI=Ankle Brachial Index, PAD=Peripheral Arterial Disease, BMI=Body
Mass Index. FBS=Fasting Blood Sugar, HbA1c=Hemoglobin A1c
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P6.03
Do diabetics have a higher proportion of infra-popliteal disease compared to nondiabetics? A pilot study
Danielle Lowry, University Hospital Birmingham NHS Foundation Trust, Birmingham, United
Kingdom
Parth Narendran, University of Birmingham, Birmingham, United Kingdom
Mujahid Saeed, University Hospital Birmingham NHS Foundation Trust, Birmingham, United
Kingdom
James Hodson, University Hospital Birmingham NHS Foundation Trust, Birmingham, United
Kingdom
Alok Tiwari, University Hospital Birmingham NHS Foundation Trust, Birmingham, United
Kingdom
Introduction: Diabetes mellitus (DM) predisposes to atherosclerotic disease. Patients with
DM and peripheral vascular disease have poorer outcomes compared to non-diabetics
(NDM).
This pilot study, by adapting Bollinger's score, tests the hypothesis that patients with DM
have increased infra-popliteal arterial disease compared to NDM.
Methods: All DM patients who had a lower limb angiogram between September 2010 and
April 2014 at a single centre were identified along with demographic data. An age and sex
matched NDM control group was extracted from the same time period. The pilot study was a
random sample of these patients.
Bollinger's score assesses morphological changes in 10 arterial segments, from the infrarenal aorta to the proximal anterior tibial (ATA), posterior tibial (PTA) and peroneal arteries
(PEA). Zero is normal artery, 15 represents occlusion in over half of the segment., For our
purposes the score was extended distally with new segments described to cover the length
of the ATA, PTA, PEA, dorsalis pedis, medial plantar and lateral plantar arteries.
Results: There were 119 patients in the DM group and 97 in the NDM group. The mean age
of the DM group was 70 years (SD ±11) and NDM group 69 years (±13, p 0.51). Seventyfour percent of NDM patients and 71% of DM were male (p 0.647).
The external iliac artery was the only artery to have a significantly higher score in the NDM
group than the DM group. The DM group had significantly higher scores in all segments of
the PTA, and higher scores in all segments of the ATA. The PEA was relatively spared
(Table 1).
Conclusions: This pilot study supports the hypothesis that DM predisposes to infra-popliteal
disease. In DM the PEA may be the optimal target for durable surgical revascularisation.
Further data is required.
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Table 1: Comparing the median Bollinger score of diabetics to non-diabetics by arterial
segment
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P6.04
Lower extremity amputations and revascularization procedures: Is there a link?
Roberto Anichini, General Hospital of Pistoia usl 3, Pistoia, Italy
flavia lombardo, National Centre for Epidemiology National Istitute of Health, Rome, Italy
Anna Tedeschi, General Hospital of Pistoia, Pistoia, Italy
Giuseppe Seghieri, General Hospital of Pistoia, Pistoia, Italy
Marina Maggini, National Centre for Epidemiology National Istitute of Health, Rome, Italy
Alessandra de Bellis, General Hospital of Pistoia, Pistoia, Italy
Background: There is a long tradition in the field of distal revascularization in Italy, which, is
one of the few countries where revascularization is routinely used to treat diabetic patients.
Lower extremity revascularization is effective in preventing amputation, but whether exists a
relationship between the, reduced number of amputations and the increased number of
revascularization procedures (RevP), remains to be clarified.
Objective: To test whether there is a relationship between, Italian and regional, trend
amputation and lower extremity revascularization in persons, with diabetes, in years 20032012.
Methods: Retrospective analysis, of the number of amputations in, persons with diabetes
occurred in years 2003-2012 in Italy, and the number of revascularization procedures
(RevP), in the same period of time .
Results: In Italy in the years 2003-2012 the number of lower extremity amputations (LEAs)
appears to be, decreased. Total amputations decreased from 3.6 for 1000 persons to 2.7 (23.4%), minor amputations reduced, from 2.2 to 1.9% (- 13.1%), and major from 1.2 to 0.7,
(-38.1%) (p<0 0001). In the same period of time, the number of total, vascular procedures, ,
progressively increased. In 2003, 4.0 for 1000 persons with diabetes underwent, RevP;, 2.5
had endoluminar revascularization (ER), while 1.4%, had surgery procedures (SP). In 2012:
RevP were 4.7 of which, 4.1 were ER and, 0.6 SP. The trend was + 61 3%, for ER, and 55.5% for SP. Gender Difference of RevP show a RR=3 ( male to female), and RevP
patiens were significantly older in 2012 compared to those in 2003 (p>0 01). The, trend of,
amputation and revascularization wasn’t homogeneus in the different regions of Italy. For
example it is clear that in some regions a lower amputation rate is clearly, linked to an
increased number of RevP, while in other regions this is not demonstrated.
Conclusion: In Italy in years 2003-2012, the number of, LEAs dramatically reduced, and in
the same period of time the number of, RevP increased. However, further analysis of data is
needed to better clarify the relationship between, the, reduced number of amputations and
the increased number of revascularization.
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P6.05
The Neuro-ischemic foot. When are they evaluated for vascular surgery and what
happens?
Klaus Kirketerp-Møller, Steno Diabetes Centre A/S, Gentofte, Denmark
Annemette Nielsen, Steno Diabetes Centre A/S, Gentofte, Denmark
Anne Rasmussen, Steno Diabetes Centre A/S, Gentofte, Denmark
Aim: To evaluate the referral pattern for vascular assessment in a specialized
multidisciplinary diabetes unit with focus on: Delay from referral and evaluation and
outcome.
Methods: We retrospectively reviewed all patients in 2012-13 with a distal blood pressure
examination and a toe pressure below 40 mmHg. We used our extensive database and the
patient files. Our institution has a large diabetes outpatient clinic with 3500 Type 1 diabetes
and 2000 Type 2.
Results: We identified 140 patients with a toe-pressure below 40. Patient characteristics see
table 1. Patients with multiple examinations were included only once. 40 patients were
referred to vascular service for evaluation. The main reason for not referring patients was
that the patients had no ulcers and no claudication. The delay from referral was median 27
days (0-80). The delay from the initial vascular assessment to vascular imaging was median
21 days (0-105). 12 patients had an intervention (PTA or by-pass) with a delay from imaging
of median 0 days (0-45). 10 patients received a PTA, nine on the day of the arteriogram.
Two patients in the referred group without intervention had a major amputation (7%) while
this applied to seven of the 12 patients with intervention (58%). Eight patients have died at
follow-up.
Conclusions: Less than 1/3 of our neuro-ischemic patients with toe-pressure below 40
mmHg were referred for vascular assessment. The delay from referral was surprisingly long
with an average of 27 days and only 1/3 of the patients received intervention. Despite
intervention 75% of the patients had a major amputation. We have to re-evaluate the referral
protocol and together with the vascular service optimize the pathway to minimize delay and
whether the offered service and intervention is sufficient.
Type 1 Diabetes
Male
Current smokers
Age, mean
Duration of Diabetes
(years)
HbA1c, mmol/mol
Without foot deformity
49%
76%
18%
70,8 (47,2-93,6)
33 (0-73)
67,5 (35.125)
12%
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P6.06
Improving major amputation rates in the multi-complex diabetic foot patient: Focus on
the severity of peripheral arterial disease
Matthias Weck, Helios Weisseritztal-Kliniken Freital, Freital, Germany
Andrej Brechow, Helios-Weisseritztal-Kliniken Freital, Freital, Germany
Aim: We tested the effects of the severity of peripheral arterial disease (PAD) on outcome
parameters as major amputation, mortality and wound healing in subjects with diabetic foot
(DF) ulcers.
Methods: In a prospective study we investigated patients with DF in a structured system of
outpatient, in-patient and rehabilitative treatment. Subjects were recruited between January
1st, 2000 and December 31, 2007. All participants underwent a two-year follow-up. The
modified University of Texas Wound Classification System was the basis for documentation
and data analysis. The severity of PAD was classified by measurement of the ankle brachial
index (ABI) and the cw Doppler flow curve into undisturbed perfusion (0.9 < ABI< 1.3),
limited but compensated perfusion (0.5 < ABI < 0.9), decompensated perfusion (ABI < 0.5)
and medial arterial calcification.
Results: 684 patients with DF were consecutively included into the study.
Major amputations were performed in 4.7 % of the patients. 22.1 % of these subjects had
decompensated PAD/ critical limb ischemia (CLI). These subjects had delayed ulcer healing,
higher risk for major amputation (OR 7.7, 95 % CI 2.8 – 21.2, p < 0.001) and mortality (OR
4.9, 95 % CI 1.1 – 22.1, p < 0.05).
Conclusion: PAD significantly influences the outcome of DF ulcers regarding to wound
healing, major amputation rate and mortality. Decompensated perfusion was the significant
risk factor for impaired wound healing, major amputation and mortality.
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P6.07
Reconstructive vascular surgery and the extent of tissue destruction are related to
risk of new ulceration in patients with diabetes and PAD
Targ Elgzyri, Skåne University Hospital SUS, Malmö, Sweden
Jan Larsson, Skåne University Hospital SUS, Lund, Sweden
Per Nyberg, Skåne University Hospital SUS, Lund, Sweden
Johan Thörne, Helsingborg’s Hospital, Helsingborg, Sweden
Karl-Fredrik Eriksson, Skåne University Hospital SUS, Malmö, Sweden
Jan Apelqvist, Skåne University Hospital SUS, Malmö, Sweden
Aim: There is limited information regarding new ulceration after healing of ischemic foot
ulcers in patients with diabetes. Our aim is to study new ulcerations in the same foot and
their outcome, as well as survival rate in patients with diabetes, severe peripheral arterial
disease (PAD), and previous foot ulcers.
Methods: Six hundred and two patients with diabetes and severe PAD with healed foot
ulcers, either primarily (n=443, 74%) or after minor amputation (n=159, 26%). Fifty-one
percent (n=305) had revascularization before healing from the previous ulcer. These 602
patients were included in this prospective study from the time of healing, with a median
follow-up time of 37 (0-170) months from the healing of the previous foot ulcer.
Results: Thirty-four percent (n=202) of these patients developed a new ulcer on the same
foot within 15 months (range 0-106). Twenty-two percent (n=45) of patients with new ulcers
required an amputation of the same foot. The median survival time of all patients (n=602)
was 54 months. By regression analysis, a low maximal Wagner grade for the previous ulcer
and reconstructive vascular surgery were related to a decreased risk of developing new
ulcers in the same foot.
Conclusion: Patients with diabetes and ischemic foot ulcers have a high risk for developing
new ulcers and amputation in the same foot after healing. The extent of tissue involvement
in the previous ulcer and reconstructive vascular surgery, affected the risk for development
of new ulcers.
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P6.08
Macroangiopathy in diabetic foot
Bhavesh Devkaran, SHIMLA, India, India
Aims and objectives:To find out the incidence of macroangiopathy in diabetic foot.
Methods: We subjected 25 patients of diabetic foot to CT angiography. Vessels were traced
up to the ankle joint.
Results: The mean age of the patients was 56.00+9.37 years.17were males (68%) and 8
were females (32%).Of the total, 19 patients (76%) were found to have involvement of major
peripheral vessels.1 patient had total occlusion of the abdominal aorta, 2 had external iliac
disease. The femoral artery was involved in 8 patients, popliteal in 4 patients, anterior tibial
in 2 patients and posterior tibial in 2patients.
Conclusion: A large majority of diabetic foot patients have macroangiopathy and there is a
predilection of involvement of the femoral and tibial vessels.
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P6.09
Defining the parameters of critical ischemia based on the number of amputations and
mortality of patients
Maksym Gorobeiko, Ukrainian Centre for Endocrine Surgery of Ministry of Health, Kyiv,
Ukraine
Aim: Determine the actual boundaries of the critical lower limb ischemia in patients with
diabetic foot syndrome.
Methods: The study included 201 patients. 159 at the time of the study had tcpO2<30
mmHg (study group-SG) and 42 patients with 30<tcpO2<40 mm Hg (control group-CG).
Observation of patients from 36 to116 months. The criteria for evaluation: General quantity
of amputation; Quantity of high amputation; The level of mortality. SG was divided into
subgroups according to level of tcpO2. It was be using Cox regression for analysis.
Results: The number of patients without amputation between the CG and subgroups tcpO2
21-30 mm Hg is not different (p=0.873). The difference between the subgroups with tcpO2
(14-19) and (20-30) significant (p<0.001). The risk of amputation in the subgroup tcpO2
(<14) in 7.401 times higher than in the sub group tcpO2 (20-30). 2.In the analysis of high
amputations there is a lack significant difference between the CG and subgroups with tcpO2
(20-30) and (14-19) (p=0.533 and p=0.063, respectively). High amputation risk in the sub
group (<14) 18 times higher in subdruppe (15-19) in a 6.51 times higher in subgroup (20-30)
of 1.41 times higher than in the CG. 3.The mortality rate of patients. Critical limb ischemia is
a mirror of the status of all vessels. The mortality rate in the CG and subgroup (20-30) did
not differ (p=0.144). There is also no significant difference between the groups (<14) and
(14-19) (p=0.759). Significant difference was between the subgroup (20-30), as subgroup
(14-19) and, as (<19) (p=0.031 and p=0.039, respectively). The difference may be higher
because we did not have full information about the deceased.
Conclusions: The actual level of critical ischemia in patients with diabetes is below is in the
range of 20 mm Hg.
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P6.10
Additional tools for assessment critical limb ischemia and its resolution after
percutaneous transluminal angioplasty in diabetic patients
Zera Abdul'vapova, Endocrinology Research Centre, Moscow, Russia
Gagik Galstyan, Endocrinology Research Centre, Moscow, Russia
Olga Bondarenko, Enocrinology Reserch Centr, Moscow, Russia
Ivan Sitkin, Endocrinology Reserch Centre, Moscow, Russia
Ivan Dedov, Endocrinology Research Centre, Moscow, Russia
Aim: Evaluation of primary patency and collateral blood flow in diabetic patients with
reocclusions after percutaneous transluminal angioplasty (PTA).
Materials and methods: Prospective single-center study was conducted involving 165
diabetic patients with critical limb ischemia (CLI)(according TASC II criteria) who underwent
PTA in 185 limbs. The mean age was 64 1[54-68] years, HbA1c 7 9±1 4%, duration of
diabetes 16 5[0 8-43] years, diabetes type 1/2–18/147. Patency of lower limb arteries
evaluated by duplex ultrasound (DU) and transcutaneous oxygen tension (TcpO2) were
performed during 3 years follow-up (FU) period. Velocity volume blood flow (Vvol) was
evaluated by DU in postocclusive tibial arterial segments: dorsalis pedis artery, plantar artery
and peroneal artery separately and by mean of 3 arteries.
Results: Patients were divided into 3 groups according to the arterial patency after
PTA:A(62 patients(37 6%)/69(37 3%)limbs)-with clinical reocclusions (CR) after PTA;
B(56patients(34%)/66(35 7%)limbs)-with morphological reocclusions (MR) after PTA;C
(47patients (28 5%)/50(27%)limbs)-with normal primary patency(NPP).Residual tibial
stenoses were in 50(72 5%)/46(69 7%)/15(30%) cases (p<0 05); cumulative primary patency
in femoropopliteal and tibial segments - 55% and 25%. The mean values of Vvol in patients
with CR(A), MR(B) and NPP(C) were 32 9[24 3;49 1], 87 7[55 3;101 4] and 84 6[53 3;104 4]
ml/min, (p<0 05), respectively; the mean values of APSV in patients with CR(A), MR(B) and
NPP(C) were 18 1[11 3;25 1], 51 1[35 3;101 4] and 54 2[33 3;98 1]ml/min, (p<0 05),
respectively. The mean value of TcpO2 for all patients prior PTA -14 8[10-19] mmHg, after
PTA 3-5 days-35 2[31-38] mmHg, during FU in patients with CR(A), MR(B) and NPP - 15
2[10-21], 34 1[30-39] and 36 2[30-37] mmHg (p<0 05).
Conclusion: Vvоl and APSV measurement may represent additional, tools for the
assessment, of CLI and effectiveness of collateral blood flow in diabetic patients with
reocclusions after PTA, during FU Vvol and APSV may also help to make decision of
reintervention in diabetic patients with reocclusions.
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