The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer

Impact of Heel Ulcers on Patients Admitted for Diabetic Foot Disease

The current study aimed to evaluate the clinical outcomes of patients admitted for diabetic foot ulcers (DFUs) located in the heel. The study is a retrospective observational study including a population of patients admitted for DFUs from April 2024 to September 2024. According to the wound location, patients were divided in two groups: those with heel ulcers and those with forefoot/midfoot ulcers without calcaneal involvement. All patients have been managed through a limb salvage protocol in the respect of international guidelines. The following hospital outcomes were evaluated: minor and major amputation, mortality, length of stay, need for regenerative surgery by using dermal-epidermal graft. Overall, 150 patients were included. The mean age was 70.2 ± 12.2 years, most patients were male (76.0%), had type 2 diabetes (92.7%) with a mean duration of 22.1±13.2 years; 27 (18%) patients had heel ulcers, while 123 (82%) had forefoot/midfoot lesions. Outcomes for patients with heel location and without were: minor amputation (18.5 vs 32.5%, p = 0.1), major amputation (7.4 vs 0.8%, p = 0.02), mortality (0 vs 0.8%, p = 0.5), length of hospital stay (17.5 ± 8.5 vs 14.4 ± 8.7 days, p = 0.08), need for regenerative therapy using dermal-epidermal substitutes (48.1 vs 19.5%, p = 0.003) respectively. In addition, heel ulcer was found to be an independent predictor for major amputation [OR 5.06, CI95% (3.1-11.4), p = 0.02] and length of stay [OR 6 CI95% (3.6-10.9), p = 0.003]. In patients admitted for DFUs, wounds located in the heel were associated to an increased risk of major amputation, need for regenerative therapy and length of stay (even though in the limit of statistical difference) than wounds not located in the heel. These data underline the need for tailored management strategies in this high-risk subgroup of patients.

A systematic review of the accuracy of prognostic tests and scoring systems for use in the Global Vascular Guidelines' PLAN concept for the treatment of chronic limb threatening ischemia

OBJECTIVE

The 2019 Global Vascular Guidelines recommend risk assessment for evidence based revascularization based on the acronym PLAN: Patient risk, Limb severity and ANatomical complexity of disease. This meta-analysis compares a multitude of prognostic tests within these categories.

METHODS

A systematic review and meta-analysis of tests that estimated 1-year major event (amputation-free survival and major adverse limb events) probability. Individual patient data were reconstructed from survival estimate curves. With presence or absence of major events, sensitivity, specificity, and area under receiver operating characteristics curves (AUC) were computed. Tests with an AUC ≥70%, or that correlated with revascularization feasibility were included. Practical application of tests was assessed to make a recommendation on PLAN implementation.

RESULTS

Ninety-six studies describing 77 unique predictive techniques were included, of which thirteen were sufficient. These 13 tests were divided in four Patient risk (5 studies), three Limb severity (3 studies), and six ANatomical complexity of disease (9 studies). Patient risk: Three tests were included: biochemical assessment of calprotectin and C-reactive protein, radiologic measurement of sarcopenia, and predictive score with the GermanVasc chronic limb-threatening ischemia (CLTI) score. These tests scored AUCs of 82.0%, 72.7%, and 71.8%, respectively, of which the GermanVasc CLTI score was deemed most applicable in clinical practice. Limb severity: The adjusted Wound Ischemia foot Infection score (WIfI) resulted as best predictive score (AUC, 78.8%), but due to the lack of external validation, the original WIfI score was deemed best applicable. ANatomical complexity of disease: No test surpassed 70% AUC for 1-year event estimation, and was correlated with feasibility of revascularization, the latter only being served by the Global Limb Anatomic Staging System.

CONCLUSIONS

In evidence-based revascularization in patients with CLTI according to the PLAN concept, we recommend to use GermanVasc, WIfI, and the Global Limb Anatomic Staging System.

A research-based, current approach to diabetes-related acute foot infections and chronic osteomyelitis

INTRODUCTION

Diabetic foot infections (DFIs) and diabetic foot osteomyelitis (DFO) are common and serious complications in patients with diabetes, often leading to severe morbidity (including amputation) and even mortality. Professional footcare, prompt diagnosis and appropriate treatment are crucial to preventing limb loss and improving outcomes in infections.

AREAS COVERED

This narrative review addresses the management of all DFIs, including the approach to clinical evaluation, appropriate diagnostic methods, and optimal therapeutic strategies. We specifically address key areas in antibiotic therapy, and surgical interventions and techniques. Based on our literature review and extensive, multidisciplinary experience, we developed a novel treatment flowchart specifically for the management of DFO.

EXPERT OPINION

Managing DFIs, including DFO, requires a multidisciplinary approach tailored to each patient's clinical presentation. While antibiotics, surgery, and wound care each play a crucial role, the decision-making process should always consider the infection's severity and chronicity. Our proposed flowchart for DFO management emphasizes the importance of logically-sequenced, easy to apply and tailored interventions to prevent unnecessary amputations and improve outcomes. Further research is needed to further refine this flowchart in clinical practice and demonstrate its effectiveness.

Fundamentals of wound care for amputation prevention

The initial skin breakdown and subsequent healing processes are complex and influenced by various parameters, including systemic factors, infectious bioburden, and perfusion. Vascular wounds comprise inadequate inflow (due to peripheral artery disease), microvascular damage (result of diabetes mellitus), or vasoconstriction. Normal healing of acute wounds occurs in a sequence of defined stages; however, if a dysregulated inflammatory state ensues, it is classified as chronic. Both chronic and vascular wounds carry an increased risk of amputation. Therefore, holistic wound care is crucial in preventing limb loss. This review outlines a systematic approach to wound assessment and examines the latest recommendations for managing vascular wounds, focusing on strategies for preventing amputations.

Epidemiology of major amputation following diabetic foot ulcer: Insights from recent nationwide data in the french national health registry (SNDS)

OBJECTIVE

The out-of-hospital care pathways of people with DFU have been little studied. We used the French National Health Data System (SNDS) to collect refund and care pathway data for all French residents. The aim of this study was to determine the incidence of major lower limb amputation (MA) and associated risk factors in a population with an incident DFU.

RESEARCH DESIGN AND METHODS

We included any person living with diabetes and incident DFU. The primary endpoint was the occurrence of MA within one year. We considered the course and consumption of care one year before and one year after the initial event.

RESULTS

In 2018, 133,791 people were included, and during the follow-up, MA was performed in 4,733 (3.5 %). Among these people with MAs, 16.4 % were included via the out-of-hospital part of the protocol, and their first contact with the hospital led to MA. Factors associated (hazard ratio, HR [95 % confidence interval, CI]) with MA were: being male (1.92 [1.78;2.08]), arteriopathy of the lower limb (10.16 [9.36;11.03]), psychiatric disease (1.10 [1.01;1.20]) and end-stage renal disease (2.12 [1.93;2.33]). Regarding the care pathway, associations (HR [95 %CI]) were observed between lower MA rates and people with more general practitioner (0.83 [0.75-0.91]), private nurse (0.88 [0.81-0.95]) and diabetologist (0.88 [0.81-0.95]) visits. Living in the most disadvantaged municipalities was associated (HR [95 %CI]) with a higher MA rate (1.17[1.06-1.29]).

CONCLUSION

This is the first national study of the care pathways followed by people with DFU. Failures in the care pathway, precariousness and several comorbidities were identified, with an impact on the MA risk.

Assessment of the diabetic foot in inpatients

Diabetic foot disease is a severe complication of diabetes, leading to significant morbidity and lower limb amputations. This review explores the pathophysiology of diabetic foot disease, highlighting the roles of peripheral neuropathy, peripheral arterial disease and immunosuppression in the development of foot ulcers and infections. Key intrinsic and extrinsic risk factors, including long-standing diabetes, poor glycaemic control, inappropriate footwear and trauma are discussed. The importance of comprehensive diabetic foot assessments using diagnostic tools such as the Ipswich Touch Test and Doppler studies is emphasised for early detection and management. Challenges such as delays in referral to specialist care, limited access to multidisciplinary foot teams, and staffing shortages are identified as critical barriers to effective care. The review builds upon extant literature by integrating the most recent evidence, including the 2023 guidelines from the International Working Group on the Diabetic Foot. It emphasises practical application, detailed referral pathways and multidisciplinary care strategies, offering updated tools and insights to improve clinical outcomes and address the often overlooked aspects within inpatient services. Future directions encompass advances in imaging, telemedicine and patient education, which may further optimise preventive and therapeutic strategies for diabetic foot disease.

Association between nutritional inflammation index and diabetic foot ulcers: a population-based study

Background

Diabetic foot ulcers (DFU), a frequent complication of the worldwide disease (diabetes), are the primary causes of amputations and early mortality. The development of DFU is inseparably linked with inflammation and nutrition, necessitating a comprehensive evaluation of their impact on DFU risk. This study aimed to establish a new predictive metric that integrated immune inflammation and nutritional markers to holistically assess the risk of DFU development.

Methods

Data were sourced from NHANES, extracting participant from 1999 to 2004. Analysis of multivariate logistic regression and restricted cubic spline were employed to elucidate the connection and non-linear relationship between albumin/neutrophil to lymphocyte ratio (ANLR) and DFU. Stratified subgroup analysis identified advantageous populations, while interaction analysis evaluated variable interactions with ANLR. These approaches collectively contributed to a sensitivity analysis, improving the reliability of the outcomes.

Results

Out of 29,608 participants extracted, 1,531 qualified based on the study criteria. Employing the ANLR low group as a reference, the high group demonstrated a 54% reduction in DFU risk. Every increase of 0.1 unit in ANLR correlated with a 5% decrease in DFU risk. Moreover, an L-shaped non-linear link was observed. The turning point was at 3.09. Left of the inflection point, the relationship was negatively correlated. Beyond this point, further increased in ANLR no longer decrease DFU risk.

Conclusion

The study not only proposed a new comprehensive indicator for predicting DFU for the first time but also specified the impact of ANLR on DFU risk. Broadly, a negative correlation existed between the two. Yet, a detailed analysis revealed that this negative correlation involved an inflection point effect. Furthermore, the study investigated how dynamic changes in ANLR affect DFU risk, aiding clinicians in more accurately assessing individual DFU risk and facilitating earlier identification and intervention of DFU. Therefore, for diabetic patients with low serum albumin, appropriate supplementation of albumin was crucial. Additionally, maintaining the NLR at an appropriate level should not be overlooked. Given the components of ANLR were widely used and readily available in clinical settings, their future clinical applications hold great potential.

Acellular fish skin grafts in diabetic foot ulcer care: Advances and clinical insights

Diabetic foot ulcers (DFUs) represents a significant public health issue, with a rising global prevalence and severe potential complications including amputation. Traditional treatments often fall short due to various limitations such as high recurrence rates and extensive resource utilization. This editorial explores the innovative use of acellular fish skin grafts as a transformative approach in DFU management. Recent studies and a detailed case report highlight the efficacy of acellular fish skin grafts in accelerating wound closure, reducing dressing changes, and enhancing patient outcomes with a lower socio-economic burden. Despite their promise, challenges such as limited availability, patient acceptance, and the need for further research persist. Addressing these through more extensive randomized controlled trials and fostering a multidisciplinary treatment approach may optimize DFU care and reduce the global health burden associated with these complex wounds.

In-House Fabrication and Validation of 3D-Printed Custom-Made Medical Devices for Planning and Simulation of Peripheral Endovascular Therapies

Objectives: This study aims to develop and validate a standardized methodology for creating high-fidelity, custom-made, patient-specific 3D-printed vascular models that serve as tools for preoperative planning and training in the endovascular treatment of peripheral artery disease (PAD). Methods: Ten custom-made 3D-printed vascular models were produced using computed tomography angiography (CTA) scans of ten patients diagnosed with PAD. CTA images were analyzed using Syngo.via by a specialist to formulate a medical prescription that guided the model's creation. The CTA data were then processed in OsiriX MD to generate the .STL file, which is further refined in a Meshmixer. Stereolithography (SLA) 3D printing technology was employed, utilizing either flexible or rigid materials. The dimensional accuracy of the models was evaluated by comparing their CT scan images with the corresponding patient data, using OsiriX MD. Additionally, both flexible and rigid models were evaluated by eight vascular surgeons during simulations in an in-house-designed setup, assessing both the technical aspects and operator perceptions of the simulation. Results: Each model took approximately 21.5 h to fabricate, costing €140 for flexible and €165 for rigid materials. Bland-Alman plots revealed a strong agreement between the 3D models and patient anatomy, with outliers ranging from 4.3% to 6.9%. Simulations showed that rigid models performed better in guidewire navigation and catheter stability, while flexible models offered improved transparency and lesion treatment. Surgeons confirmed the models' realism and utility. Conclusions: The study highlights the cost-efficient, high-fidelity production of 3D-printed vascular models, emphasizing their potential to enhance training and planning in endovascular surgery.

Cannabis (THC) Aggravates the Deleterious Effects of Alcohol (EtOH) on Skeletal Muscles' Mitochondrial Respiration: Modulation by Age and Metabolic Phenotypes

The anti-inflammatory and analgesic properties of cannabis might be useful to treat muscle diseases, including those linked or not to alcohol. Nevertheless, delta 9 tetrahydrocannabinol (THC) and ethanol (EtOH), often used concomitantly, can have deleterious effects on cardiac mitochondria. We therefore determined whether EtOH, alone and associated with THC, impairs skeletal muscle mitochondrial respiration. Further, we investigated potential modulation by metabolic phenotype and age by analyzing predominantly glycolytic gastrocnemius and oxidative soleus muscles in young and middle-aged rats (12 and 49 weeks). Considering the gastrocnemius, EtOH impaired mitochondrial respiration in a similar manner in young- and middle-aged muscles (-34.97 ± 2.97% vs. -37.50 ± 6.03% at 2.1 × 10-5 M; p < 0.05). Interestingly, concomitant THC aggravated EtOH-related mitochondrial impairment in young gastrocnemius (-49.92 ± 1.69%, vs. -34.97 ± 2.97 p < 0.05). Concerning the soleus, EtOH alone mainly decreased young muscle mitochondrial respiration (-42.39 ± 2.42% vs. -17.09 ± 7.61% at 2.1 × 10-5 M, p < 0.001, at 12 and 49 weeks). The soleus was less impaired at 12 weeks by THC and EtOH association than the gastrocnemius (-49.92 ±1.69 vs. -27.22 ± 8.96% in gastrocnemius and soleus, respectively, p < 0.05). In conclusion, EtOH, alone and associated with THC, significantly impairs skeletal muscle mitochondrial respiration and THC aggravates EtOH-induced effects on young glycolytic muscle. Age and metabolic phenotypes modulate these deleterious effects, with the glycolytic muscles of young rats being more prone to impairments than oxidative muscles.

Treatment effects of two pharmaceutical skin care creams for xerotic feet among persons with diabetes: Rationale and design of a two-armed double blind randomized controlled trial

Introduction

To minimize the risk of developing foot-ulcers, persons with diabetes are given the advice to daily inspect their feet and to apply skincare formulations. However, commercially available skincare products have rarely been developed and evaluated for diabetes foot care specifically. The primary aim of this randomized controlled trial (RCT) is to evaluate the effects in reducing foot xerosis in persons with diabetes without foot-ulcers using two skincare creams containing different humectants (interventions) against a cream base non-humectant (comparator). Secondary outcomes are to evaluate differences on skin barrier integrity, low-molecular weight biomarkers and skin microbiota, microcirculation including transcutaneous oxygen pressure, degree of neuropathy, and HbA1c between intervention-comparator creams.

Methods

Two-armed double-blind RCT, registered in ClinicalTrials.gov Identifier: NCT06427889. With 80 % power, two-tailed significance of 2.5 % in each arm, 39 study persons is needed in each arm, total 78 persons, 98 including dropouts, to be able to prove a reduction of at least one category in the Xerosis Severity Scale with the intervention creams compared to the comparator. In one arm, each participant will treat one foot with one of the intervention creams (Oviderm® or Canoderm®), while the opposite foot will be treated with the comparator cream (Decubal®lipid cream), twice a day. If needed, participants are enrolled after a wash-out period of two weeks. The participants will undergo examinations at baseline, day 14 and day 28.

Discussion

This RCT evaluate the potential effects of humectants in skin creams against foot xerosis in persons with diabetes.

Use of toe systolic blood pressures and toe brachial pressure indices in people receiving dialysis: A scoping review

INTRODUCTION

Current guidelines for noninvasive lower limb vascular testing specify a preference for toe brachial pressure measurement to aid in the diagnosis of peripheral arterial disease populations with high suspicion of peripheral vessel calcification, such as those with kidney failure with replacement therapy.

OBJECTIVES

The aim was to identify the current literature on toe systolic blood pressure and toe brachial pressure index for individuals with kidney failure who are receiving replacement therapy.

DESIGN

A scoping review.

METHODS

MEDLINE, CINAHL, AMED and SPORTDiscus were systematically searched between July 15 and July 30, 2023. The scoping review followed the Arksey and O'Malley framework, with data reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews.

RESULTS

Sixteen studies were included in the review. There was limited data examining the significance of toe systolic blood pressure and toe brachial pressure index during a dialysis session. There were differences in the normative values for toe brachial pressure index values used in the studies and limited reporting on the measurement protocols used to determine toe systolic blood pressure and toe brachial pressure index.

CONCLUSION

The review found limited data examining the clinical utility of toe systolic blood pressure and toe brachial pressure index in populations receiving dialysis. The use of toe systolic blood pressure and toe-brachial index to identify peripheral artery disease in this population is important. However, there is limited evidence and conflicting information on measurement protocols, reliability, diagnostic accuracy, and prognostic capacity.

High Prescription Rate of Medications With Rifampin Drug-drug Interactions in Patients With Diabetic Foot Osteomyelitis: Should Rifabutin Be Included in Clinical Trials for Adjunctive Therapy?

Rifampin may improve diabetic foot osteomyelitis outcomes, but its extensive drug-drug interactions could hamper its use. Here, through a review of the medications prescribed to a cohort of 190 persons with diabetic foot osteomyelitis, we show that rifabutin, a rifamycin with fewer drug-drug interactions, would be easier to implement in practice.

Toe-brachial index and toe systolic blood pressure for the diagnosis of peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) of the lower limbs is caused by atherosclerotic occlusive disease in which narrowing of arteries reduces blood flow to the lower limbs. PAD is common; it is estimated to affect 236 million individuals worldwide. Advanced age, smoking, hypertension, diabetes and concomitant cardiovascular disease are common factors associated with increased risk of PAD. Complications of PAD can include claudication pain, rest pain, wounds, gangrene, amputation and increased cardiovascular morbidity and mortality. It is therefore clinically important to use diagnostic tests that accurately identify PAD. Accurate and timely detection of PAD allows clinicians to implement appropriate risk management strategies to prevent complications, slow progression or intervene when indicated. Toe-brachial index (TBI) and toe systolic blood pressure (TSBP) are amongst a suite of non-invasive bedside tests used to detect PAD. Both TBI and TSBP are commonly utilised by a variety of clinicians in different settings, therefore a systematic review and meta-analysis of their diagnostic accuracy is warranted and highly relevant to inform clinical practice.

OBJECTIVES

To (1) estimate the accuracy of TSBP and TBI for the diagnosis of PAD in the lower extremities at different cut-off values for test positivity in populations at risk of PAD, and (2) compare the accuracy of TBI and TSBP for the diagnosis of PAD in the lower extremities. Secondary objectives were to investigate several possible sources of heterogeneity in test accuracy, including the following: patient group tested (people with type 1 or type 2 diabetes, people with renal disease and general population), type of equipment used, positivity threshold and type of reference standard.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the MEDLINE, Embase, CINAHL, Web of Science, LILACS, Zetoc and DARE databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 27 February 2024.

SELECTION CRITERIA

We included diagnostic case-control, cross-sectional, prospective and retrospective studies in which all participants had either a TSBP or TBI measurement plus a validated method of vascular diagnostic imaging for PAD. We needed to be able to cross-tabulate (2 x 2 table) results of the index test and the reference standard to include a study. To be included, study populations had to be adults aged 18 years and over. We included studies of symptomatic and asymptomatic participants. Studies had to use TSBP and TBI (also called toe-brachial pressure index (TBPI)), either individually, or in addition to other non-invasive tests as index tests to diagnose PAD in individuals with suspected disease. We included data collected by photoplethysmography, laser Doppler, continuous wave Doppler, sphygmomanometers (both manual and aneroid) and manual or automated digital equipment.

DATA COLLECTION AND ANALYSIS

Two review authors independently completed data extraction using a standardised form. We extracted data to populate 2 x 2 contingency tables when available (true positives, true negatives, false positives, false negatives). Where data were not available to enable statistical analysis, we contacted study authors directly. Two review authors working independently undertook quality assessment using QUADAS-2, with disagreements resolved by a third review author. We incorporated two additional questions into the quality appraisal to aid our understanding of the conduct of studies and make appropriate judgements about risk of bias and applicability.

MAIN RESULTS

Eighteen studies met the inclusion criteria; 13 evaluated TBI only, one evaluated TSBP only and four evaluated both TBI and TSBP. Thirteen of the studies used colour duplex ultrasound (CDU) as a reference standard, two used computed tomography angiography (CTA), one used multi-detector row tomography (MDCT), one used angiography and one used a combination of CDU, CTA and angiography. TBI was investigated in 1927 participants and 2550 limbs. TSBP was investigated in 701 participants, of which 701 limbs had TSBP measured. Studies were generally of low methodological quality, with poor reporting of participant recruitment in regard to consecutive or random sampling, and poor reporting of blinding between index test and reference standard, as well as timing between index test and reference standard. The certainty of evidence according to GRADE for most studies was very low.

AUTHORS' CONCLUSIONS

Whilst a small number of diagnostic test accuracy studies have been completed for TBI and TSBP to identify PAD, the overall methodological quality was low, with most studies providing a very low certainty of evidence. The evidence base to support the use of TBI and TSBP to identify PAD is therefore limited. Whilst both TBI and TSBP are used extensively clinically, the overall diagnostic performance of these tests remains uncertain. Future research using robust methods and clear reporting is warranted to comprehensively determine the diagnostic test accuracy of the TBI and TSBP for identification of PAD with greater certainty. However, conducting such research where some of the reference tests are invasive and only clinically indicated in populations with known PAD is challenging.

The Use of Autologous Cell Therapy in Diabetic Patients with Chronic Limb-Threatening Ischemia

Autologous cell therapy (ACT) is primarily used in diabetic patients with chronic limb-threatening ischemia (CLTI) who are not candidates for standard revascularization. According to current research, this therapy has been shown in some studies to be effective in improving ischemia parameters, decreasing the major amputation rate, and in foot ulcer healing. This review critically evaluates the efficacy of ACT in patients with no-option CLTI, discusses the use of mononuclear and mesenchymal stem cells, and compares the route of delivery of ACT. In addition to ACT, we also describe the use of new revascularization strategies, e.g., nanodiscs, microbeads, and epigenetics, that could enhance the therapeutic effect. The main aim is to summarize new findings on subcellular and molecular levels with the clinical aspects of ACT.

Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome

Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.

Determining the Best Noninvasive Test for Peripheral Arterial Disease Diagnosis to Predict Diabetic Foot Ulcer Healing in Patients Following Endovascular Revascularization

BACKGROUND/OBJECTIVES

To analyze the best noninvasive tests prognosis marker in patients with diabetic foot ulcer (DFU) who underwent endovascular revascularization based on clinical outcomes, such as healing rate, time to heal, and free amputation survival after at least a six-month follow-up.

METHODS

A multicentric prospective observational study was performed with 28 participants with ischemic or neuroischemic DFU who came to the participant centers and underwent endovascular revascularization between January 2022 and March 2023. Toe systolic pressure (TP), ankle systolic pressure (AP), the ankle brachial pressure index (ABPI), the toe brachial pressure index (TBPI), transcutaneous pressure of oxygen (TcPO2), and skin perfusion pressure (SPP) were evaluated using PeriFlux 6000 System, Perimed, Sweden, before (Visit 0) and four weeks after revascularization (Visit 1). The primary clinical outcome was an evaluation of the clinical evolution of noninvasive tests comparing Visit 0 and Visit 1, estimating the sensitivity for predicting wound healing of noninvasive tests at six months following initial recruitment.

RESULTS

After six months, 71.43% (n = 20) of DFU healed, four patients (14.3%) received major amputations, and one (3.5%) died. The two tests that best predicted wound healing after revascularization according to the ROC curve were TcPO2 and TP with sensitivities of 0.89 and 0.70 for the cut-off points of 24 mmHg and 46 mmHg, respectively.

CONCLUSIONS

TcPO2 and TP were the two tests that best predicted wound healing in patients who underwent endovascular revascularization. Clinicians should consider the importance of the evaluation of microcirculation in the healing prognosis of patients with diabetic foot ulcers.

Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients

Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.

Appropriate care in chronic limb threatening ischemia: A review of current evidence and outcomes

Chronic limb threatening ischemia (CLTI) poses a significant treatment challenge for vascular surgeons, interventionalists, podiatrists, and associated medical specialists. The evidence for what constitutes appropriate care is rapidly evolving and new treatment options are in constant development. This review examines the current guidelines for CLTI care, as well as reported outcomes for multiple care strategies in this patient population, including revascularization and medical optimization. We performed a literature review of the PubMed database, reviewing articles that reported outcomes for CLTI care between 2000 and 2023, and described these outcomes as they relate to the current state of CLTI treatment. Significant data are still forthcoming regarding CLTI care, but widespread adoption of appropriate CLTI care is essential for the treatment of this vulnerable population.

Surgical management of the diabetic foot: The current evidence

The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.

The unique multidisciplinarity of diabetes-related foot disease

Few diseases globally require treatment from so many different disciplines as diabetes-related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence-based treatment in diabetes-related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews, all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes-related foot disease.

Nationwide Study of the Outcome of Treatment of Lower Extremity Atherosclerotic Lesions With Endovascular Surgery With or Without Drug Eluting Methods in Patients With Diabetes

CLINICAL IMPACT

This retrospective observational registry trial combines national registries for vascular surgical procedures and diabetes mellitus to clarify results of drug eluting technology in treating diabetic subjects with intermittent claudication or chronic limb threatening ischemia compared to treatment of non-diabetic subjects. As earlier proposed and showed in this trial, there may be an implication for a beneficial treatment efficacy with drug eluting therapy in the diabetic population with PAD compared to the non-diabetic population. A finding worth further exploration.

Targeting Mitochondrial Dynamics during Lower-Limb Ischemia Reperfusion in Young and Old Mice: Effect of Mitochondrial Fission Inhibitor-1 (mDivi-1)

Peripheral arterial disease (PAD) strikes more than 200 million people worldwide and has a severe prognosis by potentially leading to limb amputation and/or death, particularly in older patients. Skeletal muscle mitochondrial dysfunctions and oxidative stress play major roles in this disease in relation with ischemia-reperfusion (IR) cycles. Mitochondrial dynamics through impairment of fission-fusion balance may contribute to skeletal muscle pathophysiology, but no data were reported in the setting of lower-limb IR despite the need for new therapeutic options. We, therefore, investigated the potential protective effect of mitochondrial division inhibitor-1 (mDivi-1; 50 mg/kg) in young (23 weeks) and old (83 weeks) mice submitted to two-hour ischemia followed by two-hour reperfusion on systemic lactate, muscle mitochondrial respiration and calcium retention capacity, and on transcripts specific for oxidative stress and mitochondrial dynamics. At the systemic levels, an IR-related increase in circulating lactate was still major despite mDivi-1 use (+305.9% p < 0.0001, and +269.4% p < 0.0001 in young and old mice, respectively). Further, IR-induced skeletal muscle mitochondrial dysfunctions (more severely impaired mitochondrial respiration in old mice (OXPHOS CI state, -68.2% p < 0.0001 and -84.9% p < 0.0001 in 23- and 83-week mice) and reduced calcium retention capacity (-46.1% p < 0.001 and -48.2% p = 0.09, respectively) were not corrected by mDivi-1 preconditioning, whatever the age. Further, mDivi-1 treatment did not oppose superoxide anion production (+71.4% p < 0.0001 and +37.5% p < 0.05, respectively). At the transcript level, markers of antioxidant enzymes (SOD 1, SOD 2, catalase, and GPx) and fission markers (Drp1, Fis) remained unchanged or tended to be decreased in the ischemic leg. Fusion markers such as mitofusin 1 or 2 decreased significantly after IR in both groups. In conclusion, aging enhanced the deleterious effects or IR on muscle mitochondrial respiration, and in this setting of lower-limb IR, mDivi-1 failed to protect the skeletal muscle both in young and old mice.