1
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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2
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3683. [PMID: 37477087 DOI: 10.1002/dmrr.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
As a progressive disease process, early diagnosis and ongoing monitoring and treatment of lower limb peripheral artery disease (PAD) is critical to reduce the risk of diabetes-related foot ulcer (DFU) development, non-healing of wounds, infection and amputation, in addition to cardiovascular complications. There are a variety of non-invasive tests available to diagnose PAD at the bedside, but there is no consensus as to the most diagnostically accurate of these bedside investigations or their reliability for use as a method of ongoing monitoring. Therefore, the aim of this systematic review was to first determine the diagnostic accuracy of non-invasive bedside tests for identifying PAD compared to an imaging reference test and second to determine the intra- and inter-rater reliability of non-invasive bedside tests in adults with diabetes. A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective and retrospective investigations of the diagnostic accuracy of bedside testing in people with diabetes using an imaging reference standard and reliability studies of bedside testing techniques conducted in people with diabetes were eligible. Included studies of diagnostic accuracy were required to report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) which were the primary endpoints. The quality appraisal was conducted using the Quality Assessment of Diagnostic Accuracy Studies and Quality Appraisal of Reliability quality appraisal tools. From a total of 8517 abstracts retrieved, 40 studies met the inclusion criteria for the diagnostic accuracy component of the review and seven studies met the inclusion criteria for the reliability component of the review. Most studies investigated the diagnostic accuracy of ankle -brachial index (ABI) (N = 38). In people with and without DFU, PLRs ranged from 1.69 to 19.9 and NLRs from 0.29 to 0.84 indicating an ABI <0.9 increases the likelihood of disease (but the extent of the increase ranges from a small to large amount) and an ABI within the normal range (≥0.90 and <1.3) does not exclude PAD. For toe-brachial index (TBI), a threshold of <0.70 has a moderate ability to rule PAD in and out; however, this is based on limited evidence. Similarly, a small number of studies indicate that one or more monophasic Doppler waveforms in the pedal arteries is associated with the presence of PAD, whereas tri- or biphasic waveform suggests that PAD is less likely. Several forms of bedside testing may also be useful as adjunct tests and 7 studies were identified that investigated the reliability of bedside tests including ABI, toe pressure, TBI, transcutaneous oxygen pressure (TcPO2 ) and pulse palpation. Inter-rater reliability was poor for pulse palpation and moderate for TcPO2. The ABI, toe pressure and TBI may have good inter- and intra-rater reliability, but margins of error are wide, requiring a large change in the measurement for it to be considered a true change rather than error. There is currently no single bedside test or a combination of bedside tests that has been shown to have superior diagnostic accuracy for PAD in people with diabetes with or without DFU. However, an ABI <0.9 or >1.3, TBI of <0.70, and absent or monophasic pedal Doppler waveforms are useful to identify the presence of disease. The ability of the tests to exclude disease is variable and although reliability may be acceptable, evidence of error in the measurements means test results that are within normal limits should be considered with caution and in the context of other vascular assessment findings (e.g., pedal pulse palpation and clinical signs) and progress of DFU healing.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco (UCSF) Medical Centre, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Wakabayashi I, Sotoda Y, Hirooka S, Orita H, Yanagida M, Araki Y. Peptides associated with hypertensive disorders of pregnancy as possible biomarkers for severity of lower extremity arterial disease. Atherosclerosis 2023; 376:63-70. [PMID: 37315394 DOI: 10.1016/j.atherosclerosis.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS Seven circulating peptides, consisting of 18-28 amino acids, were identified as possible biomarkers of hypertensive disorders of pregnancy (HDP) in our previous study. However, it is unknown whether these peptides are relevant to cardiovascular disease. The purpose of this study was to clarify the relationships between serum levels of these peptides and leg arterial blood flow in patients with lower extremity arterial disease (LEAD). METHODS The subjects were 165 outpatients with LEAD. Patients with advanced LEAD (stages 5 and 6 of the Rutherford classification) were not included. Leg arterial blood flow was evaluated by ankle brachial pressure index (ABI) and % decrease in ABI after leg exercise induced by a leg loader or treadmill. Concentrations of the seven peptides with m/z 2081 (P-2081), 2091 (P-2091), 2127 (P-2127), 2209 (P-2209), 2378 (P-2378), 2858 (P-2858) and 3156 (P-3156) were measured simultaneously with a mass spectrometer. RESULTS P-2081, P-2127 and P-2209 levels showed significant positive correlations with leg arterial blood flow, while P-2091, P-2378 and P-2858 levels showed significant inverse correlations with leg arterial blood flow. There was no significant correlation between P-3156 levels and leg arterial blood flow. The above positive and inverse associations between peptide levels and leg arterial blood flow were also found in logistic regression analysis using tertile groups divided by the concentrations of each peptide. CONCLUSIONS Serum levels of six HDP-related peptides (P-2081, P-2091, P-2127, P-2209, P-2378 and P-2858) were associated with lower extremity arterial blood flow in patients with LEAD, and thus these peptides are possible biomarkers for severity of LEAD.
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Affiliation(s)
- Ichiro Wakabayashi
- Department of Environmental and Preventive Medicine, School of Medicine, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Yoko Sotoda
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital, Yamagata, 990-8545, Japan
| | - Shigeki Hirooka
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital, Yamagata, 990-8545, Japan
| | - Hiroyuki Orita
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital, Yamagata, 990-8545, Japan
| | - Mitsuaki Yanagida
- Institute for Environmental and Gender-Specific Medicine, Juntendo University Graduate School of Medicine, Urayasu, Japan
| | - Yoshihiko Araki
- Institute for Environmental and Gender-Specific Medicine, Juntendo University Graduate School of Medicine, Urayasu, Japan; Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
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Poradzka AA, Czupryniak L. The use of the artificial neural network for three-month prognosis in diabetic foot syndrome. J Diabetes Complications 2023; 37:108392. [PMID: 36623424 DOI: 10.1016/j.jdiacomp.2022.108392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Anna A Poradzka
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland.
| | - Leszek Czupryniak
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
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Choi JCB, Miranda J, Greenleaf E, Conte MS, Gerhard-Herman MD, Mills JL, Barshes NR. Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia. Vasc Med 2023; 28:45-53. [PMID: 36759932 DOI: 10.1177/1358863x221147945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI). METHODS We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs. RESULTS GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters. CONCLUSIONS The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.
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Affiliation(s)
- Justin Chin-Bong Choi
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Jorge Miranda
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Erin Greenleaf
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Michael S Conte
- Division of Vascular & Endovascular Surgery, University of California at San Francisco, San Francisco, CA, USA
| | | | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Baylor-St Luke's Medical Center, Houston, TX, USA
| | - Neal R Barshes
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Brouwers JJ, Willems SA, Goncalves LN, Hamming JF, Schepers A. Reliability of bedside tests for diagnosing peripheral arterial disease in patients prone to medial arterial calcification: A systematic review. EClinicalMedicine 2022; 50:101532. [PMID: 35812995 PMCID: PMC9256539 DOI: 10.1016/j.eclinm.2022.101532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Medial arterial calcification (MAC), frequently associated with diabetes mellitus (DM) and chronic kidney disease (CKD), is a systemic vascular disorder leading to stiffness and incompressible arteries. These changes impede the accuracy of bedside tests to diagnose peripheral arterial disease (PAD). This review aimed to evaluate the reliability of bedside tests for the detection of PAD in patients prone to MAC. METHODS A systematic search (Pubmed, Embase, Web of Science, Cochrane, and Emcare) was performed according to the PRISMA guidelines to identify relevant studies providing data on the performance of bedside tests for the detection of PAD in patients prone to MAC. Studies were included when bedside test were compared to a reference standard. Primary endpoints were the positive and negative likelihood ratios (PLR, NLR). Methodological quality and risk of bias were evaluated using the QUADAS-2 tool. FINDINGS In total, 23 studies were included in this review. The most commonly evaluated test was the ankle-brachial index (ABI), followed by toe-brachial index (TBI), toe pressure (TP) measurements, and continuous wave Doppler (CWD). The majority of patients were older, male, and had DM. We found that ABI <0·9 was helpful to diagnose PAD, but failed to rule out PAD (NLR >0·2). The same applied for TP (NLR >0·3) and TBI (5 out of 6 studies revealed an NLR >0·2). CWD (loss of triphasic pattern) is reliable to exclude PAD (NLR 0-0·09), but was only validated in two studies. Overall, methodological quality was poor which led to risk of bias in 20 studies. INTERPRETATION The diagnosis of PAD in patients prone to MAC remains challenging. The ABI performed reasonably in the diagnosis of PAD, while the CWD (loss of triphasic signal) can be used to rule out PAD. This systematic review showed that test performances were generally poor with serious concerns in methodological quality of the included studies. We therefore counsel against the use of a single bedside test. FUNDING None to declare.
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Affiliation(s)
- Jeroen J.W.M. Brouwers
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Haga Teaching Hospital, the Hague, the Netherlands
- Corresponding author at: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Siem A. Willems
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Haga Teaching Hospital, the Hague, the Netherlands
| | - Lauren N. Goncalves
- Department of Surgery, Haaglanden Medical Center, the Hague, the Netherlands
| | - Jaap F. Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
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9
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Zordão CC, Gobbi A, Sapalo AT, Carvalho GD, Guirro RRDJ, Guirro ECDO. Correlation between the range of motion of the tibiotarsal joint and blood circulation in the lower limbs in diabetic individuals. Rev Assoc Med Bras (1992) 2022; 68:356-361. [PMID: 35442363 DOI: 10.1590/1806-9282.20210961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the relationship between the range of motion and lower-limb hemodynamic indices in the tibiotarsal joint of individuals with diabetic neuropathy. METHODS Twenty volunteers of both sexes, with a mean age of 61.45±7.05 years, were diagnosed with type 2 diabetes mellitus and diabetic peripheral neuropathy. Arterial blood flow was assessed using Doppler ultrasound, and the variables such as average velocity, pulsatility index, and resistivity index were also evaluated. A range of dorsiflexion and plantar flexion joint movements were assessed using digital goniometry before and after exercise. Data distribution was assessed using the Shapiro-Wilk test, followed by Pearson's correlation for normal data and Spearman's correlation for non-normal data, in order to verify the association between variables. RESULTS A moderate correlation was found between dorsiflexion and pulse rate on two occasions before (rs=0.497) and after initial evaluation (rs=0.511). A low correlation was found between plantar flexion and mean velocity (rs=-0.357), pulsatility index (rs=0.439), and resistivity index (rs=0.328); dorsiflexion and mean velocity (rs=0.374), pulse rate (rs=0.332), and resistance index (rs=0.327) before evaluation, and peak (rs=0.346) was observed after the evaluation of blood circulation. CONCLUSION There is a correlation between the range of motion of the tibiotarsal joint and the blood circulation of diabetics, ranging from moderate to poor for the different variables evaluated.
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Affiliation(s)
- Catarina Clapis Zordão
- Universidade de São Paulo, Ribeirão Preto Medical School, Department of Health Sciences - Ribeirão Preto (SP), Brazil
| | - Aline Gobbi
- Universidade de São Paulo, Medical School of Ribeirão Preto, Department of Health Sciences, Postgraduate Program in Rehabilitation and Functional Performance - Ribeirão Preto (SP), Brazil
| | - André Timóteo Sapalo
- Universidade de São Paulo, Medical School of Ribeirão Preto, Department of Health Sciences, Postgraduate Program in Rehabilitation and Functional Performance - Ribeirão Preto (SP), Brazil
| | - Gabriela de Carvalho
- Universidade de São Paulo, Medical School of Ribeirão Preto, Department of Health Sciences, Postgraduate Program in Rehabilitation and Functional Performance - Ribeirão Preto (SP), Brazil
| | - Rinaldo Roberto de Jesus Guirro
- Universidade de São Paulo, Medical School of Ribeirão Preto, Department of Health Sciences, Postgraduate Program in Rehabilitation and Functional Performance - Ribeirão Preto (SP), Brazil
| | - Elaine Caldeira de Oliveira Guirro
- Universidade de São Paulo, Medical School of Ribeirão Preto, Department of Health Sciences, Postgraduate Program in Rehabilitation and Functional Performance - Ribeirão Preto (SP), Brazil
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10
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Patr J, Bernatchez J, Beaumier M, Blanchette V. Improving the sensitivity of the ankle brachial index using an alternative calculation method in the diagnosis of lower limb peripheral arterial disease. Atherosclerosis 2022. [DOI: 10.1016/j.atherosclerosis.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/01/2022] [Indexed: 11/17/2022]
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11
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Arnold J, Marmolejo VL. Interpretation of Near-Infrared Imaging in Acute and Chronic Wound Care. Diagnostics (Basel) 2021; 11:778. [PMID: 33925990 DOI: 10.3390/diagnostics11050778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Vascular assessment is a critical component of wound care. Current routine noninvasive vascular studies have limitations which can give a false sense of security of the presence of adequate perfusion for healing. Near-infrared imaging modalities can serve as an additional diagnostic assessment of wounds in which adequate perfusion is a concern. Correct interpretation of near-infrared images obtained is critical as subtleties that exist in the acute and chronic wound population goes beyond the interpretation that increased signal is consistent with adequate perfusion for healing. The objective of this paper is to educate providers on the correct interpretation of this point-of-care imaging modality in day-to-day wound-care practice to guide clinical decision-making for rapid wound resolution.
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Abstract
Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.
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Affiliation(s)
- Pauline Wilson
- Clinical Specialist Podiatrist in Diabetes, St James's Hospital, Dublin; PhD Scholar, Royal College of Surgeons in Ireland
| | - Declan Patton
- Director of Nursing and Midwifery Research, Deputy Director of SWaT, Royal College of Surgeons in Ireland
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13
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Chuter VH, Searle A, Barwick A, Golledge J, Leigh L, Oldmeadow C, Peterson B, Tehan P, Twigg SM. Estimating the diagnostic accuracy of the ankle-brachial pressure index for detecting peripheral arterial disease in people with diabetes: A systematic review and meta-analysis. Diabet Med 2021; 38:e14379. [PMID: 32740980 DOI: 10.1111/dme.14379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 12/18/2022]
Abstract
AIM To systematically evaluate research investigating the accuracy of the ankle-brachial index (ABI) for diagnosing peripheral artery disease (PAD) in people with diabetes, as the accuracy is thought to be reduced in this cohort. METHODS A database search of EBSCO Megafile Premier, Embase and The Cochrane Library was conducted to 28 February 2019. Prospective and retrospective investigations of the diagnostic accuracy of the ABI for PAD in people with diabetes using an imaging reference standard were eligible. Sensitivity and specify of the ABI and bivariate meta-analysis against reference tests, or a standard summary receiver operating curve analysis (SROC) was performed. RESULTS Thirty-three studies met the inclusion criteria. ABI was compared with angiography in 12 studies and with colour duplex ultrasound (CDUS) in 21 studies. A SROC analysis of studies using angiography as the reference standard found a diagnostic odds ratio (DOR) of 9.06 [95% confidence interval (CI) 3.61 to 22.69], and area under the curve (AUC) of 0.76 (95% CI 0.66 to 0.86). Bivariate analysis of studies using CDUS demonstrated mean sensitivity of 0.60 (95% CI 0.48 to 0.71; P = 0.097) and mean specificity of 0.87 (95% CI 0.78 to 0.92; P < 0.001) with a DOR of 9.76 (95% CI 5.24 to 18.20; P < 0.0001) and AUC 0.72. CONCLUSIONS These results suggest the ABI has a high specificity but lower sensitivity in detecting imaging diagnosed PAD in people with diabetes. The low probability of the testing being able to rule diagnosis in or out suggest that the ABI has limited effectiveness for early detection of PAD in this cohort.
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Affiliation(s)
- V H Chuter
- School of Health Sciences, Townsville, QLD, Australia
- Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, Townsville, QLD, Australia
| | - A Searle
- School of Health Sciences, Townsville, QLD, Australia
| | - A Barwick
- School of Health Sciences, Townsville, QLD, Australia
| | - J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - L Leigh
- Hunter Medical Research Institute, Newcastle, Australia
| | - C Oldmeadow
- Hunter Medical Research Institute, Newcastle, Australia
| | - B Peterson
- School of Health Sciences, Townsville, QLD, Australia
| | - P Tehan
- School of Health Sciences, Townsville, QLD, Australia
| | - S M Twigg
- Sydney Medical School (Central), Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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14
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Kulikova AN, Tolstokorov AS, Larin IV. [Mönkeberg's sclerosis: role of calcification in arterial lesions in patients with diabetes mellitus]. Angiol Sosud Khir 2020; 26:17-22. [PMID: 33332302 DOI: 10.33529/angi02020406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The number of patients with diabetes mellitus has steadily been increasing. This disease is associated with the risk for the development of micro- and macroangiopathies. One of the variants of macroangiopathy is Mönkeberg's sclerosis characterized by the presence of calcification of the media of the arterial wall. This article is a literature review reflecting the role of calcification in arterial lesions in patients with diabetes mellitus, also covering the historical aspect of studying Mönkeberg's sclerosis. Special attention is paid to its morphological forms, aetiopathogenetic mechanisms of development, taking into account contemporary studies, demonstrating mechanisms of the effect of medial arterial calcification on haemodynamics and the risk for the development of cardiovascular complications. Also presented herein are the main non-invasive and invasive methods of its diagnosis.
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Affiliation(s)
- A N Kulikova
- Department of Hospital Surgery of the Therapeutic Faculty, Saratov State Medical University named after V.I. Razumovsky under the RF Ministry of Public Health, Saratov, Russia
| | - A S Tolstokorov
- Department of Surgery and Oncology, Saratov State Medical University named after V.I. Razumovsky under the RF Ministry of Public Health, Saratov, Russia
| | - I V Larin
- Department of Surgery and Oncology, Saratov State Medical University named after V.I. Razumovsky under the RF Ministry of Public Health, Saratov, Russia
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15
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Herraiz-Adillo Á, Cavero-Redondo I, Álvarez-Bueno C, Pozuelo-Carrascosa DP, Solera-Martínez M. The accuracy of toe brachial index and ankle brachial index in the diagnosis of lower limb peripheral arterial disease: A systematic review and meta-analysis. Atherosclerosis 2020; 315:81-92. [DOI: 10.1016/j.atherosclerosis.2020.09.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022]
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16
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Thottiyen S, Kuruvilla R, George A, Rajan P, Sajan P, Subhash VC, Varghese JC. Ankle Brachial Index vs Transcutaneous Partial Pressure of Oxygen for Predicting Healing of Diabetic Foot Ulcers with Peripheral Arterial Disease: a Comparative Study. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02587-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Peripheral arterial disease (PAD) affects many individuals worldwide and is associated with increased morbidity and mortality. Controversy exists on whether or not to screen asymptomatic patients. Further complicating this is that many patients with a chronic lower extremity wound are often asymptomatic. PAD and traditional noninvasive vascular studies may be inaccurate in providing a correct diagnosis. A review of current and novel vascular assessment modalities along with their benefits and limitations are presented here. A combination of these vascular assessments may help improve accuracy in diagnosis, providing timely care to those patients in need.
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Affiliation(s)
- Jonathan F Arnold
- Mercy Healing Center, 701 10th Street Southeast, Cedar Rapids, IA 52403, USA.
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18
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Tehan PE, Barwick AL, Casey SL, Lanting SM, Chuter VH. Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners. INT J LOW EXTR WOUND 2020; 19:215-226. [DOI: 10.1177/1534734620913705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.
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Affiliation(s)
- Peta Ellen Tehan
- University of Newcastle, Ourimbah, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Cardoso CRL, Melo JV, Salles GC, Leite NC, Salles GF. Prognostic impact of the ankle-brachial index on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study. Diabetologia 2018; 61:2266-2276. [PMID: 30112690 DOI: 10.1007/s00125-018-4709-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/16/2018] [Indexed: 12/21/2022]
Abstract
AIMS/HYPOTHESIS The prognostic importance of the ankle-brachial index (ABI) in individuals with diabetes is controversial. We aimed to evaluate the relationship between the ABI and the occurrence of micro- and macrovascular complications in individuals with type 2 diabetes. METHODS The ABI was measured at baseline in 668 individuals with type 2 diabetes, and the individuals were followed-up for a median of 10 years. Multivariate Cox analysis was used to examine associations between the ABI and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration and peripheral neuropathy) and macrovascular (total cardiovascular events, major adverse cardiovascular events [MACE] and cardiovascular mortality) complications, and all-cause mortality. The improvement in risk stratification was assessed using the C statistic and the integrated discrimination improvement (IDI) index. RESULTS During follow-up, 168 individuals had a cardiovascular event (140 MACE) and 191 individuals died (92 cardiovascular deaths); 156 individuals newly developed or experienced worsening diabetic retinopathy, 194 achieved the renal composite outcome (122 with newly developed microalbuminuria and 93 with deteriorating renal function) and 95 newly developed or experienced worsening peripheral neuropathy. The ABI, either analysed as a continuous or as a categorical variable, was significantly associated with all macrovascular and mortality outcomes, except for non-cardiovascular mortality. Individuals with a baseline ABI of ≤0.90 had a 2.1-fold increased risk of all-cause mortality (95% CI 1.3, 3.5; p = 0.004), a 2.7-fold excess risk of cardiovascular mortality (95% CI 1.4, 5.4; p = 0.004) and a 2.5-fold increased risk of MACE (95% CI 1.5, 4.4; p = 0.001). The ABI improved risk discrimination over classical risk factors, with relative IDIs ranging from 6.3% (for all-cause mortality) to 31% (for cardiovascular mortality). In addition, an ABI of ≤0.90 was associated with the development or worsening of peripheral neuropathy (2.1-fold increased risk [95% CI 1.1, 4.3]; p = 0.033), but not with retinopathy or renal outcomes. CONCLUSIONS/INTERPRETATION A low ABI is associated with excess risk of adverse cardiovascular outcomes, mortality and peripheral neuropathy development or worsening, and improves cardiovascular risk stratification. The ABI should therefore be routinely evaluated in individuals with type 2 diabetes.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil
| | - Juliana V Melo
- Department of Occupational Therapy, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Guilherme C Salles
- Civil Engineering Program, COPPE, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nathalie C Leite
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil
| | - Gil F Salles
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil.
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Henni S, Ammi M, Gourdier AS, Besnier L, Signolet I, Colas-Ribas C, Picquet J, Abraham P. Ankle brachial index is equally predictive of exercise-induced limb ischemia in diabetic and non-diabetic patients with walking limitation. J Diabetes Complications 2018; 32:702-707. [PMID: 29724591 DOI: 10.1016/j.jdiacomp.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/20/2018] [Accepted: 03/25/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND In diabetic patients, arterial stiffness may impair compressibility of vessels and result in higher ankle to brachial index (ABI) than in non-diabetic subjects. METHODS We studied 1972 non-diabetic and 601 diabetic patients, with suspected peripheral artery disease, Exercise transcutaneous oxygen pressure (Ex-tcpO2), expressed in DROP index (limb tcpO2 change minus chest tcpO2 change), is insensitive to arterial stiffness and can estimate exercise-induced regional blood flow impairment (RBFI). A minimal DROP <-15 mm Hg indicates the presence of RBFI (positive test). ABI was simplified to a category variable (ABIc) by rounding ABI to the closest first decimal. RESULTS In the ABIc range 0.4 to 1.1 linear regression for mean DROP values were: y = 34 x - 53; (R2 = 0.211) and y = 33 x - 52; (R2 = 0.186) in diabetic and Non-diabetic patients, respectively. Both Db and non-D patients showed a high proportion of positive Ex-tcpO2 tests for ABIc in the normal range (ABIc: 1.0 and over) from 27.1 to up to 58%. More than half of patients with borderline ABI (ABIc = 0.9) had RBFI during exercise. it was 65.6% in diabetic and 58.5% non-diabetic patients. CONCLUSIONS Resting ABI was not a better predictor of exercise-induced RBFI in non-Db than in Diabetic patients. Our results highlights the interest of still measuring resting-ABI in diabetic patients to argue for the vascular origin of exertional limb pain, but also of performing exercise tests in patients with walking impairment.
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Affiliation(s)
- Samir Henni
- Department of Physiology and Functional Investigations, University Hospital, 49933 Angers Cedex 09, France; Mitovasc Institute, UMR INSERM 1083/CNRS 6015, University of Angers, Université Bretagne Loire, France
| | - Myriam Ammi
- Vascular and Thoracic Surgery, University Hospital, 49933 Angers Cedex 09, France
| | - Anne-Sophie Gourdier
- Department of Physiology and Functional Investigations, University Hospital, 49933 Angers Cedex 09, France
| | - Louis Besnier
- Radiology Department, University Hospital, 49933 Angers Cedex 09, France
| | - Isabelle Signolet
- Department of Physiology and Functional Investigations, University Hospital, 49933 Angers Cedex 09, France
| | - Christophe Colas-Ribas
- Department of Physiology and Functional Investigations, University Hospital, 49933 Angers Cedex 09, France
| | - Jean Picquet
- Mitovasc Institute, UMR INSERM 1083/CNRS 6015, University of Angers, Université Bretagne Loire, France; Vascular and Thoracic Surgery, University Hospital, 49933 Angers Cedex 09, France
| | - Pierre Abraham
- Department of Physiology and Functional Investigations, University Hospital, 49933 Angers Cedex 09, France; Mitovasc Institute, UMR INSERM 1083/CNRS 6015, University of Angers, Université Bretagne Loire, France.
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Shirasu T, Hoshina K, Akagi D, Miyahara T, Yamamoto K, Watanabe T. Pulse volume recordings to identify falsely elevated ankle brachial index. Asian Cardiovasc Thorac Ann 2016; 24:517-22. [DOI: 10.1177/0218492316651527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Ankle brachial index can be falsely elevated in cases of medial arterial calcification, and its clinical use should be limited, especially in patients with diabetes. The aim of this study was to evaluate the potential role of pulse volume recording in detecting falsely elevated ankle brachial index. Methods Two parameters of the pulse waveform were automatically calculated: upstroke time and percentage mean artery pressure. Pulse volume recordings were retrospectively evaluated in 171 consecutive patients (342 limbs); 73 (43%) had a diagnosis of diabetes. Results On multivariate analysis, diabetes (hazard ratio = 1.7), ankle brachial index ≤ 0.90 (hazard ratio = 4.4), upstroke time ≥ 180 ms (hazard ratio = 2.1), and percentage mean artery pressure ≥ 45% (hazard ratio = 2.8) were significantly related to toe brachial index < 0.60. Further analysis for falsely elevated ankle brachial index was performed in 196 limbs (146 patients) with ankle brachial index > 0.90. The difference between ankle brachial index and toe brachial index differentiated the limbs of diabetic patients, with percentage mean artery pressure ≥ 45%, from controls (0.45 ± 0.17 vs. 0.35 ± 0.16, p = 0.03); upstroke time was not found to be a discriminating factor. Conclusions Although measurement of ankle brachial index remains the gold standard for diagnosing peripheral arterial disease, percentage mean artery pressure, automatically obtained in ankle brachial index measurement, may be useful to detect falsely elevated ankle brachial index, especially in patients with diabetes.
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Affiliation(s)
- Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Akagi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuya Miyahara
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kota Yamamoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Watanabe
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Stoekenbroek R, Ubbink D, Reekers J, Koelemay M. Hide and Seek: Does the Toe-brachial Index Allow for Earlier Recognition of Peripheral Arterial Disease in Diabetic Patients? Eur J Vasc Endovasc Surg 2015; 49:192-8. [DOI: 10.1016/j.ejvs.2014.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/30/2014] [Indexed: 01/11/2023]
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