Vascular screening in diabetic patients: how aggressive should we be and when to intervene?
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1 Vascular screening in diabetic patients: how aggressive should we be and when to intervene? Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy
2 Disclosure Speaker name: ROBERTO FERRARESI X X I have the following potential conflicts of interest to report: Consulting: Medtronic, Abbott, Cook, LimFlow No conflicts with this presentation
3 SYMPTOMS OF PAD IN DIABETICS Asymptomatic claudication and/or rest pain CLI with tissue loss
4 SYMPTOMS OF PAD IN DIABETICS Asymptomatic Should we treat asymptomatic patients with "chronic subclinical ischemia"?
5 PAD asymptomatic Although this logical course of the disease is intellectually appealing, not all patients with CLI have experienced any symptoms of previous claudication. claudication rest pain tissue loss
6 PAD asymptomatic <25% of diabetics with PAD report intermittent claudication, and in DM pts with foot ulcers rest pain is substantially less frequent than in non-dm pts claudication rest pain tissue loss
7 diabetics non diabetics Not claudication but chronic subclinical ischemia (TASC 2) or foot hibernation: asymptomatic claudication impaired energy use hypotermia hypotrophic skin & muscles rest pain progressive neurological & orthopedical abnormalities tissue loss
8 1) Chronic subcritical limb ischemia represents a subgroup of patients with CLI in whom severely reduced circulation to the foot does not manifest as rest pain, ischemic ulceration, or ischemic gangrene. Admittedly, there is a paucity of data describing the fate of this patient subset, and little evidence to support appropriate treatment. cohort of 20 patients was examined mean follow-up of 1.9 years no deaths or major amputations, and only one patient progressed to surgical intervention
9 2) Incidence of CLI in the controlateral asymptomatic limb 533 diabetic patients with unilateral CLI 6-year follow up almost 50% of the diabetic patients with unilateral CLI developed a CLI in the contralateral limb
10 3) 96 patients with unilateral CLI 5-year follow up Risk factor for developing CLI on the controlateral limb was skin perfusion pressure (SPP) <40mmHg at the surgery for ipsilateral limb. The presence of SPP < 40 mmhg and end stage renal failure with hemodialysis resulted in a significant high probability of tissue loss
11 2) 3) Incidence of CLI in the controlateral asymptomatic limb
12 1) attentive medical care and risk-reduction strategies may reduce mortality and alter progression of limb ischemia to amputation in patients with chronic subcritical limb ischemia. 2) both severity of foot lesion and amputation level was significantly lower. This fact can be due to prompt therapeutic interventions 3) Skin perfusion pressure <40 mmhg and ESRD in hemodialysis identify asymptomatic limbs at high risk of developing CLI and tissue los
13 SYMPTOMS OF PAD IN DIABETICS Asymptomatic Wait! attentive medical care risk-reduction strategies prompt therapeutic interventions
14 SYMPTOMS OF PAD IN DIABETICS claudication and/or rest pain
15 diabetics non diabetics asymptomatic <25% of diabetics with PAD report intermittent claudication, and in DM pts with foot ulcers rest pain is substantially less frequent than in non-dm pts tissue loss claudication rest pain
16 Revascularization therapy only in case of proximal lesion
17 SYMPTOMS OF PAD IN DIABETICS claudication and/or rest pain FOCAL REVASC. X
18 SYMPTOMS OF PAD IN DIABETICS CLI with tissue loss What type of screening?
19
20
21 For diagnosis of CLI in diabetic patients, measurement of TcPO2 is essential not only when AP is not measurable but also when this value is 70 mm Hg. Conclusions: Below-knee vascular calcification gave a high rate of false negative results for ankle brachial index.
22 Probability of above-the-ankle amputation according to TcPO 2 values after therapy
23 SYMPTOMS OF PAD IN DIABETICS TcPO 2 <40 mmhg Angio + Rev. CLI with tissue loss What type of screening?
24 SYMPTOMS OF PAD IN DIABETICS TcPO 2 <40 mmhg Angio + Rev. Is it all what we need? Nothing more? CLI with tissue loss What type of screening?
25
26 2012 Critical limb ischemia or Critical wound ischemia?
27 Male 66 yy old Type 2 DM, 25 yy After a long walk in the mountain, superficial ulcer in the heel region Deep Infected heel ulcer
28
29
30 180 days later
31 SYMPTOMS OF PAD IN DIABETICS CLI with tissue loss Aggressive Revasc.
32 SYMPTOMS OF PAD IN DIABETICS Asymptomatic Wait! claudication and/or rest pain Focal Revasc. CLI with tissue loss Aggressive Revasc.
33 SYMPTOMS OF PAD IN DIABETICS Asymptomatic Treat the patient claudication and/or rest pain Wait! ( the crucial presenting symptom) and not the ANGIO Focal Revasc. CLI with tissue loss Aggressive Revasc.
34 Vascular screening in diabetic patients: how aggressive should we be and when to intervene? Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy
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