Practical Point in Holistic Diabetic Foot Care 3 March 2016

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Diabetic Foot Ulcer : Vascular Management Practical Point in Holistic Diabetic Foot Care 3 March 2016 Supapong Arworn, MD Division of Vascular and Endovascular Surgery Department of Surgery, Chiang Mai University Hospital Email: supapong.arworn@gmail.com

Chiang Mai University Hospital 2538-2549 Division of Vascular Surgery Department of Surgery Siriraj Hospital 2549-2551

Misunderstood about Diabetic Foot Ulcer Management We don t know how dangerous of diabetic ulcer. We don t know how special of diabetic ulcer. We think that diabetic ischemic ulcer is microvascular disease. We think DM ischemic ulcer should have PAD symptoms before. We think DM ulcer cannot be treated.

Three components interplay 1. Neuropathy 2. Infection 3. PAD (ischemia) Diabetic Foot Ulcert PAD - Strongest prognostic indicator for non-healing ulcer (odd ratio 2.8) - Strongest risk of amputation & death Yamaguchi D. Wound 2011

Signs & Symptoms (problems) 1/3 have ischemic symptoms before - Neuropathy - Infection 40% have not investigated for PAD at all 1/2 amputated patients have no vasc. assessment before. Delayed revasc. Worse outcomes and higher amputation rate Br J Surg 2010

DFUs associated with PAD in Thai Population Delayed in diagnosis & treatment Consequence Possibility of revascularization Major amputation Overall mortality

Investigations (problems) Non-compressible vessels due to calcified vessel wall - ABI can be false elevated

Ankle Brachial Index (ABI) Ankle pressure/ Brachial pressure

Medial wall calcification : Non-compressible : False elevated ankle pressure : Need alternative measurements

Peripheral Artery Disease : Diagnostic Tools History taking - Walking problem - Back pain Physical examination - Sign of chronic PAD - Pulse exam. Atrophic skin change Leg & foot muscle atrophy Prominent foot tendons

Velocity Waveform : Measurement of blood flow velocity using Doppler ultrasound turns a signal to sound or a graph pattern to determine the degree of arterial stenosis A Triphasic Pattern Normal E Biphasic Pattern Mild-mod degree occlusion F Monophasic Pattern Severe occlusion

Pulse Volume Recording

Transcutaneous O2 Measurement (tcpo2)

Critical Limb Ischemia Inadequate arterial blood flow to accommodate the metabolic needs of resting tissue Rest pain, Ulceration, gangrenous foot/ toe Ankle systolic pressure <50 mmhg Toe systolic pressure <30 mmhg Fate over 1 years After primary treatment 25% CLI resolved 20% Continuing CLI 30% Alive amputated 25% Dead 3/4 CV caused TASC II, Consensus on PAD 2007

Axillo-bifemoral Bypass

Femeral-Posterior Tibial Artery Bypass

Femeral-Posterior Tibial Artery Bypass

Femeral-Posterior Tibial Artery Bypass Post-Operative Study Preoperative Study

Adjuvant AVF L. Harris. Adjuvant arteriovenous fistula at the distal anastomosis of a femorotibial bypass graft. In: R. M. Greenhalgh, editor. Vascular and Endovascular Surgical Techniques. 4th ed. Philadelphia: W.B. Saunders; 2001. p373-376

Femoral Artery- Posterior Tibial Vein Bypass

Iliac-femoral Artery : Angioplasty with primary stenting Ischemic ulcer at 5 th toe & rest pain Decrease pulse left femoral artery Ankle pressure 20 mmhg

Iliac-femoral Artery : Angioplasty with Primary Stenting Ankle pressure 60 mmhg Ischemic ulcer & pain resolved Fem-pop segment No further treatment

Femoropopliteal Artery : Angioplasty with Stenting Known case CAD S/P CABG 4 months ago Ischemic ulcer at dorsum of R foot & rest pain Decrease pulse right popliteal artery Ankle pressure 0 mmhg

Femoropopliteal Artery : Angioplasty with Stenting Ischemic ulcer & pain improved Ankle pressure 50 mmhg

Hybrid Vascular Reconstruction

Hybrid Vascular Reconstruction

Hybrid Vascular Reconstruction

Hybrid Vascular Reconstruction

Hybrid Vascular Reconstruction

Hybrid Vascular Reconstruction

Key Points In Thai population, PAOD is underdiagnosed and under-rated. DFUs patients with vascular disease are associated with significant morbidity/mortality. Revascularization is the main stay treatment. Endovascular Surgery Bypass Surgery

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