4/16/2016 Neurovascular Complications of Diabetes The Vascular Component UCSF Vascular Symposium 2016 No Disclosures Impact Neuroischemic ulcers � 15-20% of diabetic patients will have PAD at 10 years � 45% of diabetic patients will have PAD at 20 year vs Neuropathic ulcers: � One recent survey found a prevalence of PAD in people w/DM >40 years of age to be 20% { � Additional survey showed patients w/DM >50 years of age to be Is there a difference? 29% 3 1
4/16/2016 What defines a wound as neuropathic vs neuroischemic? Neuropathic Ulceration Neuroischemic Ulceration “An individual possesses a ‘diabetic foot’ when the diabetic neuropathy and/or arteriopathy of the lower limbs compromise foot function or structure.” These two situations: neuropathic foot or ischemic foot � Different entities � In most patients both co-exist � Co-existence termed: neuroischemic Photo obtained from Photo obtained from http://www.footfundamentals.com.au/diabetic-problems http://www.footfundamentals.com.au/diabetic-problems Cavanagh, Peter R., et al. "Treatment for diabetic foot ulcers." April 11, 2016 April 11, 2016 The Lancet 366.9498 (2005): 1725-1735. Comparison of clinical characteristics of Neuropathic and Neuroischemic ulcers. Agbor et al. (2009) How Prevalent are Neuroischemic Ulcers? Characteristics Neuropathic Neuroischemic Caused by Minor trauma, (foot wear) Spontaneous, s/p trauma Mode of occurrence Fortuitous, patient may be Sudden with discoloration • Galkowska et al. reported 42% of ulcers in their clinic to be unaware of onset & pain neuroischemic Foot temperature Normal (warm if AV Usually cold shunt) • Oyibo et al, study identifying presence of ulcers referred to Foot pulses Palpable usually bounding +/- palpable pulse Manchester Diabetes Center ABI Normal or elevated <.9; possibly elevated • 52.3% of ulcers neuroischemic, 36% neuropathic, , 11.7% Doppler waveforms Usually triphasic Biphasic/Monophasic purely ischemic Edges of ulcer Raised, callused 2/2 Atrophic, depend. rubor pressure Site of ulcer Mostly pressure areas Edge of foot, toes, heel Appearance of ulcer Indented borders Gangrene Pain during debridement Mitigated by less sensation Moderate pain, pure ischemic exquisite pain Patient behavioral Disconnected Aware of ulcer response to ulcer pain 2
4/16/2016 Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients Care and How to Adapt Practice Jan Apelquist , MD, PhD, Targ Elgzryi, MD, Jan Larsson, MD, PhD, Magnus Londahl, MD, PhD, Per Nyberg, Agbor Ndop, MD, and Edward B. Jude MD, MRCP MD, PhD, and Johan Thorne, MD, PhD The International Journal of Lower Extremity Wounds 8(2): 2009. J Vasc Surg 2011:53 Neuropathic Ulcer “Earlier suggestions in the Objective : Prospectively to Identify factors related to healing in patients 1980s…neuropathy was the main with DFU and severe PVD factor responsible for DFU…” Perspective of the study was to intervene in an earlier phase to achieve healing and to achieve ulcer healing, and hence reduce the risk of amputation. “Last two decades have witnessed a Neuroischemic Ulcer paradigm shift from neuropathy… to increasing preponderance of ischemic or neuroischemic ulceration” Factors related to outcome of neuroischemic/ischemic foot ulcer in Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients diabetic patients Jan Apelquist , MD, PhD, Targ Elgzryi, MD, Jan Larsson, MD, PhD, Magnus Londahl, MD, PhD, Per Nyberg, Jan Apelquist , MD, PhD, Targ Elgzryi, MD, Jan Larsson, MD, PhD, Magnus Londahl, MD, PhD, Per Nyberg, MD, PhD, and Johan Thorne, MD, PhD MD, PhD, and Johan Thorne, MD, PhD J Vasc Surg 2011:53 J Vasc Surg 2011:53 � Patients with DFU Results: � Systolic toe pressure <45 mmHg or ABI <88mmHg Methods � Subjected to angiography , offered vascular procedures when � 1,150 patients included applicable � 82% toe pressure <45mmHg � F/u until healing � 49% ankle pressure <80 mmHg � Subjected to angiography when applicable � N=1,151 � 801 (70%) patients underwent angiography Study � Ulcers Wagner 1-5 at or below ankle � Of these, 63% had vascular intervention Population � 1984-2006 � 39%, had Percutaneous transluminal angioplasty (PTA) � All patients fulfilled Fontaine grade 4 � Or reconstructive surgery (24%) � Team: Orthopedic surgeon, Vascular surgeon Podiatrist, RN Study � Physical exam performed at inclusion Design � Systolic toe and ankle BP measured by standardized strain gauge � Signs of sensory polyneuropathy tested using Biothesiometer � Patients were followed for 5 years 3
4/16/2016 Factors related to outcome of neuroischemic/ischemic foot ulcer in Prediction of outcome in individuals with diabetic foot ulcers: diabetic patients focus on the differences between individuals with and without Jan Apelquist , MD, PhD, Targ Elgzryi, MD, Jan Larsson, MD, PhD, Magnus Londahl, MD, PhD, Per Nyberg, peripheral arterial disease. The EURODIALE Study MD, PhD, and Johan Thorne, MD, PhD J Vasc Surg 2011:53 L. Prompers, N. Schaper, J. Apelqvist, M. Edmonds, E. Jude, D. Mauricio, L. Uccioli, V. Urbancic, K. Bakker, P. Holstein, A. Jirkovs ka, A. Piaggesi, G. Ragnarson-Tennvall, H. Reike, M. Spraul, K. Van Acker, J. Van Baal, F. Van Merode, I. Ferreira, M. Huijberts. Diabetologia (2008) 51: 747-755 Results: Aims/Hypothesis � Healing of DFUs without major amputation in surviving patients � Outcomes data on individuals with DFUs with and without PAD was 72% � Assess clinical characteristics that best predict poor outcome � To see if these predictors differ in patients with and without PAD � Angioplasty and Open bypass surgery increased probability of healing Methods � Severity of PAD, age, CHF, Dialysis, and extent of tissue � Prospective Cohort study destruction were also related to probability of healing � N=1,088 DFU, 14 centers in Europe � Regression modeling used to identify independent predictors of outcome Prediction of outcome in individuals with diabetic foot ulcers: Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study peripheral arterial disease. The EURODIALE Study L. Prompers, N. Schaper, J. Apelqvist, M. Edmonds, E. Jude, D. Mauricio, L. Uccioli, V. Urbancic, K. Bakker, P. Holstein, A. Jirkovs L. Prompers, N. Schaper, J. Apelqvist, M. Edmonds, E. Jude, D. Mauricio, L. Uccioli, V. Urbancic, K. Bakker, P. Holstein, A. Jirkovsk ka, A. Piaggesi, G. Ragnarson-Tennvall, H. Reike, M. Spraul, K. Van Acker, J. Van Baal, F. Van Merode, I. Ferreira, M. Huijberts. a, A. Piaggesi, G. Ragnarson-Tennvall, H. Reike, M. Spraul, K. Van Acker, J. Van Baal, F. Van Merode, I. Ferreira, M. Huijberts. Diabetologia (2008) 51: 747-755 Diabetologia (2008) 51: 747-755 Results In Comparing Patients In Comparing patients w/PAD to w/o PAD with infection After 1 yr follow-up, 23% patients had not healed 69% w/PAD healed Patients with PAD and infection had higher odds of Vs Healing in patients with PAD was significantly worse. non-healing than patients 84% w/o PAD Predictors of healing were different in patients with and without PAD. without PAD healed p< 0.001 P<0.001 Infection specific predictor of non healing in PAD patients vs. patients without PAD 4
4/16/2016 Conclusion: Thank You PAD Neuopathic and Neuroischemic ulcers are not the same and should be approached differently PAD Infection and PAD has worse outcomes than Infection without PAD PAD More education and vigilance is needed in promoting earlier recognition of Neuroischemic ulcers. PAD There’s evidence to suggest that Neuroischemic ulcers should be a PAD category in it of itself. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008." Margolis, D, Malay DS, Hoffstad OJ, Leonard CE, MaCurdy T, Lopez de Nava K, Tan Y, Molina T, Siegel KL. (2011) Findings: Prevalence of LEA in diabetics is 3x higher as in diabetic baseline pop This prevalence is 7x higher in non-elderly diabetics with PAD 5
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