EPIDEMIOLOGY PATHOPHYSIOLOGY AND EPIDEMIOLOGY PATHOPHYSIOLOGY AND

NATURAL HISTORY OF ARTERIOPATHY OF THE NATURAL HISTORY OF ARTERIOPATHY OF THE

LOWER LIMB amp ISCHEMIC DIABETIC FOOTLOWER LIMB amp ISCHEMIC DIABETIC FOOT

Giuseppe Biondi ZoccaiGiuseppe Biondi Zoccai

Ospedale San Giovanni Battista ldquoMolinetterdquoOspedale San Giovanni Battista ldquoMolinetterdquoUniversitagrave di TorinoUniversitagrave di Torino

gbiondizoccaigmailcomgbiondizoccaigmailcom

Minicorso GISEInterventistica per gli arti inferiori

e per il piede diabetico

Genova martedigrave 2 ottobre 2007 ndash 1320-1335

DISCLOSURE

bull Consultant Boston Scientific Cordis Mediolanum Cardio Research

bull Lecture fees Bristol-Myers Squibb

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE

ACCAHA Circulation 2005

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DISCLOSURE

bull Consultant Boston Scientific Cordis Mediolanum Cardio Research

bull Lecture fees Bristol-Myers Squibb

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE

ACCAHA Circulation 2005

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE

ACCAHA Circulation 2005

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE

ACCAHA Circulation 2005

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ACUTE ISCHEMIA IS NOT THE FOCUS OF THIS MINICOURSE

ACCAHA Circulation 2005

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CLINICAL PRESENTATION OF PAD PATIENTS

Chronic Limb Ischemia

Acute Limb Ischemia

AsymptomaticPAD

StableClaudication

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

THE TIP OF THE ICEBERG

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

BURDEN OF PAD

Transient ischemic attackTransient ischemic attackIschemic strokeIschemic strokeTransient ischemic attackTransient ischemic attackIschemic strokeIschemic stroke

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Angina pectoris (Stable Angina pectoris (Stable Unstable angina)Unstable angina)

Myocardial infarctionMyocardial infarction

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Renovascular HTN Renovascular HTN Ischemic renal injuryIschemic renal injury

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

Peripheral arterial diseasePeripheral arterial diseaseCritical limb ischemia Critical limb ischemia

claudication claudication gangrene necrosisgangrene necrosis

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CLASSIFICATION

Mukherjee et al AHJ 2005

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CASE FATALITY OF PAD

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

LONG-TERM PROGNOSIS

16440 index patients diagnosed with peripheral arterial disease in Saskatchewan Canada between 1985 and

1995 with follow-up complete to March 1998

Caro et al BMC Cardiovasc Dis 2005

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

OVERLAP IN ATHEROTHROMBOSIS

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PAD IN ITALY

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

COMPARING SEVERITY

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ATHEROSCLEROSIS

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

LARGE VS SMALL VESSELS

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

RISK FACTORS FOR PAD

TASC EJVES 2007

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

LEARNING GOALS

bull Epidemiology

bull Pathophysiology

bull Natural history

of lower limb atherosclerotic disease and ischemic diabetic foot

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CRITICAL LIMB ISCHEMIA

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CLASSIFICATION

Mukherjee et al AHJ 2005

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CRITICAL LIMB ISCHEMIA

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DIABETES AND ULCER

bull Diabetes is 1st cause of lower extremity amputation in Europe

bull Lifetime risk of ulcer 15 (up to 25)

bull Foot disordersndash Major cause of morbidityndash A leading cause of hospitalizationndash Costly when result in amputation gt $6 billion

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PRIMARY REASONS FOR FOOT PROBLEMS IN DIABETES

bull Microvascular Peripheral neuropathy amp loss of protective sensationndash ~50 of people having diabetes gt 15 years have a peripheral

sensory neuropathy lack protective sensationndash Vulnerable to physical amp thermal trauma

bull Macrovascular Vascular insufficiency (peripheral vascular disease) -gt risk of limb ischemia

bull Metabolic disorders Hyperglycemia -gt dries skin facilitates growth of pathogens contributes to microvascular

bull Impaired immune system Decreased host responsebull Trauma Repetitive and acutebull Foot deformities Excess plantar pressures

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PATHOPHYSIOLOGY OF PADISCHEMIC DIABETIC FOOT

bull Older agebull Male genderbull Diabetes (especially diabetes duration

HbA1c insulin use and retinopathy)bull Chronic kidney failurebull Hyperuricemiabull Smokebull Body weight (BMI WHR)bull Dyslipidemiabull History of CAD

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CLAUDICATION IN DIABETICS

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

CAUSES OF FOOT ULCERS

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CAUSES OF ULCERS Causal Pathways

NEUROPATHY Neuropathy 78

Minor trauma 79

DEFORMITY Deformity 63

Behavioral issues

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER Diabetes Care 1999 22157

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DIABETIC NEUROPATHY

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

NEUROPATHY VS ISCHEMIA

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

CHARCOT FOOT

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

FOOT TRAUMA

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DIABETIC FOOT TRIAD

TRAUMATRAUMAN

euro

path

y

Neu

ropa

thy

IschemiaIschemia

ULCERULCER

Infection

Infection

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

BILATERAL INVOLVEMENT

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

RISK FACTORS FOR CLI

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull The development of a foot ulcer has traditionally been considered to result from a combination of peripheral vascular disease (PVD) peripheral neuropathy (PNP) and infection

bull There has been no convincing evidence that infection is a direct cause but it rather complicates an established ulcer and impedes its healing

bull Other factors have been identified such as repetitive stress and pressure on insensitive feet poor glycaemic control and others

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PATHOPHYSIOLOGY OF DIABETIC FOOT ULCERS

bull Patients with DM have a high risk of atherosclerotic PVDbull PVD alone is rarely a cause of ulceration but usually inbull combination with PNP and minor trauma leads to tissuebull Breakdownbull It also has a major role in delayed wound healing and the development ofbull gangrenebull Reduced lower limb transcutaneous oxygen tensionbull (TcPO2) and reduced large vessel perfusion werebull associated with the increased risk of DFUbull A TcPO2 lt 30 Hg was a very strong predictor for DFUbull Diabetic patients also appear to have an increased risk ofbull coagulability and thrombosis and this may have a role inbull the impairment of tissue perfusionbull Foot deformities such as Charcot deformity and claw toesbull are also risk factors for DFU

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Peripheral sensory neuropathy

bull Structural foot deformitybull Trauma and improperly

fitted shoesbull Callusbull History prior

ulcersamputationsbull Prolonged elevated

pressures on foot

bull Limited joint mobilitybull Uncontrolled

hyperglycemiabull Duration of diabetesbull Blindnesspartial sightbull Chronic renal diseasebull Older age

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

RISK FACTORS FOR DIABETIC FOOT ULCERS

bull Diabetes mellitus (DM) is one of the most important and common metabolic disorders affecting 2ndash5 of the population in Europe and between 1 and 20 of the population in various other parts of the world

bull It is characterised by multiple long-term complications affecting almost every system in the body

bull Foot ulcers are one of the main complications of DM with a 15 lifetime risk for foot ulcers in all diabetic patients

bull There is wide variation reported in the incidence andbull prevalence of diabetic foot ulcers (DFU) with the incidencebull ranging from 10 to 40 and prevalence between 53 andbull 105bull Twenty percent of diabetic patients are admitted to hospitalbull because of foot problemsbull DFU precede 85 of lower extremity amputations (LEAs)bull There is a two-fold increase in mortality rate in patients withbull DFU

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

WOUND CLASSIFICATION

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DIABETIC VASCULOPATHY

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ATHEROSCLEROSIS DIABETICS VS NON-DIABETICS

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

FOOT ULCERS IN DIABETES

Precipitate 85 of amputations ldquoRule of 15rdquo

bull 15 of diabetes patients Foot ulcer in lifetime

bull 15 of foot ulcers Osteomyelitis

bull 15 of foot ulcers Amputation

Clinical Care of the Diabetic Foot 2005

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

AMPUTATIONS IN DIABETES

Tragic ldquoRules of 50rdquo

bull 50 of amputations transfemoraltranstibial level

bull 50 of patients 2nd amputation in 5y

bull 50 of patients Die in 5y

Clinical Care of the Diabetic Foot 2005

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

RISK FACTORS FOR AMPUTATION

bull 10487081048708 Absence of protective sensationbull 10487081048708 Arterial insufficiency ABIlt045bull 10487081048708 Foot deformity decreased joint mobilitybull 10487081048708 Autonomic neuropathybull 10487081048708 Poor glucose controlbull 10487081048708 Low HDLbull 10487081048708 Infectionbull 10487081048708 Lack of diabetes educationbull 10487081048708 Decreased visionbull 10487081048708 Obesitybull 10487081048708 Improper foot wearbull 10487081048708 Foot ulcer or previous amputation

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TASC EJVES 2007

PROGNOSIS OF CLI

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PROBABILITY OF HEALING

Documento di Consenso internazionale sul Piede Diabetico 1999

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

QUESTIONS

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TAKE HOME MESSAGES

bull PAD prevalence and incidence are increasing in developed countries

bull PAD may be asymtomatic symptomatic for claudication or critical limb ischemia

bull Diabetes is one of the most important pathophysiologic factors underlying PAD and CLI

bull A comprehensive appraisal of causes and mechanisms of PAD and CLI beyond revascularization is pivotal to maximize clinical success

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

THE RISK OF PROGRESSION IS HIGH

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

SHOULD WE TREAT OR PREVENT

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ALGORITHM FOR FOOT ULCER

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PAD in patients with CAD

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PULSE PALPATION

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ABI

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ABI

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

PVR

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

TcPO2

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

OSSIMETRIA TRANSCUTANEA

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DOPPLER ECHOGRAPHY

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ALGORITMO STANDARD

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

APPROPRIATE SHOES

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

ALGORITHM

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

DEBRIDEMENT

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

VASCULAR SURGERY

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml

For further slides on these topics please feel free to visit the metcardioorg website

httpwwwmetcardioorgslideshtml