Vascular Issues

Recommendations

Identify and Treat the Cause
1 Perform a clinical evaluation of vascular status as part of the assessment of the diabetic foot, including history, physical examination and vascular examination. Level of Evidence
Not Assessed
2 Determine the ankle-brachial index for both legs as part of the vascular status assessment. Level of Evidence
Not Assessed
3 Obtain a toe brachial index or transcutaneous oxygen tension reading in patients in whom the ankle-brachial index indicates vessel calcification. Level of Evidence
Not Assessed


Address patient-centered Concerns
4 Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. (GAP) Level of Evidence
Not Assessed


Provide Local Wound Care
5 Refer patients with likely or diagnosed peripheral arterial disease for a vascular surgery evaluation for a definitive diagnosis, to plan ulcer treatment and to determine the need for revascularization surgery. Level of Evidence
Not Assessed


Provide Organizational Support
6 Establish and empower an interprofessional team to work with Persons With Diabetes (PWD). Level of Evidence
Not Assessed


Background

People with diabetes have an increased risk of atherosclerosis, and peripheral arterial disease (PAD) is approximately five times as common in the diabetic as the nondiabetic population. PAD is a contributing or the underlying cause of ulceration in approximately 25 to 30% of cases. In addition, the presence of vascular insufficiency can both determine the probability of ulcer healing and affect treatment choices.

The earliest symptom of PAD is intermittent claudication, leg pain or cramping when the patient is walking. As the vascular com promise becomes more severe, claudication may progress to rest pain or nocturnal leg pain. Leg pain is not diagnostic for PAD, as neuropathy may also cause leg pain. Similarly, absence of claudication does not exclude PAD, as pain may be absent in patients with neuropathy.

For these reasons, both clinical evaluation and appropriate investigations are necessary for a complete assessment of vascular status. History, physical and vascular examination and determination of the ankle-brachial index (ABI) comprise a minimum assessment. Physical examination of the feet and legs includes a search for clinical signs of vascular compromise, such as abnormal skin temperature and colour, increased capillary refill time, skin atrophy and dull, thickened nails. A vascular examination includes palpation and examination of femoral, popliteal, posterior tibial and dorsalis pedis pulses. Clinical examination provides an indicator of vascular status, but it is not a reliable way of either excluding or diagnosing PAD.

ABI is a simple, noninvasive and reliable technique for diagnosing vascular insufficiency. ABI is calculated by dividing the ankle systolic pressure by the brachial systolic pressure for each side of the body. A normal ABI is 1.0 [NEED TO VERIFY NORMAL—SOME AUTHORS STATE 0.9, OTHERS 0.95], and values less than this indicate varying degrees of vascular insufficiency, with lower values associated with more severe disease. The exception is the presence of calcified, non-compressible vessels, which may be seen in patients with longstanding diabetes and which increase ABI, sometimes above 1.0. Vessels in the toe are less likely to calcify, allowing the toe systolic pressure to be measured and the toe brachial index to be calculated. Transcutaneous oxygen tension determination provides a noninvasive measure of perfusion, the possibility of ulcer healing and post-amputation healing. Severe PAD is associated with transcutaneous oxygen readings significantly reduced below normal values (>40 mmHg).

A vascular surgery referral is appropriate for patients with likely or diagnosed PAD for a full assessment, including peripheral angiography, to diagnose PAD, facilitate ulcer treatment and determine the need for revascularization surgery.

References

Essential Publications
1 AngioSeal Closure Device in Treatment of diabetics with critical limb ischemia Quality Indicator
 Type: Retrospective Analysis
Lupattelli T, Clerissi J, Clerici G, Minnella DP, Casini A, Losa S, Faglia E. The efficacy and safety of closure of brachial access using the AngioSeal closure device: experience with 161 interventions in diabetic patients with critical limb ischemia. J Vasc Surg. 2008 Apr;47(4):782-8. Epub 2008 Mar 4.
This study examines the effectiveness of closure of brachial access in patients with critical limb ischemia. The results demonstrate that the AngioSeal closure device is safe and effective brachial closure device, and ccan be implemented into practice
2 Peripheral Arterial Disease in analysis of the Diabetic Foot Quality Indicator
 Type: Cohort study (2 groups)
Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G, Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008 May;51(5):747-55. Epub 2008 Feb 23.
The purpose of this study is to examine diabetic foot ulcer patients to determine the clinical characteristics which indicate poor outcomes. Furthermore, the study examines whether these factors are different for patients with or without peripheral arterial disease. The results show that infection has a much greater impact on diabetic patients with peripheral arterial disease. Consequently, the publication asserts that diabetic foot ulcers with and without peripheral arterial disease should be treated as two different disease states.


Enablers for practice

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