Foot reconstruction in diabetes mellitus and peripheral vascular insufficiency

The great majority of diabetic patients have diabetic foot symptoms. Significant recent advances in reconstructive surgery, as well as improvements in the management of both diabetes mellitus and peripheral vascular disease, make these patients eligible for plastic and reconstructive surgery. Many diabetic patients who would previously have had below-the-knee amputations are now having their complex foot wounds reconstructed. In addition to the metabolic consequences of the disease and the increased susceptibility to infection and wound healing complications, infrapopliteal arterial occlusive disease, peripheral neuropathy, and hemorrheologic changes are addressed in this article.     

Assessment of peripheral vascular disease in patients with diabetes. Two case studies.

This report proposes that perfusion scanning in combination with arteriography be included in the diagnostic work-up of the diabetic patient who, because of peripheral vascular complications, is a candidate for surgery. Two cases are reported which illustrate the extremes of the findings: abnormal arteriogram-normal scan indicating large-vessel disease without significant small-vessel involvement. It is suggested that these patients are candidates for vascular reconstruction. The other extreme is the normal arteriogram-abnormal scan indicating small-vessels disease without significant large-vessel involvement. It is apparent that these patients are not candidates for vascular reconstruction.     

Neurogenic claudication secondary to vascular disease.

Neurogenic claudication is characterized by sensory symptoms which appear during exercise or while maintaining a fixed posture. They are paraesthetic in quality, may be associated with 'march' phenomena, and patients may have bowel and bladder disturbance. The problem is most commonly secondary to lumbar canal stenosis (LCS) but rarely due to aortic disease, as shown in this case report. This report concerns a 66 year old woman who presented with symptoms of paraesthesia radiating from the buttocks to the thigh and, intermittent loss of bladder and bowel function, all associated with walking. There were no associated symptoms of vascular claudication. Clinically, there was evidence of aorto-iliac obstruction with absence of femoral pulses and a vascular index of 0.4 at both ankles. Neurological examination was normal at rest but the left ankle jerk was absent immediately after exercise. Myelogram and computerized tomographic (CT) scan were normal. An aortogram revealed a very tight irregular stenosis of the aorta at the level of the renal and mesenteric arteries. Very few lumbar vessels were seen. An aortic endarterectomy via a thoraco-abdominal approach was performed and an aortobifemoral graft inserted. The patient's symptoms resolved following this procedure. We postulate that her symptoms were caused by a 'steal' from the blood supply to the cauda equinda due to the severe athromatous disease of her upper abdominal aorta.     

Review of prevalence and outcome of vascular disease in patients with diabetes mellitus.

OBJECTIVES: Review the literature to determine the prevalence and outcome in patients with diabetes that undergo surgery to correct carotid artery stenosis, lower extremity arterial disease, and abdominal aortic aneurysm (AAA). DESIGN AND MATERIALS: Studies were obtained from searches over the past 15 years on the National Library of Medicine's online search engine. RESULTS: The review demonstrated an equivalent prevalence of carotid artery stenosis requiring surgery in patients with diabetes, it favored no increase risk of post-CEA stroke, and it was split on perioperative morbidity and mortality risk. There was an increase prevalence of lower extremity arterial disease requiring surgery in patients with diabetes, it favored equivalent patency and limb salvage rates, and it was split on the morbidity and mortality risk. The review demonstrated a decrease in AAA prevalence among patients with diabetes, it found an increase in the morbidity risk, and equivalent mortality risk. CONCLUSIONS: Stroke, graft patency, and limb salvage rates in patients with diabetes after surgery are similar to patients without diabetes; however, their risk of complications is increased after surgery and the mortality risk may be higher after CEA.     

Hypercoagulability in patients with peripheral vascular disease.

Twenty-seven patients with peripheral vascular disease had studies of thrombin generation, antithrombin III -alues, factor VIII values, platelet adhesitivity, and activated partial thromboplastin time. Of the studies performed, the thrombin generation index, antithrombin III values, and, to a lesser extent, activated partial thromboplastin time were reliable in confirming clinically suspected hypercoagulability. When patients were placed into groups with and without operative complications, it was noted that the group with operative complications had higher average values of thrombin generation index and lower average values of antithrombin III and activated partial thromboplastin time than did the group without operative complications. It is thought that these tests may be useful in selecting those patients with a high risk of thrombotic complications from vascular surgery and who may benefit from anticoagulant management while undergoing necessary vascular reconstructive procedures.     

Renal transplantation in diabetes mellitus. Influence of preexisting vascular disease on outcome

We reviewed the recommendations and outcomes for all patients with diabetes mellitus and end-stage renal disease referred to the Medical Center Hospital of Vermont from 1971 through December 1983. During this period, we recommended transplantation in 53 of 73 patients evaluated. Thirty-two transplants were performed in 30 patients. Of the 30 patients, 10 had clinical vascular disease prior to transplantation, i.e., claudication, amputation, active angina, myocardial infarction, or stroke. Seven of the 10 had only claudication or amputation. These 10 patients showed a clear excess in graft failure and mortality. One- and 2-year graft survival was 37 and 13%; patient survival was 48 and 24%. By comparison, the 20 patients without evident vascular disease had 1- and 2-year graft survival rates of 83 and 75% and patient survival rates of 85% at both 1 and 2 years. The incidence of cardiovascular death in the group with vascular disease was 45% at 1 year and 63% at 2 years, as compared with none in the group without vascular disease. The high graft loss and mortality in this group after transplantation should be a major consideration when therapeutic alternatives are considered in diabetics with end-stage renal disease.     

Osteomyelitis associated with Crohn's disease. A case report and literature review

The case of a patient with pelvic osteomyelitis in association with Crohn's disease is presented. A review of the literature is discussed. The location most frequently affected is the right ileum, but other sites may be involved. The osteomyelitis usually develops as a result of direct extention of internal fistulae, with enteric flora being the infecting organisms. The importance of resecting the diseased segment of bowel is discussed. Many patients do not require bony resection. The possibility of pelvic osteomyelitis must be considered in patients with Crohn's disease who present with suggestive symptoms and radiographic evidence of osteomyelitis. Patients who initially present with pelvic osteomyelitis should be suspected of having intraabdominal pathology.     

Two cases of persistent hypouricemia associated with diabetes mellitus.

Two patients with diabetes mellitus had persistent hypouricemia due to increased urate clearance; the degree of the apparent renal hypouricemia with uricosuria was quite mild. At the onset of diabetes, their serum urate levels were normal. Even after good diabetes control in both cases, hypouricemia continued. Based on the pharmacological evaluation in both patients, pyrazinamide administration could partially decrease urate clearance, however, suppression by pyrazinamide was less than in normal subjects, and probenecid increased urate clearance. These results suggest that the present cases had a renal abnormality affecting tubular presecretory reabsorption of urate, which might be due to diabetes mellitus.     

Insulin deposits in membranous nephropathy associated with diabetes mellitus.

Seven diabetic patients with membranous nephropathy were immunohistologically studied in order to clarify the role of extrinsic insulin in membranous nephropathy. In three cases (group A), granular deposits of insulin were detected along the glomerular capillary wall with indirect immunoperoxidase technique using anti-porcine insulin antibody, where IgG and C3 were deposited in the identical pattern. The other four cases (group B), 8 of idiopathic membranous nephropathy, and 5 of diabetic glomerulosclerosis showed no insulin deposit in the glomerulus. Clinically, proteinuria was heavier in group A (mean +/- SE; 32.0 +/- 5.4 g/day) than in group B (5.5 +/- 0.5). Nephrotic syndrome developed after the beginning of the therapy with porcine insulin, and in two of them, proteinuria was ameliorated after porcine insulin was replaced by human insulin. Since porcine insulin is a heterologous peptide for human beings and has antigenicity when injected into patients, immune complex composed of insulin and anti-insulin antibody may cause membranous nephropathy in some diabetic patients treated with this animal insulin.     

Exercise and peripheral vascular disease.

The use of exercise as a nonsurgical therapy for peripheral arterial disease has been shown to be effective. Studies have demonstrated improved walking tolerances, alterations in skeletal muscle metabolism, and improved blood distribution with exercise.     

Transmetatarsal amputation in patients with peripheral vascular disease.

Transmetatarsal amputation has the reputation of being an operation with a poor healing rate, and less than a 50% success rate had recently been reported. The outcome of this amputation in patients with peripheral vascular disease has been retrospectively studied in this paper by examining 34 transmetatarsal amputations performed over a 5-year period. Twelve patients had had previous toe amputations and 22 were diabetic with an overall healing rate of 68%. There was no significant difference in the success rate between diabetics and non-diabetics. One patient died in the postoperative period, giving an early post-operative mortality of 3%. Revision of failed transmetatarsal below-knee amputation resulted in healing in seven patients out of nine, suggesting that it does not compromise later amputation at a higher level. Healing did not appear to be influenced by factors such as sympathectomy, previous arterial reconstruction or peripheral pulses. Transmetatarsal amputation provides patients who have a short life expectancy with a durable functional stump which is prosthesis free.     

Asymptomatic carotid artery stenosis associated with peripheral vascular disease: a prospective study

This study aimed to determine the prevalence of symptomless internal carotid artery stenosis in consecutive patients presenting with peripheral vascular disease. Duplex ultrasound screening of the carotid arteries was used to determine the degree of stenosis. Co-morbidities were recorded together with age, sex and tobacco use. Internal carotid artery stenosis of > 50% was found in 35% of patients. Among these there was > or = 70% stenosis in 18% of patients and of this group 5% had an occluded carotid vessel at first presentation. Males presented with peripheral vascular disease and associated carotid stenoses at a younger age than females. Male smokers had a higher prevalence of stenosis (P = 0.036) but all smokers had developed stenoses 3-5 years before non-smokers. Females with abdominal aortic aneurysms had a greater prevalence of carotid stenosis (P = 0.037), and male aneurysmal disease diminished stenosis prevalence (P = 0.023). Men with an elevated serum creatinine were more likely to have a stenosis (P = 0.019), but not women. The other co-morbidities were not specifically associated with carotid artery stenosis.