Clinical manifestations and characteristics of vascular bed involvement in atherosclerosis of lower extremities in patients with type 2 diabetes

Clinical manifestations of arterial insufficiency and characteristics of vascular damage were compared in 68 patients (54 men, 14 women, mean age 64.5+/-1.1 years) with atherosclerosis of arteries of lower extremities including 40 patients with type 2 diabetes. Color duplex scanning was used for assessment of severity of vascular wall involvement. Ankle blood pressure was measured by Doppler technique with calculation of ankle-brachial index. Atherosclerosis of arteries of lower extremities in patients with diabetes manifested clinically as neuropathy while intermittent claudication was more characteristic of patients without diabetes. Severity of medial calcinosis and vascular wall rigidity were related to duration of diabetes. Ankle-brachial index in patients with diabetes was 20-30% and 1.5-2 times higher compared with those without diabetes with similar occlusive and nonocclusive changes of arteries of lower extremities, respectively. Color duplex scanning did not reveal differences between patients with and without diabetes in frequency of large multiple atherosclerotic plaques in abdominal aorta, iliac, popliteal arteries.     

Peculiarities of atherosclerotic damage of brachiocephalic arteries in patients with type 2 diabetes mellitus

The state of vascular bed of brachiocephalic arteries was studied by the method of color duplex scanning in 250 patients (116 men and 134 women) with atherosclerosis of various vascular basins which in 62 of them took place at the background of type 2 diabetes mellitus (DM). Two hundred five patients had atherosclerosis of brachiocephalic arteries, 45 patients without atherosclerotic plaques in carotid arteries comprised control group. Mean age of patients was 65.3 +/- 7.6 years. A correlation was revealed between parameters of carotid artery stenosis and age of patients, level of arterial pressure, blood plasma concentration of total cholesterol. Degree of interrelation of these parameters was closer in patients with type 2 DM. Among patients with IHD with class I-III effort angina severity of carotid artery stenoses increased with elevation of functional class of angina. This dependence was most pronounced in patients with type 2 DM. Unstable and calcinated plaques were significantly more frequent in patients with type 2 DM than in patients without DM.     

彩色多普勒超声对2型糖尿病伴高血压患者下肢动脉病变的诊断

目的 通过对2型糖尿病伴高血压患者下肢血管的彩色多普勒超声检查,认识2型糖尿病伴高血压下肢动脉病变情况,为临床诊断和治疗提供依据.方法 将2型糖尿病病人共70例,分成单纯糖尿病组(35例)和2型糖尿病伴高血压组(35例);另选取35例健康者作为对照.对受试者行双下肢动脉血管超声多普勒检查,观察双下肢股动脉、腘动脉、胫后动脉、足背动脉,记录每个受试者双下肢股动脉和腘动脉内膜中膜厚度及斑块大小、回声、分布情况,以及血流动力学指标.结果 单纯糖尿病组及2型糖尿病伴高血压组下肢动脉斑块发生率均明显高于对照组(P<0.05),单纯糖尿病组斑块发生率明显低于2型糖尿病伴高血压组(P<0.05);与对照组比较,单纯糖尿病组及2型糖尿病伴高血压组的股动脉、腘动脉、足背动脉血流峰值流速降低,搏动指数增加(P<0.05).结论 应用彩色多普勒能探测到糖尿病伴高血压病人下肢动脉粥样硬化,二维图象主要表现为双下肢动脉内膜中膜厚度不规则增厚、斑块形成,尤以远端小动脉为主;彩色多普勒显示股动脉、腘动脉、足背动脉血流峰值流速降低,搏动指数增加.     

Diabetic peripheral arterial disease

Macrovascular impairment of peripheral arteries in diabetes mellitus corresponds with such an impairment in atherosclerosis. Furthermore, peripheral angiopathy, microangiopathy, and polyneuropathy resulting from microangiopathy develop in diabetes. Impairment of microcirculation worsens peripheral blood flow. Infection and insufficient trophism worsen state. A wide range of factors participate in development of vascular disease in diabetes with adverse influence both on veins and reactions coming under rheology, haemocoagulation, and immune reactions. In type II diabetes an average interval of arterial impairment is 9-10 years, in type I diabetes approximately 17-22 years. A relative risk of non-traumatic amputation of a lower limb in diabetics is several times higher than in non-diabetics. A prevention of lower limbs impairment in diabetics is the most efficient method of reducing risk of amputation. An intervention therapy, endovascular intervention or angiosurgery are indicated in patients with clinical problems. A state of distal bed is an important factor for success of interventions. As a pivotal drug treatment in intervention and traditional methods is considered an effective antiaggregation treatment. A diabetic peripheral arterial disease is a complex disease requiring a wide view and considering various and changing pathophysiological mechanisms.     

Medial arterial calcification and diabetes mellitus

Summary Medial arterial calcification (MAC) is a frequent vascular finding in patients with type II diabetes mellitus. Morphologically distinct from focal calcifications of atherosclerosis its radiographically distinct tramline pattern is frequently encountered in the arteries of the lower extremities. MAC is inconsistently related to age, duration and therapy of diabetes. In contrast, a strong association with diabetic polyneuropathy and familial aggregation have been documented. Although initially considered benign MAC is now recognized as a strong predictor of cardiovascular morbidity and mortality in diabetic patients. Investigations into MAC pathogenes and into its role in vascular pathophysiology are underway.     

2型糖尿病患者下肢血管病变及斑块形成的超声表现与冠状动脉粥样硬化形成的相关性研究

目的探究2型糖尿病患者下肢血管病变及斑块形成的超声表现与冠状动脉粥样硬化形成的相关性。方法该研究选取2018年4月—2020年4月纳入的240例经过下肢动脉血管和冠状动脉血管彩色超声检查的2型糖尿病患者,根据下肢动脉血管超声结果将患者分为下肢血管疾病(LEAD)组(n=126)和非LEAD组(n=114),根据冠状动脉血管彩色超声检查结果和询问病史将患者分为冠状动脉粥样组(n=111)和非冠状动脉粥样组(n=129)。分析2型糖尿病患者下肢血管病变及斑块形成的超声表现与冠状动脉粥样硬化形成的相关性。结果非LEAD组中冠状动脉粥样发生率为28.95%(n=33),LEAD组中下肢动脉硬化患者44例,冠状动脉粥样发生率为36.36%(n=16),下肢动脉狭窄<50%或者管道存在斑块患者59例,冠状动脉粥样发生率为61.02%(n=36),下肢动脉狭窄大于50%或管道闭塞患者23例,冠状动脉粥样发生率为78.26%(n=18)。LEAD组三种级别患者于非LEAD组患者比较,差异有统计学意义(P<0.05)。使用Logistic多元逐步回归分析冠状动脉粥样硬化的影响因素显示,冠状动脉粥样硬化的独立影响因素是LEAD和T2DM病程糖尿病病程。在单变量分析中,T2DM患者在合并下肢动脉病变时,冠状动脉粥样患病风险不明显。在超声提示的不同程度下肢动脉病变中,未校正模型中,存在下LEAD患者冠状动脉粥样风险均显著提高。在纠正其他混杂因素(年龄、糖尿病病程、血脂水平)后,下肢血管狭窄率<50%或存在斑块(OR:5.949,95%CI:2.628~18.172,P<0.001)和下肢血管狭窄率>50%或血管阻塞(OR:15.165,95%CI:7.286~38.579,P<0.001)具有明显的相关性。结论2型糖尿病患者下肢血管超声检测对发现并提示冠状动脉粥样具有一定"预警"意义。     

Pathogenesis of atherosclerosis in diabetes and hypertension

Prevalence of atherosclerotic vascular disease is markedly increased among individuals with diabetes-mellitus and hypertension. Its major clinical manifestations are consequences of atherosclerosis of coronary arteries, cerebral arteries and large arteries of lower extremities. Thus, atherosclerotic vascular disease is the major cause of mortality and significant morbidity in diabetes and hypertension. Dyslipidemia, hyperinsulinemia, and central obesity seem to be associated with increased risk of atherosclerosis, along with the development of hypertension and diabetes (NIDDM). Insulin resistance is the fundamental factor in this situation which has strong genetic predisposition. Accelerated atherosclerosis in diabetes due to mechanism unique to diabetes like non-enzymatic glycation of proteins, oxidative modification of lipoproteins, formation of lipoproteins immune complexes, lipoproteins aggregation, disturbances of cell replication and growth factors and propensity to thrombosis are clearly established. Therapeutic implication for the prevention of atherosclerosis in diabetes and hypertension clearly emphasizes the need to achieve tight control of hyperglycemia, hypertension, and hyperlipidemia in addition to avoiding cigarette smoking and developing obesity.     

彩色多普勒超声在糖尿病患者下肢血管病变中的应用

目的探讨彩色多普勒超声在糖尿病患者下肢血管病变中的应用价值。方法选择2010年10月至2012年12月期间广东省人民医院院收治的2型糖尿病患者96例作为研究组,另选同期在我院进行健康体检者100名作为对照组。采用彩色多普勒超声诊断仪对两组受检者行下肢动脉血管血流动力学检测。比较分析两组受检者下肢动脉血管病变发生情况以及下肢动脉血流变学情况。结果与对照组比较,研究组2型糖尿病患者硬化斑块、血管狭窄以及血管闭塞等下肢动脉血管病变的发生率均明显提高,分别达63．54％、23．96％和11．46％,两组组间差异均有统计学意义（P〈0．05）。与此同时,与对照组比较,研究组下肢股动脉、胭动脉、胫动脉以及足背动脉血管内径均明显缩小,血流量均明显减少,频谱宽度均明显提高,两组间差异均有统计学意义（P〈0．05）。结论彩色多普勒超声在2型糖尿病患者下肢血管病变的早期诊断、治疗以及相关并发症的预防中均具有重要的临床应用价值。     

Hemorheologic studies for evaluating microcirculation in patients with peripheral arterial circulatory disorders and diabetes mellitus

Haemorheological investigations in 73 male patients with chronic disturbances of the arterial blood supply of the lower extremities and 54 male non-insulin-requiring (type-II-) diabetics with and without micro- and macroangiopathy resulted in significant changes of the flow properties of the blood in contrast to 20 comparable clinically healthy males. In all groups of patients a clear increase of the aggregation of erythrocytes and the viscosity of plasma as well as a decrease of the deformability of erythrocytes were to be proved. The size of the deviations of all three parameters from the normal correlated with the degree of severity of the arterial obstructive disease and in diabetics with the occurrence of vascular complications (macroangiopathy, retinopathy) as well as with the situation of metabolism. The decreased fluidity of blood may lead to the development of further enlargement of disturbances of microcirculation. Therefore, haemorheological viewpoints should be included into the total diagnostic and therapeutic concept of the arterial obstructive disease and the diabetes mellitus.     

Beyond peripheral arteries in Buerger's disease: angiographic considerations in thromboangiitis obliterans.

Thromboangiitis obliterans is an inflammatory peripheral vascular disease that is strongly associated with smoking. It predominantly affects distal small- and medium-sized blood vessels of both the upper and lower extremities. We present histological evidence of this disease process affecting the internal mammary arteries. This can be of paramount clinical significance for patients with Buerger's disease who present with obstructive coronary artery disease and require coronary artery bypass grafting surgery (CABG). Internal mammary arteries involved with thromboangiitis obliterans cannot be utilized as arterial conduits during CABG and other alternatives have to be used. Therefore, we recommend preoperative angiography of both internal mammary arteries in patients with Buerger's disease requiring CABG to prevent extensive intraoperative dissection of diseased internal mammary arteries.     

Significance of microalbuminuria in atherosclerotic vascular disease

Microalbuminuria is considered as a sign of high risk of renal disease in type 1 diabetes mellitus, and of cardiovascular disease in types 1 and 2 diabetes. In recent years numerous studies have suggested that microalbuminuria may be associated with atherosclerotic vascular disease, independently from diabetes mellitus. The presence of microalbuminuria was investigated in 30 patients suffering from atherosclerotic vascular disease: ischemic heart disease, cerebrovascular disease or arterial disease of the lower extremities. They were divided into two groups similar in age: 13 with type 2 diabetes mellitus, and 17 without diabetes. The aim of the research was to reveal eventually different prevalence of microalbuminuria in patients with vascular disease associated with diabetes or without diabetes. Microalbuminuria was present in 52.9% of the non diabetic patients and in 76.9% of the diabetics, but the difference did not reach statistical significance (in Mann-Whitney test p = 0.18; Chi-square test = 0.83; p = 0.3). No significant correlation was found between microalbuminuria and fibrinogen, total cholesterol, HDL-cholesterol and triglycerides. The hypertensive patients presented higher mean values of microalbuminuria than the normotensive ones (3.2 +/- 3.8 and 2.8 +/- 4.4 mg %, respectively), but the difference was again not significant (t = 0.25; p = 0.8). In the light of this research microalbuminuria seems to be a condition associated with atherosclerotic vascular disease, independently from the presence of diabetes mellitus and arterial hypertension.     

Prevalence of multifocal atherosclerosis in different age groups

Aim of the study was to assess prevalence of lesions in several arterial beds in patients with atherosclerosis of various localization in the clinic of cardiovascular surgery. We examined 1018 patients (825 men and 193 women, aged 31-78 years, mean age 59+/-12 years) in the period of preparation to elective surgical interventions on coronary arteries or other arterial beds. All patients were divided into 4 age groups: group 1 - younger than 60 years (n=542), group 2 - 60-64 years (n=215), group 3 - 65-69 years (n=141), group 4-70 years and older (n=120). All patients were subjected to coronary angiography and Doppler ultrasound investigation (USI) of extracranial arteries. USI of arteries of lower extremities and angiography of peripheral arteries were carried out if indicated. Presence of 50% or greater stenosis was considered a criterion of involvement of an arterial vascular bed. Lesions in 2 or more beds were found in 321 patients (31.5%). Stenoses in 2 and 3 arterial beds were revealed in 24 and 3.5%, respectively, of patients in group 1, and in 31.8 and 10%, respectively, of patients in group 4 (p=0.008). Purposeful diagnostics of multifocal atherosclerosis in patients of the given category apparently should not be limited by older age groups.     

Risk factors for asymptomatic atherosclerosis in Japanese type 2 diabetic patients without diabetic microvascular complications

Atherosclerotic vascular diseases are frequently associated with diabetes mellitus. There has been increasing evidence showing that the atherosclerotic diseases in diabetic patients are distinct from diabetic microvascular complications as to their pathophysiology and epidemiology. However, we have no information on the prevalence of asymptomatic atherosclerosis in diabetic patients before the onset of microvascular diseases. In the present investigation, we aimed to evaluate risk factors for the atherosclerosis in type 2 diabetic patients without the microvascular diseases. For this purpose, we evaluated atherosclerotic change of carotid arteries in 125 Japanese type 2 diabetic patients who had neither atherosclerotic vascular diseases nor diabetic microvascular complications. When atherosclerotic change was defined as the mean intima-media thickness (IMT) of >/= 1.1 mm and/or the presence of plaque lesion, 50% of patients had atherosclerosis of the carotid arteries. Risk factors for the carotid atherosclerosis were age, low-density lipoprotein (LDL)-cholesterol, hypertension, and diabetes treatment. Age and LDL-cholesterol were associated with mean IMT. Age, diabetes treatment, LDL-cholesterol, and hypertension were positively associated with plaque lesion, while high-density lipoprotein (HDL)-cholesterol was negatively associated with it. Fasting plasma glucose, glycosylated hemoglobin (HbA(1c)), and known diabetes duration remained unassociated with any parameters of asymptomatic atherosclerosis of the carotid arteries. These results indicate that glycemic control is unrelated with asymptomatic atherosclerosis in type 2 diabetic patients without diabetic microvascular complications. Conventional risk factors and diabetes treatment are independently associated with atherosclerosis of the carotid arteries in these patients.     

64层CT在糖尿病下肢动脉硬化闭塞症中的应用探究

目的 64层螺旋CT下肢动脉成像在诊断糖尿病下肢动脉硬化闭塞症中的临床价值。方法对50例可疑下肢血管病变合并糖尿病患者进行64层螺旋CT血管造影检查,对其临床资料进行回顾性分析。结果 50例患者经64层螺旋CT血管造影技术扫描后,46例患者图像显示清晰,4例患者CT成像模糊,46例患者中下肢血管硬化现象35例(76.08%),其中16例(34.78%)为Ⅰ级动脉狭窄;19例(41.30%)为Ⅱ、Ⅲ、Ⅳ级下肢动脉狭窄。结论 64层螺旋CT造影技术具有无创、操作方便、检查准确率高等优点,对糖尿病下肢动脉硬化闭塞症的诊断和治疗具有重要价值。     

Skin capillary circulation severely impaired in toes of patients with IDDM,with and without late diabetic complications

Summary We have recently shown that the skin microcirculation of toes is significantly impaired in patients with diabetes and peripheral vascular disease, and this may be one major reason why these patients are highly susceptible to developing skin ulcers. The aim of the present study was to investigate whether the skin microcirculation is impaired also in diabetic patients free from macroangiopathy. One foot in each of 20 patients with insulin-dependent diabetes was investigated: 10 patients with and 10 patients without late complications. All patients had normal arterial circulation of their lower extremities. Two groups of age- and sex-matched healthy subjects served as controls. The capillary blood cell velocity in the nailfold of the great toe was investigated by computerised videophotometric capillaroscopy, and the total microcirculation within the same area evaluated by laser Doppler fluxmetry. The capillary blood cell velocity and the total skin microcirculation were studied during rest, and during postocclusive reactive hyperaemia. The total microcirculation was similar in patients and control subjects, whereas the capillary circulation was markedly reduced (p<0.01) in the patients. The ratio between the capillary and total microcirculation was significantly decreased (p<0.05–0.01) in the patients as compared to the control subjects, indicating a local maldistribution of blood in the skin microcirculation of the diabetic patients. The results of the present study show that in spite of a normal total skin microcirculation in the toes of insulin-dependent diabetic patients, both with and without late complications, the nutritional capillary circulation is severely impaired. These findings indicate that a chronic ischaemia is present in the skin capillaries of diabetic feet, and is related to the diabetic disease per se and not to late diabetic complications, and may be a cause for these complications.Abbreviations PVD Peripheral vascular disease - IDDM insulin-dependent diabetes mellitus - CBV capillary blood cell velocity - LDF laser Doppler fluxmetry     

2型糖尿病皮肤微循环改变与其微血管并发症的关系

研究糖尿病皮肤微循环改变与其它微血管并发症的。方法应用激光多普勒血流仪对８１例２型糖尿病者及２６名正常对照进行了皮肤微循环的测定。结果糖尿病患者四肢皮肤最大血流在不同病程,不同视网膜病变,不同尿微量白蛋白排泄率各组均低于正常     

Treatment of coronary insufficiency in diabetics. Part 1: objectives and targets

Coronary insufficiency affects 55% of insulin-dependant diabetics and is responsible for 60% of deaths in this population. Its particular severity is essentially due to the severity of coronary atherosclerosis, which is usually multi-vessel, involves both large trunks and microcirculation, is made of frequently lipid-rich and therefore fragile plaques, and is accompanied by abnormal but specific reactions of the arterial wall (tendency to vasoconstriction and increased neointimal proliferation after trauma). Coronary atherosclerosis is also often associated with HT, lower limb arteriopathy or cerebral atherosclerosis. Quality of blood glucose control, other organic lesions of diabetes (nephropathy, retinopathy), disturbances of platelet function and dyslipidaemias (hypercholesterolaemia, hypertriglyceridaemia, increased levels of highly atherogenic small LDL particles) are also involved in the development of coronary insufficiency. A precise knowledge of the diseases to be treated and their particularly rigorous prevention and treatment can improve the prognosis of coronary insufficiency in diabetics.     

Comparison of carotid and lower limb atherosclerotic lesions in both previously known and newly diagnosed type 2 diabetes mellitus

Aims/Introduction

To compare carotid and lower limb atherosclerotic lesions, and examine if carotid atherosclerotic lesions are in line with lower limb atherosclerotic lesions, and can reflect generalized atherosclerosis in inpatients with type 2 diabetes.

Materials and Methods

This was an observational study carried out in 867 Chinese inpatients with type 2 diabetes, including 573 previously known and 294 newly diagnosed patients. Ultrasonographic assessments of intima-media thickness (IMT), plaques, and stenosis in the carotid and lower limb arteries were evaluated. Atherosclerotic lesions between the carotid and lower limb arteries were compared in both previously known and newly diagnosed diabetes, respectively.

Results

In both the known (77.3% vs 49.4%, P < 0.001) and the newly diagnosed diabetes (55.4% vs 29.9%, P < 0.001), the prevalence of atherosclerotic plaques was significantly higher in the lower limb arteries than in the carotid arteries. Likewise, the prevalence of stenosis was also significantly higher (P < 0.001) in the lower limb arteries (16.9%) than in the carotid arteries (4.2%) in the established diabetes patients. However, there was no significant difference in the mean IMT between common carotid and common femoral arteries in both the previously known (0.90 ± 0.24 mm vs 0.89 ± 0.20 mm, P = 0.675) and the newly diagnosed diabetes patients (0.86 ± 0.22 mm vs 0.85 ± 0.16 mm, P = 0.436).

Conclusions

Carotid plaques might underestimate generalized plaques in inpatients with type 2 diabetes, as shown by its significantly lower prevalence compared with that of the lower extremity arteries. A combined carotid and lower limb ultrasound examination can improve the detection of atherosclerotic lesions in inpatients with type 2 diabetes.     

糖尿病足与下肢闭塞性动脉硬化的相关性研究

本研究分析了188例2型糖尿病患者下肢闭塞性动脉硬化(ASO)与糖尿病足发病的关系,并应用彩色多普勒方法分析了糖尿病足患者下肢动脉的病变特点。发现ASO与糖尿病足的发生密切相关,且糖尿病足合并ASO者的下肢动脉血管内径缩窄、管壁增厚、血流缓慢。     

Clinical indications for performing Doppler ultrasonography of the extracranial carotid vessels. A series of 805 subjects

Duplex scanning of the extracranial carotid vessels is a highly reliable medical investigation for identifying atherosclerotic or other pathology in this vascular region. The introduction of this technique into hospital practice has posed the problem of when it is indicated. The present study has shown that almost half the examinations carried out (45.2%) were requested on the basis of what were defined as "general" symptoms (vertigo, lipothymia, migraine, etc.); this group showed a low prevalence of atheromatous plaques. 22.7% of the examinations were requested as a control in the presence of atherosclerosis in another vascular region (coronaries, arteries of the lower extremities, etc.) and in these patients the prevalence of carotid stenosis was high or very high. Patients examined subsequently to a neurological episode came to 15.3% of the total. There was a high prevalence of carotid atheromatous lesions. Numerous controls were requested in subjects with type 2A and 2B hyperlipoproteinaemia (6.7% of the total) with a prevalence of atheromatous lesions higher than the homogeneous-for-age group. A limited number of patients (2%) underwent the study following visual disturbances of presumable ischaemic origin. The prevalence of carotid stenoses in these subjects is high. Patients who underwent carotid TEA (8.1%) represent a special group in whom intervention brings a general improvement although the percentage of vessel restenosis exceeds 20%.