Diabetes and Peripheral Arterial Disease
Peripheral arterial disease is a term that refers to blockages in the arteries that supply blood to a person's body except coronary vessels. The cause is atherosclerosis, or arteriosclerosis. The reasons that predispose to atherosclerosis are smoking and tobacco product consumption, high blood pressure, diabetes, familial hypercholesterolemia,high homocysteine levels, genetic predisposition and sedentary lifestyle.
80-85% of peripheral arterial diseases occur in the lower extremities (legs). In addition to the risk factors mentioned above, the likelihood of occurrence increases with age. Most patients with peripheral arterial disease suffer from Intermittent Claudication (IC). IC is a kind of muscle pain and cramp-like complaints in the hip, thigh or calf muscles when walking and stops at rest depending on the location of the disease. It is an indication that the blood that should go to the muscles does not go to these tissues in sufficient quantity.Generally, intervention is required in the patient group with complaints under 200 meters.
In addition to the IC, most of the patients may have decreased hair growth on their legs, nail changes, discoloration of fingers and toes, difference in diameter between both legs, and in more advanced cases, gangrene with non-healing hand and foot ulcers. Non-healing foot ulcers , pain at rest and gangrene in the fingers or feet are indicators of advanced disease and are called Critical Limb Ischemia (CLI).
Even if patients with peripheral arterial disease are asymptomatic, i.e. the patient has no complaints, an impaired ABI (Ankle-Brachial Index) is an indicator of insufficient blood supply to the legs. The ABI is calculated as the ratio of ankle pressure to arm pressure. Values below 0.9 are abnormal. These patients are not aware that they have vascular disease. Patients with peripheral arterial disease have a 1% annual risk of limb loss, while 30-40% of these patients also have a risk of stenosis and/or occlusion of the heart vessels, with an annual mortality rate from cardiac causes ranging between 3-5%. Therefore, patients with peripheral vascular disease should also be checked for other vascular systems.
Peripheral Arterial Disease Treatment
Very few patients with PAD require intervention. Most of these patients do not require intervention because they are asymptomatic. However, treatment of these patients should start with lifestyle changes from the moment of diagnosis. Elimination of risk factors, cessation of smoking and tobacco product use, dietary recommendations to regulate cholesterol and sugar levels, exercise programs for sedentary patients, and blood pressure control for patients with high blood pressure should be ensured.
The second stage of treatment is the regulation of medications. Anti aggregants, cholesterol-lowering and vasodilating drugs are used in these patients. It is also of great importance to regulate the blood sugar levels and medications of diabetics. Cholesterol lowering medications are used to prevent the consolidation and growth of plaques that cause vascular occlusion.
The last stage of treatment is interventional/surgical treatments. As in other diseases, interventional methods have come to the forefront in the treatment of this disease as a result of developing knowledge and technology. However, the most important thing to emphasize here is the correct selection of the treatment method. Interventional methods are not suitable for all patients. These methods are more suitable for patients with short segment stenosis or occlusion, advanced age and poor medical condition. These methods can also be successfully applied to patients who have undergone previous surgery and have a high surgical risk with appropriate patient selection. It should be emphasized once again that the important point here is to choose the right method at the beginning of treatment and that this varies for each patient.
PTA or PTA/STENT applications are used in interventional treatment. Recently developed methods such as intravascular shaving are also available. With these methods, a needle is inserted into the vessel, a guide wire is passed through the stenosis or occluded area and a balloon and/or stent is applied to this area. Stenting is usually performed in the groin and intra-abdominal veins where larger diameter vessels are present. Balloon angioplasty is usually performed in the area below the knee.
Surgically, endarterectomy (plaque removal) or by-pass (bridging) operations are performed in these patients. As mentioned in the interventional treatments section, since short segment stenosis or occlusions are usually treated with interventional methods, by-pass surgeries are performed in patients with sequential stenosis or long segment occlusions. The most commonly used vein in these operations is the saphenous vein. In cases where this vein is not suitable or when it is thought that the vein should be saved for coronary bypass surgery, biological or synthetic grafts called PTFE / DACRON can be used.
Many studies have been conducted to compare surgical or interventional methods in patients with peripheral arterial disease. Each method has its own advantages and disadvantages. While both methods can be applied by selecting the appropriate method on a patient basis, some of these methods can be used as supportive and complementary to each other. Some patients can even be treated by using both methods.
PRE GANGRENE FOOT
ADVANCED STAGE PERIPHERAL ARTERY DISEASE
No, it is not correct to say such a thing. Even after stenting and blockage, there is still a chance of by-pass if there is an intact target vessel in the leg.
Fortunately, there is always something to do. Especially when there is a vascular occlusion below the knee or when the target vessel cannot be detected in the angiography, our patients are confronted with such statements. This may be due to the inability of the angiography to provide adequate visualization, or sometimes it may be due to the disease being too advanced. A target vessel can usually be found with detailed imaging methods. Even in cases of small vessel disease called SAD or desert foot, you have a chance of surgery, although the chance of success is lower.
Patients may encounter such expressions, especially because diabetic arteriosclerosis blocks the veins below the knee and the vasculature is poor. Contrary to popular belief, diabetes is not a disease that involves capillaries. On the contrary, it causes macrovasculopathy, that is, larger diameter vessel involvement. Of course, it also involves small vessels, but the main involvement is in larger vessels and treatment is usually possible.
DSA may not be suitable for every patient. Especially in patients with chronic kidney disease or kidney damage due to diabetes, it is not suitable for all patients due to the harmful effects of the opaque substance used on the kidney. CO2-DSA (carbon dioxide angiography) can also be used in these patients. CO2 is preferred in these patients because it is not harmful to the kidneys.