The complex clinical picture involving the skin, muscles, joints and bones due to diabetes-related infection, malnutrition of the foot and nerve involvement is considered as diabetic foot.
Arterial involvement in diabetes:
In patients with diabetes, arterial involvement mostly develops at the level of capillaries at the end points, where the vessels begin to thin. At the capillary level, the mechanism that provides neural stimulation that regulates the flow of the vessel is also impaired. At the same time, occlusion develops in large vessels due to the contribution of diabetes to arteriosclerosis.
As a result of diabetes-related vascular involvement, critical leg malnutrition, referred to as diabetic foot, develops in advanced stages. In this table;
- Rest pain
- Foot ulcer and gangrene
- Structural changes develop.
Diabetic foot Nerve involvement, as well as vascular involvement, has an important place in its development.
35-60% of diabetic foot ulcers/necroses are due to nerve involvement (neuropathic)
General While no significant vascular involvement is detected in 50% of patients presenting with diabetic foot, significant vascular involvement is detected in 50%.
- Every year, 10% of patients who have no complaints but show vascular involvement develop diabetic foot. is developing.
Risk group in terms of vascular involvement
- Age
- Family history
- Hypertension
- Hyperlipidemia
- Smoking
- Atherosclerotic disease history
symptoms and signs suggestive of arterial involvement in DM
- Thin skin, thick nails
- Decreased hair growth
- Painful lesions
- Cold feet
- Peripheral pulses weak or none
- Slow venous filling and standing edema
Evaluation in terms of vascular involvement in patients with diabetes
- The most important evaluations are the pressure measured at the ankle. It is a comparison of the pressure measured from the arm. The pressure measured from the ankle should be higher than that measured from the arm. When measured from the arm If n is low, it suggests narrowing of the vessel.
- Doppler ultrasound
- Angiography
Treatment in diabetic foot patients with arterial involvement
Treatment It is aimed to increase the amount of tissue oxygen by providing high pressure blood flow.
Treatments that increase blood flow in diabetic feet
1. Drug treatments: vasodilator drugs
2. Vascular dilation with balloon (Endovascular interventions)
3. Surgical interventions (Bypass surgeries)
4. Hyperbaric oxygen therapy
Balloon or Surgical revascularization decision
- Life expectancy
- Functional status
- Arterial anatomy
- The decision is made considering the surgical risks.
Surgery indications in the diabetic foot
- Lesions where balloon or stent is not possible
- Angiographic evaluations The vein must be suitable for surgery
- Patients must be able to handle the surgical treatment to be applied
Patients who are not suitable for surgery
- The risk of surgical treatment depends on age and Being high due to other factors
- Advanced tissue loss in the weight-bearing surface areas of the foot
- Being bedridden
- In radiographic evaluations, the arteries are not suitable for surgery (bypass).
- Inadequate quality or quantity of veins to be used in below-knee bypass
- Extensive infection or necrosis in the target area to be bleed
- Very damaged arterial structures to be bypassed
Preoperative evaluation
- In the patient for whom bypass is planned, the vein area from which blood will be taken and sent is evaluated.
- The quality of the vein to be used in bypass is evaluated. >
Sometimes, during bypass application, there is a problem in reaching the vein in the abdomen. In these cases, a solution is sought without opening the abdomen. For example, in case of left leg occlusion, blood flow is provided from the right leg (Femorofemoral bypass). Sometimes, blood flow is provided to the legs from the armpit area through the veins that feed the arm (Axillofemoral bypass). These are considered to be applications outside normal anatomy.
These;
- Elderly
- High operative risk
- Renal impairment grave
- Severe COPD
- Previous bypass surgery from the abdomen to the leg
- Infection
Bypass from the groin to the knee area
- Bypass in the above-knee region
- Bypass below the knee
- Bypass below the ankle (planter bypass)
- The artery selected for bypass should feed the arch at the sole of the foot.
Medical treatment after surgery
- Aspirin treatment is sufficient after surgical interventions applied to large vessels.
- If long and small diameter artificial vessels are used, aspirin treatment is sufficient. Adding additional anticoagulant medication will increase the patency rate.
Generally 5-year patency rates
- Average patency rate in bypasses performed using veins above/below the knee, % 66
- It is around 47% in the use of artificial veins above the knee and 33% in the use of artificial veins below the knee.
As a result,
Diabetic foot is not developed. The vascular system should be routinely evaluated in patients and protective measures should be taken. In the treatment of diabetic foot due to vascular occlusion, the result should be sought by opening the vessel with a balloon or stent, or if this is not possible, by performing a bypass to ensure blood flow.
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