Chapter V: Diabetic Foot

Abstract

Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.

Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective?

“…The results we observed are in agreement with the recent guidelines of the European Society for Vascular Surgery on the treatment of diabetic foot [34], which notes, ''Endovascular therapy for infrapopliteal arterial disease is gaining acceptance as a first-line revascularization method to improve ulcer healing and limb salvage.'' We also agree with the recommendation of these guidelines: ''The choice between different methods of revascularization-open, endovascular or hybrid-depends on comorbidity, severity and extension of the arterial lesions as well as the expertise of the center (Level 2c; Grade B)'' [34].…”

“…We also agree with the recommendation of these guidelines: ''The choice between different methods of revascularization-open, endovascular or hybrid-depends on comorbidity, severity and extension of the arterial lesions as well as the expertise of the center (Level 2c; Grade B)'' [34].…”

A perifériás verőérbetegséggel és a cukorbetegséggel összefüggő alsó végtagi amputációk. Epidemiológiai adatok bemutatása és a megelőző stratégia lehetőségeinek elemzése

“…Az esetek többsége döntően a perifériás verőérbetegség előrehaladott stádiumához, a kritikus végtagi keringészavarhoz köthető [1], illetve a diabeteses láb szindróma következménye [2]. Utóbbi esetben a végtagot ellátó artériák keringészavarán túl, a diabeteses neuropathia, kisérkeringési zavar, csont-és ízületi eltéré-sek, infekciók változó arányú jelenléte tehető felelőssé a végtag elvesztéséért [3,4].…”

An intelligent telemedicine system for detection of diabetic foot complications

“…If not adequately treated, these ulcers may lead to The causal pathways to diabetic foot ulceration and amputation [4,9,[11][12][13][14][15] (modified based on the work of Lepäntalo et al , reprint with permission). The tissue damages in lower extremities caused by DM result in diabetic neuropathy, whereafter the somatosensory and autonomic functions are diminished or completely lost.…”

“…Besides, tissue structures and contents, such as thickness of the epidermis layer, determine the formation of the scattered diffuse reflection, which also accounts for changes in spectral reflection [45][46][47]. Impairments in microcirculation and macrocirculation of the diabetic foot play an important role in the development of diabetic foot ulcerations and the subsequent failure to heal [4,9,[12][13][14][15]48]. Initial studies found that reduced oxygen supply might be the main reason for the development of the tissue hypoxia and nerve dysfunction [49].…”