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Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease
L Graziani1, A Silvestro, V Bertone
1Servizio di Emodinamica, Istituto Clinico Città di Brescia, Brescia, Italy. langrazi@tin.it
Insights
Diabetic patients with critical limb ischemia (CLI) and foot ulcers show widespread arterial blockages, especially in below-the-knee arteries. A new classification system helps stratify these patients based on vascular disease severity.
Area of Science:
- Vascular Surgery
- Diabetic Complications
- Angiology
Background:
- Critical limb ischemia (CLI) in diabetic patients with foot ulcers presents significant challenges.
- Understanding the extent and pattern of vascular involvement is crucial for effective treatment stratification.
Purpose of the Study:
- To retrospectively analyze arteriographic lesions in diabetic subjects with CLI and ischemic foot ulcers.
- To develop new criteria for stratifying these patients based on their specific vascular involvement patterns.
Main Methods:
- Retrospective review of lower limb angiograms in 417 consecutive diabetic CLI patients with ischemic foot ulcers.
- Lesions were characterized by type (stenosis/occlusion), location, and length.
- Patients were categorized into 7 classes based on angiographic findings, with a subgroup analysis of foot arteries.
Main Results:
- A total of 2893 lesions were identified, with 74% located below the knee (BTK), predominantly as long occlusions (50% of BTK lesions >10 cm).
- 28% of patients had occlusions in all BTK arteries, yet 55% had at least one patent foot artery.
- Morphologic Class 4 (two arteries occluded with multiple stenoses) was most frequent (36%), correlating inversely with transcutaneous oxygen pressure (TcPO2).
Conclusions:
- Diabetic patients with CLI and foot ulcers exhibit diffuse and severe vascular disease, particularly affecting tibial arteries with frequent long occlusions.
- A novel morphologic classification system is proposed to better categorize vascular involvement in this patient population.
Objectives:
Arteriographic lesions of diabetic subjects with critical limb ischemia (CLI) and ischemic foot ulcer were reviewed retrospectively, to provide new criteria for stratification of these patients on the basis of their vascular involvement.
Patients:
In 417 consecutive CLI diabetic subjects with ischemic foot ulcer undergoing lower limb angiography, lesions were defined as stenosis or occlusion, localization, and length (<5 cm, 5-10 cm, >10 cm). In a subgroup of 389 subjects, foot arteries also were evaluated. Patients then were categorized into 7 classes of progressive vascular involvement based on angiographic findings.
Results:
Of the 2893 found lesions (55% occlusions) 1% were in the iliac arteries, whereas 74% were in below-the-knee (BTK) arteries. Sixty-six % of all BTK lesions were occlusions, and 50% were occlusions >10 cm (p<0.001 vs proximal segments). Occlusions of all BTK were present in 28% of patients, although there was patency of at least one foot artery in 55% of patients. The morphologic Class 4 (two arteries occluded and multiple stenoses of tibial/peroneal and/or femoral/popliteal vessels) was the most common (36%). An inverse correlation between morphologic class and TcPO2 was observed (r=-0.187, p=0.003).
Conclusions:
In CLI diabetic subjects with ischemic foot ulcer, the vascular involvement is extremely diffuse and particularly severe in tibial arteries, with high prevalence of long occlusions. A new morphologic categorization of these patients is proposed.
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