Thursday, June 7, 2012

Critical Limb Ischemia in the Diabetic Population

By Brenton Quinney, MD of Birmingham Vascular Associates

Peripheral arterial disease is a common disease process treated by vascular surgeons.  From asymptomatic disease to claudication and critical limb ischemia, these patients present a challenging clinical problem for the vascular surgeon and primary care team. 
Critical limb ischemia is the reduction of arterial blood flow severe enough to warrant immediate intervention to prevent limb loss.  Hallmarks of critical limb ischemia are the symptoms of rest pain in the foot that tends to improve with positioning (e.g. hanging one’s foot off the side of the bed) and ulcerations to the feet. 
Critical limb ischemic patients pose significant problems due to systemic co-morbidities.  Atherosclerosis in other vascular beds (coronary and cerebrovascular) increases mortality in this group.  Outcomes of patients with critical limb ischemia six months after diagnosis are dismal with 20% mortality, 40% alive with amputation and 40% alive without amputation¹.  With the added burden of providing cost effective care, the challenge of these patients is formidable.
Diabetics with critical limb ischemia pose an even more difficult clinical scenario.  Peripheral arterial disease caused by smoking and hypertension have more proximal vascular lesions.  In contrast, diabetics with critical limb ischemia tend to have diffuse lesions in the distal tibio-peroneal vessels making revascularization more difficult. Additionally, the associated neuropathy can mask ulcerations that typically could be detected sooner in other patient populations. 
Developing a comprehensive treatment plan for diabetics with critical limb ischemia is best served by a variety of specialties that treat not only the arterial pathology, but the systemic co-morbidities as well.  Intensive risk factor modification and treatment of other associated atherosclerotic disease is critical.  Daily foot care and skin examinations are vital to identify ischemic ulcerations in their early stage.  Also, early consultation for appropriate non-invasive vascular studies can assist in the management of this complicated patient population. 
Further information for vascular surgery issues can be found at:

¹ Norgren L, Hiatt WR, Dormandy JA, et al.  TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45:S9A.

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