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Save My Leg, Doc!

The danger of deep damage in diabetics

Elderly woman in wheel chair holding hands with young caretakerHere is a little-known fact: a major lower limb amputation due to complications from diabetes occurs once every 30 seconds worldwide. In Singapore, an estimated 700 major lower limb amputations take place every year, or approximately two a day. These sobering numbers reflect the grim outcomes that diabetics with Peripheral Arterial Disease (PAD) face if they are not well managed.

PAD is the narrowing or blockage of the lower limb arteries that results in reduced blood flow to the legs. Once a patient has lost a limb, his/her quality of life decreases dramatically due to the loss of mobility. As a result, these patients often find it extremely difficult to keep their jobs and become very depressed. Many either spend their days in bed or are wheelchair-bound, making them prone to pneumonia and pressure sores. Family members and caregivers also experience significant physical, emotional and financial strain as patients require constant support, nursing and medical care. Therefore, every effort must be made to preserve the limbs of diabetics with PAD.

What happens in PAD?

PAD of the lower limbs results from narrowing (stenoses) or complete blockage (occlusions) of the arteries in the lower limbs. These arteries are responsible for carrying oxygen and nutrient-rich blood to the muscles and tissues of the lower limbs.

Aside from diabetes, other risk factors include chronic smoking, hypertension and end-stage renal failure. In Singapore and Asia, diabetes remains the most significant of these risk factors. PAD especially affects diabetic patients whose blood glucose control is poor or less than optimal. Multiple studies have shown that poor blood glucose level control is linked to the development of PAD. This is further aggravated if patients also have poorly controlled blood cholesterol levels or continue to smoke cigarettes.

Patients with PAD are classified into two broad groups according to their signs and symptoms:

  1. Intermittent ClaudicationiStock_000003090441_Medium

These patients have severe cramping pain in the affected part of the lower limb (thigh, calf or foot) that develops on walking or exercise. This severe cramping pain usually sets in after a repeated, fixed distance of walking or duration of exercise and is relieved by simply standing still (not sitting down). The pulse in the lower limb or foot may also be weak or absent. A simple clinic test known as the Ankle-Brachial Pressure Index (ABPI) or an ultrasound scan of the lower limb arteries can help confirm the presence of PAD.

Over time, if left untreated, these patients may gradually find that they can no longer walk or exercise for long without pain. As a result, many of these patients find themselves limiting their mobility to avoid the pain. Even a walk downstairs to the nearby market may become very difficult.

  1. Critical Ischaemia and Tissue Loss

These patients progress from intermittent claudication to pain even at rest, especially when lying down. They may also notice that the affected lower limb is cold and pale. The pain is relieved by keeping the limb dangling (since gravity improves blood flow) and patients frequently sleep sitting in a chair.

Some of these patients may develop non-healing foot ulcers, or gangrene of the toes/foot. They can have underlying tissue or bone infections and may develop life-threatening systemic sepsis from the infected ulcer/gangrene. Other signs include absent limb pulses and pus discharge from the wounds. These patients have a high risk of undergoing major below-knee or above-knee amputations, thus losing a limb. Hence, they require very urgent treatment.

How is PAD treated?

Patients with diabetes and PAD can benefit greatly from a holistic three-prong approach to prevent major lower limb amputations:

  1. Controlling Risk Factors and Exercise Therapy

This forms the cornerstone of treatment for patients with diabetes and PAD. Our aim is for patients to have optimal blood glucose, cholesterol and blood pressure levels.  This can be achieved by taking the correct types and doses of medication to control these risk factors. Patients are also started on anti-platelet drug therapy (aspirin or clopidogrel), which has been proven to reduce the risk of heart attack or stroke in PAD patients.

For patients with Intermittent Claudication, exercise therapy is also encouraged. This involves getting patients to continue walking despite the pain. This encourages smaller collateral arteries to enlarge and grow, creating additional blood supply to the limb muscles.

  1. Improving Arterial Blood Flow

Another key pillar of treatment involves improving the blood flow in the narrowed and blocked main arteries to the limb. This can be done using minimally invasive angioplasty, stenting techniques or open bypass surgery.

More and more patients take up the option of minimally invasive angioplasty and stenting procedures. In angioplasty, a small puncture wound is made in the groin artery or the foot arteries, under local anaesthesia and light sedation. A wire is used to cross the narrowed or blocked artery and an angioplasty balloon is used to re-open or widen the artery. In stenting, special metal stents keep the arteries open after the initial angioplasties, to prevent repeat narrowing or blockage. Other special devices can be used to keep the arteries open longer, such as special cutting balloons and drug-eluting (drug-delivering) angioplasty balloons and stents.

In open bypass surgery, the patient’s own lower limb vein is first harvested and then used to bypass the blocked artery. Sometimes, an artificial blood vessel graft is used instead. Open bypass surgery is effective and long-lasting, and is akin to starting a new ‘highway’ of blood flow. However, patients have to be medically fit to undergo the surgery and accept long incisions. The surgery is carried out either under general or regional anaesthesia. Recovery from open bypass surgery can be slow because of the painful incision wounds.

Angioplasty and stenting may not be as durable as open bypass surgery. Patients may require repeated angioplasty procedures to keep the arteries open. However, the key upside of angioplasty and stenting is that the risks to patients are much lower. Many patients with multiple diseases or those who are older, making them unsuitable for open bypass surgery, may benefit from angioplasty and stenting. These patients can also be discharged home earlier compared to patients who have undergone open bypass surgery. Angioplasty also allows vascular surgeons to treat multiple target arteries in the lower limb, as opposed to only one artery in open surgery.

With techniques and technology constantly advancing, most patients are now first offered an angioplasty/stenting approach to improve the lower limb arterial blood flow instead of open bypass surgery. Patients should have a good discussion with their vascular surgeon, who can better advise them on which type of procedure they should undergo, and also help them understand the pros and cons of each procedure.

  1. Controlling Wound Infections

The third pillar is early and effective treatment of wound infections. When infections are detected early, antibiotics can be prescribed to target specific bacteria. Infected tissues are extensively removed while taking care to preserve a functional lower limb and foot. Major amputations are avoided unless absolutely required. After removing infected tissues, the surgical wounds are cared for using a wide range of techniques. These include special anti-bacterial and negative pressure wound care dressings. Sometimes, skin/muscle flaps or skin grafts may be required to cover the wounds to speed up healing. This process allows the patient to regain his/her mobility and resume the activities of daily living.

Early Intervention = Good Outcomes

Early intervention for diabetics with PAD is crucial in ensuring good outcomes. The rapidly improving techniques and technology such as angioplasty and stenting now offer most patients a lower risk solution to saving their lower limbs. When combined with advanced wound care techniques, patients whose options for limb salvage were once limited now have a much better chance of avoiding limb loss. The main aim is to keep patients walking, thus maintaining their quality of life.

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Dr Benjamin Chua is a Senior Consultant Vascular Surgeon and Medical Director at the Vascular and Interventional Centre, Mount Elizabeth Novena Specialist Centre, Singapore. He is dedicated exclusively to the care of disorders of the circulatory system, primarily the arteries and veins. His passion is in saving limbs of diabetics with PAD as he feels that once their limbs are lost, it adversely affects their quality of life as well as that of their family members.
Posted by ezyhealth on Mar 5 2015. Filed under Health. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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