Chapter 27. Treatment of Peripheral Vascular Disease

  1. R. Williams3,
  2. W. Herman4,
  3. A.-L. Kinmonth6 and
  4. N. J. Wareham5
  1. Allen D. Hamdan1 and
  2. Frank B. Pomposelli Jr2

Published Online: 9 APR 2003

DOI: 10.1002/0470846585.ch27

The Evidence Base for Diabetes Care

The Evidence Base for Diabetes Care

How to Cite

Hamdan, A. D. and Pomposelli, F. B. (2002) Treatment of Peripheral Vascular Disease, in The Evidence Base for Diabetes Care (eds R. Williams, W. Herman, A.-L. Kinmonth and N. J. Wareham), John Wiley & Sons, Ltd, Chichester, UK. doi: 10.1002/0470846585.ch27

Editor Information

  1. 3

    Nuffield Institute for Health, University of Leeds, 71-75 Clarendon Road, Leeds LS2 9PL, UK

  2. 4

    Department of Internal Medicine and Epidemiology, 1500 East Medical Center Drive, 3920 Taubman Center, Box 0345, Ann Arbor, MI 48109, USA

  3. 5

    Department of Public Health and Primary Care, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 2SR, UK

  4. 6

    General Practice and Primary Care Research Unit, Dept. of Public Health & Primary Care, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 2SR, UK

Author Information

  1. 1

    110 Francis Street, Suite 5B, Boston MA 02215, USA

  2. 2

    Division of Vascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

Publication History

  1. Published Online: 9 APR 2003
  2. Published Print: 27 AUG 2002

ISBN Information

Print ISBN: 9780471988762

Online ISBN: 9780470846582

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Keywords:

  • diabetes complications;
  • peripheral vascular disease;
  • vascular surgery;
  • amputation;
  • lower extremity revascularization;
  • lower limb;
  • circulatory disease;
  • arterial reconstruction

Summary

More than 50% of all lower extremity amputations in the United States are performed on persons with diabetes even though that population accounts for less than 5% of the total. The pathogenesis of vascular disease in diabetes is unique. The pattern of occlusion generally involves the tibial and peroneal arteries with sparing of both the superficial femoral artery as well as the arteries of the foot. Although this is different than the more proximal location of disease in patients with smoking history, the gross histology of the plaque is the same. While there is not a prerequisite occlusion of the microcirculation in diabetic as was thought in the past, there are certainly changes in the pathobiology. There is thickening of the capillary basement membrane, interfering with exchange of nutrients. In addition, with ischemia there is less recruitment of new capillaries in the circulation. Polyneuropathy also has a significant effect on the complications leading to intrinsic muscle atrophy and change in the configuration of the foot as well as sensory neuropathy leading to diminished awareness of trauma. Patients with diabetic foot infections should have prompt drainage of infection. They should then be evaluated for macrovascular circulatory disease. Arterial reconstruction should be performed based on the angiogram findings. If secondary revisions or closures of the foot are required, these should be done after adequate drainage and revascularization. In general, autogenous vein is the appropriate conduit for bypass in these patients especially since approximately 25% will require bypass to the dosalis pedis artery. The results of lower extremity bypass in diabetics are excellent with limb salvage rate of over 80% at five years.