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      Impact of Diabetes and Peripheral Arterial Occlusive Disease on the Functional Microcirculation at the Plantar Foot

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          Abstract

          Background:

          Plastic and reconstructive surgeons are commonly faced with chronic ulcerations and consecutive wound infections of the feet as complications in patients with diabetes and/or peripheral arterial occlusive disease (PAOD). Microcirculatory changes seem to play an important role. However, the evaluation of functional changes in the soft tissue microcirculation at the plantar foot using combined Laser-Doppler and Photospectrometry System has not yet been performed in patients with DM or PAOD.

          Methods:

          A prospective, controlled cohort study was designed consisting of a total of 107 subjects allocated to 1 of 3 groups—group A: healthy subjects (57% males, 63.3 y); group B: patients with diabetes mellitus (DM) (53% males, 59.4 y); and group C: patients with PAOD (81% males, 66.1 y). Microcirculatory data were assessed using a combined Laser-Doppler and Photospectrometry System.

          Results:

          Global cutaneous oxygen saturation microcirculation at the plantar foot of healthy individuals was 8.4% higher than in patients with DM and 8.1% higher than in patients with PAOD (both P = 0.033). Patients with diabetes did not show significant differences in global cutaneous blood flow when compared with either healthy subjects or patients suffering from PAOD.

          Conclusions:

          Functional microcirculation at the plantar foot differs between healthy subjects and patients suffering from diabetes or PAOD of the same age. Patients with either diabetes or PAOD demonstrate deteriorated cutaneous oxygen saturation with equivalent blood perfusion at the plantar foot. More clinical studies have to be conducted to evaluate therapeutical methods that might ameliorate cutaneous oxygen saturation within diabetic foot disease and PAOD.

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          Most cited references54

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          The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus.

          P Reichard, Y Nilsson, U Rosenqvist (1993)
          A cause-and-effect relation between blood glucose concentrations and microvascular complications in patients with insulin-dependent diabetes mellitus has not been established. We randomly assigned 102 patients with insulin-dependent diabetes mellitus, nonproliferative retinopathy, normal serum creatinine concentrations, and unsatisfactory blood glucose control to intensified insulin treatment (48 patients) or standard insulin treatment (54 patients). We then evaluated them for microvascular complications after 18 months and 3, 5, and 7.5 years. Mean (+/- SD) glycosylated hemoglobin values were reduced from 9.5 +/- 1.3 percent to 7.1 +/- 0.7 percent in the group receiving intensified treatment and from 9.4 +/- 1.4 percent to 8.5 +/- 0.7 percent in the group receiving standard treatment (P = 0.001). In 12 of the patients receiving intensified treatment (27 percent of those included in the analysis) and 27 of those receiving standard treatment (52 percent), serious retinopathy requiring photocoagulation developed (P = 0.01). Visual acuity decreased in 6 patients receiving intensified treatment (14 percent) and in 18 receiving standard treatment (35 percent) (P = 0.02). Nephropathy (urinary albumin excretion, > 200 micrograms per minute) developed in one patient in the group receiving intensified treatment, as compared with nine patients in the group receiving standard treatment (P = 0.01). No patient in the intensified-treatment group had nephropathy with subnormal glomerular filtration rates, as compared with six patients in the standard-treatment group (P = 0.02). The conduction velocities of the ulnar, tibial, peroneal, and sural nerves decreased significantly more in the standard-treatment group than in the intensified-treatment group. The odds ratio for serious retinopathy was 0.4 (95 percent confidence interval, 0.2 to 1.0; P = 0.04) in the intensified-treatment group as compared with the standard-treatment group. The corresponding odds ratio for nephropathy was 0.1 (95 percent confidence interval, 0 to 0.8; P = 0.04). Long-term intensified insulin treatment, as compared with standard treatment, retards the development of microvascular complications in patients with insulin-dependent diabetes mellitus.
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            Vascular factors and metabolic interactions in the pathogenesis of diabetic neuropathy.

            Peggy A. Cotter, S. Tesfaye, N Cameron … (2001)
            Diabetes mellitus is a major cause of peripheral neuropathy, commonly manifested as distal symmetrical polyneuropathy. This review examines evidence for the importance of vascular factors and their metabolic substrate from human and animal studies. Diabetic neuropathy is associated with risk factors for macrovascular disease and with other microvascular complications such as poor metabolic control, dyslipidaemia, body mass index, smoking, microalbuminuria and retinopathy. Studies in human and animal models have shown reduced nerve perfusion and endoneurial hypoxia. Investigations on biopsy material from patients with mild to severe neuropathy show graded structural changes in nerve microvasculature including basement membrane thickening, pericyte degeneration and endothelial cell hyperplasia. Arterio-venous shunting also contributes to reduced endoneurial perfusion. These vascular changes strongly correlate with clinical defects and nerve pathology. Vasodilator treatment in patients and animals improves nerve function. Early vasa nervorum functional changes are caused by the metabolic insults of diabetes, the balance between vasodilation and vasoconstriction is altered. Vascular endothelium is particularly vulnerable, with deficits in the major endothelial vasodilators, nitric oxide, endothelium-derived hyperpolarising factor and prostacyclin. Hyperglycaemia and dyslipidaemia driven oxidative stress is a major contributor, enhanced by advanced glycation end product formation and polyol pathway activation. These are coupled to protein kinase C activation and omega-6 essential fatty acid dysmetabolism. Together, this complex of interacting metabolic factors accounts for endothelial dysfunction, reduced nerve perfusion and function. Thus, the evidence emphasises the importance of vascular dysfunction, driven by metabolic change, as a cause of diabetic neuropathy, and highlights potential therapeutic approaches.
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              Peripheral arterial disease.

              K Ouriel (2001)
              Lower extremity peripheral arterial disease (PAD) most frequently presents with pain during ambulation, which is known as "intermittent claudication". Some relief of symptoms is possible with exercise, pharmacotherapy, and cessation of smoking. The risk of limb-loss is overshadowed by the risk of mortality from coexistent coronary artery and cerebrovascular atherosclerosis. Primary therapy should be directed at treating the generalised atherosclerotic process, managing lipids, blood sugar, and blood pressure. By contrast, the risk of limb-loss becomes substantial when there is pain at rest, ischaemic ulceration, or gangrene. Interventions such as balloon angioplasty, stenting, and surgical revascularisation should be considered in these patients with so-called "critical limb ischaemia". The choice of the intervention is dependent on the anatomy of the stenotic or occlusive lesion; percutaneous interventions are appropriate when the lesion is focal and short but longer lesions must be treated with surgical revascularisation to achieve acceptable long-term outcome.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Plast Reconstr Surg Glob Open
                Journal ID (iso-abbrev): Plast Reconstr Surg Glob Open
                Journal ID (publisher-id): GOX
                Title: Plastic and Reconstructive Surgery Global Open
                Publisher: Wolters Kluwer Health
                ISSN (Electronic): 2169-7574
                Publication date Collection: October 2013
                Publication date (Electronic): 07 November 2013
                Volume: 1
                Issue: 7
                Electronic Location Identifier: e48
                Affiliations
                From the [* ]Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany; [† ]Department of Trauma and Reconstructive Surgery, University of Rostock, Rostock, Germany; [‡ ]Plastic and Aesthetic Surgery, Hospital Essen Mitte, Essen, Germany; [§ ]Department of Otolaryngology, Hannover Medical School, Hannover, Germany; and [‖ ]Sport Practice, Hanover, Germany.
                Author notes
                Robert Kraemer, MD, Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, Hannover 30625, Germany, E-mail: kraemer.robert@ 123456mh-hannover.de
                Article
                Accession ID: 00008
                DOI: 10.1097/GOX.0b013e3182a4b9cb
                PMC ID: 4174050
                PubMed ID: 25289243
                SO-VID: bcf8f87a-4477-4ba9-954c-0d7537f182d6
                Copyright © Copyright © 2013 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

                History
                Date received : 18 February 2013
                Date accepted : 05 July 2013
                Categories
                Subject: Original Articles
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                OPEN-ACCESS TRUE

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