Diabetic Foot Ulcers and Diabetes-related Arterial Disease

Diabetes can damage both the nerves and the arteries in your legs and feet. This raises the risk of foot sores (ulcers) that are slow to heal, and in severe cases gangrene. The most feared complication is amputation – which good care can usually prevent.

012 Diabetes: Silent Saboteur

Diabetes Associated Peripheral Arterial Disease

In diabetes, high blood sugar gradually damages blood vessels and nerves throughout the body. Over time this can affect:

the eyes (retinopathy)
the kidneys (nephropathy)
the nerves (neuropathy – loss of feeling, often in the feet)
the arteries, speeding up hardening of the arteries and raising the risk of heart attack, stroke and poor circulation in the legs

Good control of your blood sugar – together with your blood pressure, cholesterol and not smoking – is the best way to slow or prevent these problems. Left unmanaged, diabetes can lead to serious harm, including foot sores that may turn to gangrene and lead to amputation.

Causes

The longer you have had diabetes, the higher your risk of these vascular problems. The risk is greater still if you also have high blood pressure, smoke, do not exercise, are overweight, or eat a high-fat diet.

Symptoms

Diabetes-related vascular problems can show up in several ways:

Blurred vision or floating spots
Swelling of the face or limbs, or sudden weight gain
Frothy urine
Foot sores (diabetic foot ulcers)
Loss of feeling, or burning, in the hands or feet
Leg pain when walking
Chest pain or breathlessness on exertion

High blood pressure usually causes no symptoms at all – it is found only when it is measured, so have it checked regularly.

Tests

I start with your history and an examination, and a blood test to measure your blood sugar and cholesterol. Depending on your symptoms, other checks may include:

Eyes – an eye examination for retinopathy.
Kidneys – a urine test for protein (albumin).
Feeling in the feet – a simple test with a thin nylon filament (monofilament) and a tuning fork to detect nerve damage (neuropathy).
Leg circulation – an ankle-brachial pressure index (ABPI) compares the blood pressure at your ankle and arm, and a duplex ultrasound scan shows where the arteries are narrowed.

One important point: in diabetes the ankle arteries are often stiff and calcified, which can make the ABPI falsely normal. For this reason a toe pressure (toe-brachial index) is more reliable in people with diabetes.

If you have a foot ulcer, I also check for infection: a swab or tissue sample, blood tests and usually an x-ray. If the ulcer reaches the bone, or a probe passes down to bone, an infection of the bone (osteomyelitis) is likely, and an MRI scan or a bone sample may be needed.

Treatment Options

Optimal Medical Therapy

Treatment aims to control everything that damages your arteries: blood sugar (with insulin or glucose-lowering medication), blood pressure, and cholesterol (usually a statin). An antiplatelet such as aspirin or clopidogrel lowers the risk of clots.

Treat Peripheral Arterial Disease

When a foot ulcer develops, the most important treatment is offloading – taking the pressure off the ulcer with a removable or non-removable cast boot or special footwear, so that you do not walk on it. Without offloading, ulcers heal far more slowly or not at all. The ulcer is also treated promptly with dressings, removal of dead tissue and, if infected, antibiotics – while I check whether enough blood is reaching the foot for it to heal. Treating ulcers early matters, because if the tissue dies, part of the foot or leg can be lost.

If the circulation is poor, blood flow can be restored by angioplasty (a balloon, sometimes with a stent, to open the artery from the inside) or by bypass surgery (a vein or fabric graft that routes blood around the blockage). Sometimes the plaque is removed directly (endarterectomy). The best option depends on where the blockages are.

General Guidelines

You can do a great deal to protect yourself:

Stop smoking
Eat a Mediterranean-style diet and keep to a healthy weight
Exercise regularly
Check your blood sugar as advised
Inspect your feet every day, protect them from injury, and keep them clean and dry

References
Intersocietal IWGDF, ESVS and SVS Guidelines on Peripheral Artery Disease in People with Diabetes and a Foot Ulcer (2023).
IWGDF Practical Guidelines on the Prevention and Management of Diabetes-related Foot Disease (2023 update).
Conte MS, Bradbury AW, Kolh P, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019;58(1S):S1–S109. doi:10.1016/j.ejvs.2019.05.006
Farber A, Menard MT, Conte MS, et al. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia (BEST-CLI). N Engl J Med 2022;387(25):2305–2316. doi:10.1056/NEJMoa2207899

SVS Guidelines for Patients: Peripheral arterial disease with diabetic foot ulcerSVS Guidelines for Patients: Diabetic Foot

Our Services

Arterial Procedures

Standard open arterial surgical procedures to repair or reconstruct blood flow to extremities.

Femoropopliteal bypass
Femoral endarterectomy
Femoropopliteal thrombectomy
Femorotibial bypass

Endovascular Procedures

These less invasive procedures are often the first choice, particularly when no suitable vein is available for bypass. For severe disease that threatens the leg, bypass with a good-quality vein can give better results (BEST-CLI trial), so the choice is made for each patient.

Angioplasty with or without stent of
Superficial femoral artery
Popliteal artery
Tibial arteries

Peripheral arterial catheter directed thrombolysis

Hybrid Procedures

Combined endovascular and open surgical procedures are selectively utilised to repair or restore blood flow to the extremities.

Femoral endarterectomy with peripheral angioplasty
Femoropopliteal thrombectomy with peripheral angioplasty with or without stent

Wound Care

We offer the whole range of conservative wound care modalities as well as advanced wound care modalities including surgical debridement, negative pressure wound therapy and / or hyperbaric oxygen therapy for complex wounds related to arterial insufficiency or peripheral neuropathy secondary to diabetes. For more information please visit www.wondsorg.co.za

Hyperbaric Oxygen Therapy

Our team of hyperbaric technologists assists me in offering Hyperbaric Oxygen Therapy for indications accepted by the Undersea and Hyperbaric Medical Society (UHMS). For diabetic foot ulcers it is used as an add-on for ischaemic or neuro-ischaemic ulcers that have not healed with good standard care; the IWGDF 2023 guideline makes only a conditional recommendation for it, based on low-certainty evidence. For more information please visit www.hbo.co.za

If you have any problems with any of these conditions, please contact your General Practitioner, or your Vascular Surgeon. If you live in Pretoria and have not seen a Vascular Surgeon before, you are more than welcome to contact our rooms for a formal consultation.