[Diabetic angiopathy: the role of microvascular exploration in routine practice. Consequences of a new algorithm for care of the diabetic foot].
Diabetes mellitus is the chief medical cause of amputation. The risk of amputation is 15-fold higher in diabetic subjects and 5 out of 6 amputees are diabetic. There are three types of clinical presentation of diabetes-neurological, infectious and ischemic. In clinical practice, these three forms are often intertwined but the most frequent clinical sequence of events is neuropathy --> ulceration --> infection --> amputation. In this sequence, ischemia is not mentioned. The explanation is that the ischemic component of the diabetic foot is only recognized when ankle pulses are missing and when duplex scanning shows stenosis or occlusion of the main arterial trunks of the legs. This manner of diagnosing the ischemic component of diabetic foot is wrong as it fails to recognize the possibility of distal diabetic arteritis. Some experts in diabetology deny the existence of this arteritis which is obvious for those who measure systolic toe pressure. This distal arteritis is present in about 15% of all diabetic patients without trophic changes and in 35% of those with trophic changes. This foot arteritis is closely related to neuropathy. Toe pressure is not usually mentioned in text books or in consensus conferences concerning the diabetic foot. This is the main explanation for the calamitous number of amputations among diabetic patients. Nothing will change as long as physicians do not include toe pressure as a useful diagnostic tool in patients with diabetes. We present here a four-stage algorithm including toe pressure measurement for the management of the diabetic foot.
Vayssairat
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Fédération AP-HP de Pathologie Vasculaire, Hôpital Tenon, 4 rue de la Chine, 75020 Paris.
Le Dévéhat
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C
D000465:Algorithms; D000671:Amputation, Surgical; D001167:Arteritis / Q000503:physiopathology / Q000517:prevention & control; D003925:Diabetic Angiopathies / Q000150:complications / Q000473:pathology / Q000503:physiopathology*; D017719:Diabetic Foot / Q000517:prevention & control* / Q000601:surgery; D006801:Humans; D008833:Microcirculation / Q000503:physiopathology*