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Diabetes can lead to amputation

How Diabetes Can Lead to Amputation

Diabetes is a collection of conditions involving the hormone insulin and how your body uses glucose. Type 1 and type 2 diabetes are chronic forms of diabetes. These chronic forms of the disease can lead to various complications that could affect all parts of the body.

There is unease among the diabetic population because complications include toe, foot, and limb amputation. We aim to educate patients about how diabetes mellitus can progress to peripheral artery disease (PAD), the leading cause of amputation for people with diabetes.

How Does Diabetes Affect the Arteries?

Diabetes mellitus is a condition in which the hormone insulin, produced by the pancreas, is either lacking or ineffective. Insulin acts as the gatekeeper of sugar, also known as glucose, by allowing sugar to leave the bloodstream and enter other cells in the body to be used as energy. Without adequate insulin, the sugar stays in the bloodstream at increased levels. Chronic high blood sugar in turn leads to internal blood vessel walls that are rough and inflexible. Sticky plaques can easily build up on these damaged vessel walls in a condition called atherosclerosis and efficient blood flow is occluded.

Diabetes and PAD Infographic

The smallest blood vessels in the body, located at the extremities, are most likely to be affected by occlusion. This is why most peripheral extremities can experience the worst blood flow when blood sugars are consistently high. Known as peripheral artery disease (PAD), restricted blood flow prevents oxygen, nutrients, and healing cells from reaching the toes, feet, and legs. This makes them prone to numbness, infection, and poor wound healing. Sometimes a wound will go unnoticed by a patient due to a lack of nerve sensation in the wound; this is called neuropathy. Chronic wounds may cause tissue damage or infection that may become so severe that amputation is necessary.

PAD Prevention for Diabetic Patients

It is important to prevent peripheral artery disease and detect it early to avoid amputations. To prevent peripheral artery disease, it is crucial to control blood sugar levels by adhering to an appropriate diet. Test blood glucose and A1C levels regularly, and take all medications as prescribed by your doctor. As discussed earlier, keeping blood sugar levels stable will prevent blood vessel damage and the subsequent effects of poor blood flow.

Other ways to prevent PAD are to exercise regularly, avoid smoking, and prevent or control other medical conditions such as high blood pressure and high cholesterol.

Diabetic Amputation and Limb Loss Infographic

Detect Peripheral Artery Disease Early

Early detection of peripheral artery disease is both possible and crucial. One classic symptom of PAD is leg or foot pain that increases with activity such as walking or exercise. Other symptoms may include leg numbness and/or weakness. One leg or foot may feel cold, especially compared to the other foot or the rest of the body. Also, watch out for slowed hair or nail growth and sores that don’t appear to be healing well. You may notice discoloration of the skin on the legs or feet. Your doctor may notice other signs such as a weak pulse in an extremity. Take care to observe and care for feet daily by checking all skin surfaces, keeping feet and legs clean and dry, and wearing comfortable shoes that fit appropriately.

29 million Americans are affected by diabetes and 12 million are affected by peripheral artery disease. Fortunately, by taking the above measures and working closely with vascular experts, lower limb amputations have been reduced by half over the past 20 years. Vascular experts help educate patients about peripheral artery disease prevention, screen for it regularly and determine the best form of treatment. If peripheral artery disease is detected early, studies show that up to 90% of associated amputations can be avoided.

How to Detect & Treat PAD

It is important to find a vascular team you trust. The interventional radiologists, interventional cardiologists, and vascular surgeons at Modern Vascular work with your endocrinologists, podiatrists, PCPs, and other physicians to provide the care that you need. The top priority of our physicians is to prevent unnecessary amputations. Modern Vascular is committed to utilizing state-of-the-art technology and modern, advanced techniques, such as minimally invasive outpatient endovascular procedures, for providing positive outcomes. Our vascular providers are committed to finding the best solutions to save your toes, feet, and limbs. Diabetic patients with PAD should seek providers with extensive training, a specialized focus, and plenty of experience diagnosing and treating those conditions. Consider seeking a second opinion if your doctor has indicated that amputation is your only option

National Kidney Month

National Kidney Month

March is National Kidney Month, so we’re taking the time to spread awareness about Chronic Kidney Disease (CKD). This is especially important to note as people with CKD are at a higher risk of developing peripheral artery disease (PAD) and its adverse health outcomes than individuals with normal renal function.

Caused by narrowing and blockages in the arteries in your legs, PAD is a progressive condition most commonly due to atherosclerosis, which is an accumulation of plaque on the inner walls of the artery.1 CKD also contributes to atherosclerosis.2

CKD is characterized by reduced kidney function, while PAD is characterized by reduced blood flow to the extremities, particularly the legs. This can potentially cause wounds to heal slowly or not at all.

Reportedly, there’s evidence suggesting CKD patients are at an increased risk of developing atherosclerosis and other cardiovascular diseases. With atherosclerosis as the common denominator, it has become more apparent that there could be a link between PAD & CKD in the form of an increased risk.4 However, until recently, there was little research on their possible correlation.

According to researchers, it appears that patients with CKD have an increased risk of developing PAD.4

Additionally, CKD and PAD share some notable risk factors like diabetes, high blood pressure, and 60+ age. The prevalence of PAD in patients with chronic kidney disease is higher than the prevalence of heart attack and stroke in CKD patients.4

Renal Failure & Contrast

Although contrast dyes are generally safe for most patients, those with renal failure may be at additional risks of developing contrast-induced nephropathy (CIN) a rare disorder that occurs when kidney problems are caused by the use of certain contrast dyes.

In most cases contrast dyes used in tests, such as CT and angiograms, have no reported problems, with only 2% of people receiving dyes can develop CIN. That being said, the risk for CIN can increase for people with diabetes, a history of heart and blood diseases, and CKD.4

Modern Vascular uses minimal contrast and we have a CO2 option for renal patients in order to carefully evaluate patients while being cognizant of the risks associated with reduced kidney function.

Screening for PAD

Since roughly half of PAD patients have no apparent symptoms, it’s difficult at times to know if someone has the disease,1 making early detection and treatment of PAD that much more important to stay on top of. It’s imperative to avoid infections and prioritize treatment to avoid the necessity of amputation.

Patients who have chronic kidney disease should undergo evaluation, even if they show no symptoms of peripheral artery disease.

In order to screen for PAD several imaging tests are used to diagnose and evaluate PAD:

  • Vascular ultrasound
  • Doppler ultrasound
  • Catheter angiography
  • CT angiography (CTA)
  • MR angiography (MRA)

Your Healthcare Team

Patients with both CKD and PAD should have healthcare providers from several specialties working in cooperation on their care. According to doctors in a 2015 paper, it is recommended that patients with PAD-CKD be managed by a multidisciplinary team including the following specialists: vascular specialists, nephrologists (kidney experts) and wound care specialists.3

Even with a great team, the role the patient plays in their own healthcare is crucial. If you have CKD it’s always a good idea to get checked for PAD even if you aren’t experiencing any PAD symptoms and asking your team for more information about your risks. Keep your entire healthcare team up to date on your health history, including your current medications and any new or changing symptoms.

It is also important to adhere to a healthy diet, exercise regularly (we recommend walking), avoid smoking and drinking excessive alcohol. Finally, always follow the advice of your healthcare providers and take any medications as prescribed.

Sources:

  1. Johns Hopkins. Peripheral Vascular Disease. (accessed 3/18/2021)
  2. Kon, V., Linton, M. & Fazio, S. Atherosclerosis in chronic kidney disease: the role of macrophages. Nat Rev Nephrol 7, 45–54 (2011). https://doi.org/10.1038/nrneph.2010.157
  3. Garimella, P.S., Hirsch, A.T. “Peripheral Artery Disease and Chronic Kidney Disease: Clinical Synergy to Improve Outcomes.” Adv. Chronic Kidney Dis., 2014. 21(6): p. 460-471
  4. National Kidney Foundation “Contrast Dye and the Kidneys” Accessed (3/18/2021)
Diabetic Endocrinologist and Podiatrist

Diabetic Coordination of Care

It is estimated worldwide that every 30 seconds a leg is amputated and 85% of those are due to a diabetic foot ulcer.1 Treatment of diabetic patients that come to Modern Vascular cannot happen without coordination of care between our interventional radiologist and the endocrinologists and podiatrists who regularly treat diabetic patients.

Coordination of Care for Diabetes Patients with PAD Reduces Amputations

One example of such collaboration that occurs regularly is among San Antonio-area physicians Dr. Firas Akhrass, an Endocrinologist, Dr. Russell Stanley, a Podiatrist, and an Interventional Radiologist that used to manage Modern Vascular’s original San Antonio clinic. How do these doctors work together to reduce diabetic-related amputations?

How do an Endocrinologist, a Podiatrist, and an Interventional Radiologist work together?

All three participated in our Webinar, but here’s a preview of their talk:

Interventional Radiologist

From an Interventional Radiologist’s point of view, patients do not magically realize they need an interventional radiology procedure of their own accord. They need education on PAD, its symptoms, and its treatments, and that often comes with the help of the other physicians treating them for diabetes and related complications. “These doctors are able to identify symptoms of PAD, and know when to escalate treatment to prevent amputation. This coordination of care is important in saving limbs and restoring lives.” Recommendation by your physician is the most common way to find out you may be at risk for PAD, but another tool available to anyone is this easy self-assessment quiz to check for significant risk factors.

Podiatrist

Dr. Stanley, a Podiatrist, notes common indicators that his patients should be evaluated for PAD are discoloration in the skin, bruising, mottling of small blood vessels distally, foot ulcers (holes in the skin), skin temperature, and sometimes ischemia. Patients often don’t feel pain from PAD symptoms, due to diabetic neuropathy. The most important thing to note is that left untreated, any of these symptoms can lead to worsening problems and future amputation. Patient awareness is paramount, he says: “Having patients be able to identify that there is a problem, they need help, and it’s not going to get better and self-resolve, is of utmost importance.” When referring patients to Modern Vascular, Dr. Stanley is always pleased to receive reports of progress, including from patients who received an interventional radiology procedure, as they often report a return to normal neurological sensation, decrease in swelling, and nocturnal cramping. “This is the result of a team approach for patient care,” he adds.

Endocrinologist

Dr. Akhrass, an Endocrinologist, treats many patients with type 2 diabetes who have a wide range of symptoms. While lifestyle changes – such as a healthy diet and regular exercise – and medication help many people keep their diabetes under control, he notes that he also looks for symptoms such as leg pain, color change, and pain while walking. Patients with these symptoms get a PVD (Peripheral Vascular Disease) screening in his office. That said, Dr. Akhrass adds that caution is recommended: “it is better to screen for PVD before symptoms are present than after.” If a PVD screening indicates the patient may have PVD, Dr. Akhrass refers patients to treatment at Modern Vascular. Specialists do not evaluate and treat patients in a vacuum; when endocrinologists and podiatrists coordinate care to include interventional radiologists like those at Modern Vascular in the management of type 2 diabetes, it can result in life-altering – and limb-saving – interventions.

Sources

  1. Diabetic amputations may be rising in the United States / AJMC
Diabetes and PAD

The Connection Between Diabetes & Peripheral Artery Disease

Knowledge of diabetes, its risks, and symptoms are very important to everyone who may be susceptible to this disease or have loved ones who are. Just as important is awareness of how to recognize and what to do about the most serious effects of diabetes, particularly those who risk lower limb amputation from Peripheral Artery Disease (PAD).

What to Know About Diabetes and PAD

Diabetes is common, but it gets more common to those over 65 – one in four people in that age group will develop the disease.1 Add to that, people with histories of smoking, obesity, or diabetes in the family, and overall more than 34 million Americans have diabetes, according to the Centers for Disease Control.2 What’s more, one in five diabetes sufferers don’t even know they have it.3

Diabetic foot infections cause the most hospitalizations

20 percent of all hospitalizations are due to diabetic foot infections4, including ulcers. One reason they go untreated too long is that due to PAD – which is commonly attributed to diabetes (20% of cases5), diabetics often do not notice an injury or ulcer to their lower limb until well after it has happened.

Diabetes and Peripheral Artery Disease Facts and Statistics Infographic

Diabetic Foot Care: Avoiding Diabetic Amputations

Lower limb amputation is a serious risk for those with Diabetes. Currently, as many as 25 percent of the diabetic population have a chance of losing some part of their foot or leg due to PAD. To put that number into sharper focus, someone undergoes an amputation every 20 seconds6 – an event that is becoming more frequent. Amputation is not merely the loss of a toe, leg, or a foot; it is life-changing, with at least a third of amputees never walking again, and with that comes the risk of nursing home placement and increased mortality rates7. The financial burden is heavy as well; the estimated lifetime medical costs for an amputee can grow to more than $500,000.8

Awareness and treatment lower the rate of amputations

Being aware of symptoms and having regular checkups with primary doctors and podiatrists helps spot dangers early and prevent symptoms from progressing to the point of amputation. In addition, Interventional Radiology (IR), a minimally invasive, image-guided procedure is becoming a more common way to treat vascular disease. Vascular procedures like IR are already reducing amputation rates due to PAD by 20 percent9, and these procedures are becoming more common as awareness grows. Concerned about your risk? Take this easy interactive quiz.

Diabetes Awareness Month is about more than awareness of the disease itself, but also of how to treat its most severe effects, and as a result, saving limbs and the hope for an untold number of patients to continue their normal lives. It is a great opportunity to learn more about the disease and develop a better understanding of the treatment options that are available. September is peripheral artery disease month, another opportunity to learn about a disease that is prevalent in people that are living with diabetes.

Sources

  1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2011. Atlanta, Georgia, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011
  2. Centers for Disease Control, 2020
  3. Centers for Disease Control, 2020
  4. Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg. 2007;24:469–82. [PubMed] [Google Scholar]
  5. Wu, S., Driver, V., Wrobel J., and Armstrong D., Foot Ulcers in the Diabetic Patient, Prevention and Treatment. Vascular Health Risk Management. 2007 Feb; 3(1): 65-76
  6. A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU), NIH, 2018
  7. Frykberg RG, Arora S, Pomposelli FB Jr, LoGerfo F. Functional outcome in the elderly following lower extremity amputation. J Foot Ankle Surg. 1998;37(3):181-5; discussion 261.
  8. Blough DK, Hubbard S, McFarland LV, Reiber GE, Smith DG, Gambel JM. “Prosthetic Cost Projections for Servicemembers with Major Limb Loss From Vietnam and OIF/OEF.” Journal of Rehabilitation Research and Development 2010;47(4):387-402
  9. Mentias A, Qazi A, McCoy K, et al. Trends in Hospitalization, Management, and Clinical Outcomes Among Veterans with Critical Limb Ischemia. Circ Cardiovasc Interv 2020 Feb 13
Diabetes, neuropathy and PAD

A Growing Epidemic

Diabetes has been a growing epidemic over the past 30 years. Notably, it has been on the rise with the increase of corn syrup and high sugar substrates in our diets. However, hereditary and cultural influences also contribute factors to diabetes. It is increasingly common to see signs of neuropathy and PAD in pre-diabetic patients.

Diabetes Disease Progression

 

  1. Fatty deposits in the blood

    Diabetes

    Puts fatty deposits and other substances in the blood.

  2. Deposition of plaques of fatty material on inner artery walls

    Peripheral Artery Disease (PAD)

    Atherosclerosis clogged artery.

  3. Inadequate supply of blood to lower extremities

    Neuropathy and Ischemia

    Oxygen starved nerves and tissue.

  4. Amputation due to infection, ulcers, or gangrene

    Dead Tissue and Amputation

    If left untreated, the lack of blood to your feet and toes can lead to infection, foot ulcers and gangrene.

Diabetic blood cells

Neuropathy may occur in over 60% of patients with diabetes. The symptoms of diabetic neuropathy may also include leg cramping or a sensation of aching pain, similar to the PAD. Therefore, from a practical standpoint, neuropathy and PAD frequently coexist as related conditions. That makes it hard to tell vascular pain and neuropathic pain apart.

Diabetes can lead to neuropathy… and the path it takes is through PAD

Neuropathy may occur in over 60% of patients with diabetes. The symptoms of diabetic neuropathy may also include leg cramping or a sensation of aching pain, similar to PAD. So from a practical standpoint, neuropathy and peripheral artery disease frequently coexist as related conditions, which makes it difficult to differentiate vascular pain from neuropathic pain.

The leading risk factors of PAD are age and diabetes. Some of the common warning signs are pain and cramping in your legs and feet. PAD restricts blood flow to your lower legs and feet,  preventing oxygen-rich blood cells from reaching your lower extremities.

Ultimately, this can lead to a breakdown of the skin and diabetic skin ulcers. Sores that will not heal can lead to infections. What you need to know about the relationship between diabetes, neuropathy, and PAD is that diabetes can lead to neuropathy, and the path it takes is through PAD.

The leg pains and warning signs are similar enough that if you are experiencing one or more of these symptoms you should seek a comprehensive evaluation. This is your time to take preventative action. Contact one of the Modern Vascular clinics for a PAD evaluation if you are experiencing warning signs of neuropathy and peripheral artery disease.

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