COMPARISON OF ANGIOGRAPHIC

FINDINGS BETWEEN PATIENTS WITH

NON-HEALING DIABETIC FOOT ULCERS

WITH AND WITHOUT CHARCOT FOOTRobert Bem, Alexandra Jirkovská, Michal Dubský, Andrea Němcová,

Veronika Wosková, Vladimíra Fejfarová, Jelena Skibová

Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague

Backround

• Association between Charcot foot (CF) and peripheral arterial

disease (PAD) is not fully understood

• The pathogenesis of CF is mainly based on diabetic

neuropathy

• In clinical practice, it is frequently observed that CF patients

treated for non-healing diabetic foot ulcers (DFU) are under

clinical suspicion on PAD as well

Aims

• The aim of our study was to assess the role of lower limb

angiography in patients with non-healing DFU with and

without CF with the respect to pathological findings and

possibility of vascularization

Rajbhandari et al, Diabetologia, 2002

International Consensus on the Diabetic Foot, 2007

Molines et al, J Diabetes Metabolism, 2010

Palena LM et al, Cardioavasc Intervent Radiol, 2013

Patients and methods

Characteristics CF group Controls P

n 29 48 -

Age (years) 64±9.6 66.4±9.5 NS

Sex (M/F) 22/7 40/8 NS

Duration of DM (years) 23.9±9.4 18.5±10 0.02

Type 2 Diabetes n (%) 21 (72) 36(75) NS

HbA1C (%) 8.32±1.19 8.03±1.38 NS

VPT (%) 100 83.3 NS

Data are mean ± SDVPT= vibration perception treshold

The presence of PAD was compared between:- 29 diabetic patients with ulcerated Charcot foot (CF group)

- 48 consecutive patients presenting with a new DFU, but without

CF (Controls)

The diagnosis of PAD

Clinical suspicion (e.g. nonhealing ulcer,

gangrene, ...)

TcpO2 < 40mm Hg

Angiography

The presence of PAD was defined as anabnormal angiographic findings on lower limb arteries (stenosis >70% or oclusion)

Diagnosis of Charcot

foot

Active:

- Clinical - hot, swollen foot with/without redness and skin temperatures ≥2 0C compared to the contralateral foot

- Radiological examination (positive three phase technetium-99m-labelled bisphosphonate bone scan)

Inactive:

- Active CNO in history- Reduction of clinical signs and

temperature difference below 2°C, typicaldeformity

Graziani L et al, Eur J Vasc Endovasc Surg, 2007

Graziani classification

Characteristics of the study subjects

Results

The distribution of PAD by Graziani classification

Class Angiographic Finding CF group (%) Controls (%) p

1Isolated, one vessel tibial or peroneal artery

obstruction0 0 NS

2aIsolated femoral/popliteal artery or two below

knee arteries obstructed but with patency of

one of the two tibial arteries

6.9 0 NS

2bIsolated femoral/popliteal artery or two below

knee tibial arteries obstructed but with patency

of the peroneal artery

31.1 6.3 0.01

3Isolated, one artery occluded and multiple

stenosis of tibial/peroneal and/or femoral/

popliteal arteries

27.6 25 NS

4Two arteries occluded and multiple stenosis of

tibial/peroneal and/or femoral/popliteal vessels27.6 41.6 0.04

5Occlusion of all tibial and peroneal arteries

(below knee cross-sectional occlusion)3.4 12.5 NS

6Three arteries occluded and multiple stenosis of

tibial/peroneal and/or femoral/popliteal arteries3.4 14.6 NS

7Multiple femoro-popliteal obstructions with no

visible below the knee arterial segments0 0 NS

Revascularization rates based on angiographic findingsin patients with non-healing DFU

Charcot group (n=29) Controls (n=48)

NS■ PTA= percutaneous transluminal angioplasty ■ bypass ■ revascularization was not possible

72.4% 68.8%

17.3% 18.7%

10.3% 12.5%

Patients without CNO had significant more frequent presence of most severe findings (Graziani class 4 and higher – 68.7%) in comparison with CF group (34.4%; p<0.001).

ConclusionsOur results indicate that patients with CF and non-healing DFU had lower grade of PAD impairment than patients without CF,

nevertheless angiographic findings led to equally frequent

revascularization as in non-CF patients.