An Extension of the Bollinger Scoring System to Analyse the Distribution of Macrovascular Disease of the Lower Limb in Diabetes.

OBJECTIVE: While it is generally considered that patients with diabetes mellitus (DM) have more distal peripheral arterial disease (PAD), there is little information on how individual vessels are affected. The aim of this study was to adapt Bollinger's scoring system for lower limb angiograms (DSAs) to include the distal and planter vessels. The reliability of this extension was tested and was used to compare the distribution of disease in two cohorts of patients with and without DM. METHODS: Patients who had undergone DSA ± angioplasty for PAD at a single centre between September 2010 and April 2014 were identified. Twenty-five patients' images were reviewed by four clinicians and scored using an extended version of the Bollinger score. A total of 153 patients with DM were matched, for age, sex, ethnicity, smoking, and hypertension, with 153 patients without DM. The infrainguinal vessels were divided into 16 arterial segments, including plantar vessels, and scored using the Bollinger score. The score ranges from 0 to 15. Fifteen represents an arterial segment with more than 50% of its length occluded. Interobserver reliability was tested using interclass correlation (ICC) and Cohen's kappa coefficient. RESULTS: The ICC demonstrated good agreement between observers (0.76 [0.72-0.79]) with good internal consistency (Cronbach's alpha 0.93). When the Bollinger scores were categorised, the results were weaker, Cohen's kappa ranged from 0.39 (standard error 0.033) to 0.54 (0.030). Patients with DM had a higher burden of disease in the anterior tibial and posterior tibial arteries with relative sparing of the peroneal artery and no difference in the plantar vessels. CONCLUSION: It has been demonstrated that the Bollinger score can be extended to include the distal vessels. This amended scoring system can be used to compare the burden of distal disease in patients with PAD. How the score relates to clinical presentation and outcomes needs further investigation.

A Review of Distribution of Atherosclerosis in the Lower Limb Arteries of Patients With Diabetes Mellitus and Peripheral Vascular Disease.

OBJECTIVE: There is a generally accepted hypothesis that patients with diabetes mellitus (DM) have a higher burden of atherosclerotic disease below the knee compared to patients without DM (NDM). The aim of this review was to summarize the evidence regarding this hypothesis. METHODS: The literature was searched for papers that compared the anatomical distribution of atherosclerotic disease in patients with DM and those without using radiological imaging. Search terms used included "diabetes mellitus," "peripheral vascular disease," "distribution of disease," "angiography," "computed tomography angiography," and "magnetic resonance angiography." Where possible, the number of patients with disease in each arterial segment was extracted and included in a forest plot. A descriptive approach was taken when this was not possible or a scoring system was used. RESULTS: Fourteen studies were included in the review and it was possible to summarize data from 9 of these in a forest plot. Fifteen different arterial segments were described; however, the most commonly used segments that differentiated between proximal and distal disease were aortoiliac (A-I; DM = 466 patients, NDM = 458), femoropopliteal (F-P; DM = 568, NDM = 585), tibial (DM = 306, NDM = 417). The resulting forest plot showed that those with DM were significantly less likely to have disease in the A-I segment (odds ratio [OR]: 0.25 [0.15-0.42]) and significantly more likely to have disease in the tibial segment (OR 1.94 [1.27-2.96]). In the DM group, there was a trend toward relative sparing in the F-P segment, but this does not reach significance (0.66 [0.33-1.31]). CONCLUSIONS: These results support the hypothesis that patients with DM are more likely to have atherosclerotic disease in the tibial vessels than NDM. There is however limited information on how individual vessels are affected. Further information on this and a greater understanding of why the distal vessels are more affected are avenues for future research.

Safety and Outcomes of Ipsilateral Antegrade Angioplasty for Femoropopliteal Disease.

PURPOSE: Previous reports have suggested higher periprocedural complications after ipsilateral antegrade femoral arterial access (AA). We looked at a contemporary series comparing complication rates between AA and contralateral retrograde femoral arterial access (RA) for femoropopliteal angioplasty. METHOD: A prospective review of all cases between 2010 and 2015 in a United Kingdom tertiary vascular center. Demographical and procedural data were obtained for those undergoing percutaneous femoropopliteal angioplasty. The primary outcome looked at periprocedural complications including retroperitoneal hematoma, pseudoaneurysm, hematoma requiring transfusion, arteriovenous fistulation, and surgical intervention. Secondary outcomes included contrast and radiation doses in addition to procedural failure leading to major amputation. RESULTS: A total of 556 (66% male) patients underwent femoropopliteal angioplasty, 461 (82%) via AA. Groups were of comparable age, sex, comorbidity, and symptomatology. AA patients had a lower body mass index, 26 versus 29 ( P = .005). No significant difference was seen in periprocedural (15.8% AA vs 11.6% RA; P = 0.292) or access site complications (3.7% AA vs 1.1% RA; P = 0.186). There was less need for a closure device, 40.3% AA vs 73% RA ( P < .01), less contrast, 94 mL AA: 114 mL RA ( P < .001), and less radiation, 3487 cGy cm2 AA: 9697 cGy cm2 RA ( P < .001). Arterial access was also associated with greater technical success of 83.8%: 73.3% RA ( P = .002). CONCLUSIONS: Arterial access is associated with higher technical success and reduced contrast/radiation doses with no significant difference in complications compared to RA contrary to previous reports.

The Difference Between the Healing and the Nonhealing Diabetic Foot Ulcer: A Review of the Role of the Microcirculation.

BACKGROUND: Diabetic foot disease carries a high morbidity and is a leading cause of lower limb amputation. This may in part be due to the effect diabetes mellitus (DM) has on the microcirculation including in the skin. METHOD: We conducted a review of studies that have examined the relationship between microcirculatory function and wound healing in patients with DM. A search of the Medline, Embase, and Web of Science databases was performed coupled with a review of references for the period 1946 to March 2015. RESULTS: Nineteen studies of diverse methodology and cohort selection were identified. Poor function of the microcirculation was related to poor outcome. Transcutaneous oxygen pressure (TcPO2) was the most commonly used method to measure the microcirculation and thresholds for poor outcome proposed ranged from 10 mmHg to <34 mmHg. Two studies reexamined microcirculatory function following revascularization. Both found an increase in TcPO2, however only 1 reached statistical significance. No significant difference in the results of microcirculation tests was found between diabetic and nondiabetic patients. CONCLUSIONS: While it is not possible to draw firm conclusions from the evidence currently available there are clear areas that warrant research. Good microcirculation unsurprisingly appears to associate with better wound healing. The influence of DM is not clear, and neither is the degree of improvement required to achieve healing. Studies that examine a clearly defined cohort both with and without DM are urgently required. Accurate quantitative assessment of microcirculation will aid prediction of wound healing identifying those at greatest risk of amputation.

Prescribing antibiotics in diabetic foot infection: what is the role of initial microscopy and culture of tissue samples?

The aim of this study was to evaluate the role of microscopy, Gram stain and the culture of tissue samples in the antibiotic treatment of patients with diabetic foot infection. A retrospective review of patients with a diabetic foot infection was undertaken. Data analysed included the severity of infection, antibiotic prescribing patterns, microscopy and culture results. A total of 71 patients were included, from whom 114 tissue samples were collected. Gram stain results were in agreement with final culture results in 45·8% (n = 54) of samples. Overall sensitivity and specificity of the Gram stains were low (74·5% and 69·8%, respectively), although the specificity for Gram-negative rods was high (98·5%). The presence or absence of 'pus cells' on microscopy was a poor predictor of culture results. Empirical prescribing of antibiotics was in accordance with local policy in 31·1% of patients, improving to 86·8 % following culture results. Microscopy, a skilled laboratory procedure, was generally a poor predictor of tissue culture results. However, the presence of Gram-negative rods was suggestive of isolation in the culture of such organisms and could allow the early broadening of antibiotic treatment. Despite initial poor compliance of empirical antibiotic treatment regimens, prescribing was adjusted in light of culture results, suggesting these were important for clinicians.

Effect of treated length in endovenous laser ablation of great saphenous vein on early outcomes.

OBJECTIVE: The aim of this preliminary study was to document the effect of treated great saphenous vein (GSV) length on short-term outcomes using freedom from secondary intervention as a marker. METHODS: Analysis was performed of a prospective database of endovascular laser therapy (EVLT) procedures performed by a single surgeon in an NHS hospital setting using a standardized technique in a series of consecutive ambulatory patients. During a 2-year period, 131 episodes with sufficient data were recorded. The effect of GSV vein length treated was assessed at 6 weeks. Hospital records were monitored for unplanned events for a minimum of 6 months. RESULTS: All patients with primary or recurrent varicose veins affecting the GSV were offered EVLT ablation. Aneurysmal vein segments, severely tortuous veins, ankle-brachial pressure index of <0.5, and presence of thrombus in the vein were excluded. Patients on anticoagulation were not excluded. Of 192 patients scheduled for EVLT for varicose veins, 61 were excluded from the analysis (40 small saphenous veins, 5 failures to complete procedure, 16 with incomplete data). There were 79 women (60.3%) and 52 men (39.7%), with a mean age of 54 ± 16 (standard deviation) years. CEAP clinical categories were C2, 30 (22.9%); C3, 33 (25.2%); C4, 52 (39.7%); C5, 1 (0.8%); and C6, 15 (11.5%). In addition to EVLT, ultrasound-guided foam sclerotherapy or surgical avulsions were used when required. The main outcome measure was freedom from ancillary treatment with foam sclerotherapy or multiple avulsions. The freedom from reintervention was 68.9% if the treated vein length was 0 to 20 cm (n = 17), 86.5% for a vein length of 21 to 39 cm (n = 74), and 100% for a vein length >40 cm (n = 41; P = .003). CONCLUSIONS: The total length of vein treated appears to have a significant effect on reintervention rates. This may be due to better occlusion of tributaries. Where possible, ≥30 cm should be treated; otherwise, sclerotherapy or avulsions may be incorporated simultaneously to allow for one-stop treatment.

Duplex ultrasound surveillance after carotid artery endarterectomy.

OBJECTIVE: After carotid endarterectomy (CEA), patients have been regularly followed up by duplex ultrasound imaging. However, the evidence for long-term follow-up is not clear, especially if the results from an early duplex scan are normal. This study assessed and systematically reviewed the evidence base for long-term surveillance after CEA and a normal early scan. METHODS: Electronic databases were searched for studies assessing duplex surveillance after CEA in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome for this study was the incidence of restenosis after a normal early scan. The secondary outcome was the number of reinterventions after a normal early scan. RESULTS: The review included seven studies that reported 2317 procedures. Of those patients with a normal early scan, 2.8% (95% confidence interval, 0.7%-6%) developed a restenosis, and 0.4% (95% confidence interval, 0%-0.9%) underwent a reintervention for their restenosis during the follow-up period. CONCLUSIONS: This review confirms that routine postoperative duplex ultrasound surveillance after CEA is not necessary if the early duplex scan is normal.

Common femoral vein canal lipoma causing chronic unilateral lower limb swelling.

A 64-year-old woman presented to vascular clinic with a 2-year history of right ankle swelling, associated with pain on walking. Initial venous duplex imaging showed no obvious cause. Further imaging showed a lipoma compressing the common femoral vein. We consider the relative merits of the imaging modalities of the groin and the literature available on lipomas causing compression.