Winter 2009

Diabetes and PAD: Dangerous, but Treatable Combination

"Diabetic patients with peripheral artery disease (PAD) can respond as well as their non-diabetic counterparts to PAD treatment, despite widespread assumptions that they do not," says Michael S. Conte, M.D., chief of Vascular and Endovascular Surgery at UCSF Medical Center. "That's why it's important to make the PAD diagnosis early in diabetics and to monitor their PAD aggressively."

It's especially important because the more than 23 million Americans who have diabetes are at substantially increased risk for PAD's most severe complications — especially loss of limb. If a diabetic PAD patient is also a smoker, there is a markedly increased risk of amputation. "It's like lighting matches in a gas station," says Conte.

Disease Progression in Diabetics

Diabetics, of course, are at risk for sores and blisters in weight-bearing areas. Because diabetes can affect blood vessels, nerves and the immune system, even a minor foot infection can be limb-threatening. PAD exacerbates these clinical issues because of the way it hampers circulation and, therefore, the ability of the body to self-heal open wounds.

"In addition, PAD in diabetics is usually a more diffuse process that attacks the smaller blood vessels in the calf," says Conte. "The farther down the blockage, the less effective the collateral pathways and the less reserve these people have."

Blockages in these diffuse, smaller vessels and neuropathy from their diabetes obscure the warning signs, so diabetics rarely present with early-stage disease. Instead, they are much more likely to show up in a physician's office with an ulcer or a black toe from advanced PAD — or in an emergency room with a heart attack or stroke.

"The downturn in diabetics can be quite rapid," says Conte. "It's why we argue that every visit, every diabetic should have a pulse exam and an ankle-brachial index."

Preventive foot care with a podiatrist — who can make sure these people have the right shoes, monitor their foot status and educate them about proper foot care — is also essential. And at the first sign of an open sore that doesn't rapidly resolve, diabetics should be referred to a vascular specialist.

"Even without a foot ulceration, if there are no pulses in the foot, diabetics should be followed by a vascular specialist because they are much more likely to progress rapidly and unpredictably, and we can't judge their reserve," says Conte.

This close monitoring, along with appropriately timed interventions, can salvage diabetics' limbs. "We need to avoid therapeutic nihilism," says Conte, who is known nationwide for his limb salvage interventions. "We can open or bypass problem vessels that are far down the leg, but surveillance is the key."

To contact Michael S. Conte, M.D., call (415) 353-4366.

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