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Outcome of Ischaemic Foot Ulcers in Patients with Diabetes, with or without Revascularization

Elgzyri, Targ LU (2014) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2014:99.
Abstract (Swedish)
Popular Abstract in Swedish

Syftet med de fyra delarbeten som presenteras i denna avhandling var att studera dels utfall av fotsår samt identifiera faktorer relaterade till utfall och dels risken för att utveckla nya sår efter läkning av tidigare sår hos patienter med diabetes, fotsår och uttalad perifer kärlsjukdom.

Patienter med diabetes och fotsår med ett systoliskt tåtryck <45 mmHg eller ett ankeltryck <80 mmHg som uppsökte och behandlades av ett multidisciplinär diabetes fotteam inkluderades prospektivt och behandlades enligt ett vårdprogram. Alla patienter följdes upp kontinuerligt till läkning eller död oberoende av kärlkirurgisk åtgärd (revaskularisering).

Trettiosex procent av patienterna... (More)
Popular Abstract in Swedish

Syftet med de fyra delarbeten som presenteras i denna avhandling var att studera dels utfall av fotsår samt identifiera faktorer relaterade till utfall och dels risken för att utveckla nya sår efter läkning av tidigare sår hos patienter med diabetes, fotsår och uttalad perifer kärlsjukdom.

Patienter med diabetes och fotsår med ett systoliskt tåtryck <45 mmHg eller ett ankeltryck <80 mmHg som uppsökte och behandlades av ett multidisciplinär diabetes fotteam inkluderades prospektivt och behandlades enligt ett vårdprogram. Alla patienter följdes upp kontinuerligt till läkning eller död oberoende av kärlkirurgisk åtgärd (revaskularisering).

Trettiosex procent av patienterna läkte primärt, 16% efter mindre amputation (amputation genom eller nedom fotleden), 13% efter större amputation (amputation ovanför fotleden) och 27% dog oläkta. Hos patienter utan revaskularisering, läkte 38% primärt, 12% läkte efter mindre amputation, 17% läkte efter större amputation och 33% dog oläkta. Samsjuklighet, svårighetsgraden av perifer kärlsjukdom och graden av sårskada var starkt relaterade till sämre sårläkning oavsett revaskularisering. Tiden från ankomsten till diabetes fotteamet till revaskularisering var också relaterad till sannolikheten för läkning utan större amputation.

Efter läkning av tidigare sår, utvecklade 34% nya sår på samma fot inom observationstiden. Tjugotvå procent av patienter som utvecklade nya sår genomgick en amputation innan de nya såren läkte. Lägre grad av maximal sårskada som förelåg för det tidigare såret, och öppen rekonstruktiv kärlkirurgi, var relaterad till lägre risk för utveckling av nya sår. Patienter med diabetes och fotsår orsakat av nedsatt cirkulation hade en medianöverlevnad på 33 månader.

Sammanfattningsvis visar denna avhandling att hos patienter med diabetes och fotsår orsakat av nedsatt cirkulation är sannolikheten för sårläkning starkt relaterad till samsjuklighet, graden av sårskada, och svårighetsgraden av perifer kärlsjukdom. Resultatet visar också att fotsår orsakat av nedsatt cirkulation hos patienter med diabetes som inte är tillgängliga för revaskularisering kan läka utan större amputation. Vid nedsatt perifer cirkulation är, förutom revaskularisering, tiden till revaskularisering också viktig för sårläkning utan större amputation. Efter sårläkning, har dessa patienter hög risk för att utveckla nya sår. Graden av tidigare sårskada och rekonstruktiv kärlkirurgi påverkade risken för utveckling av nya sår. (Less)
Abstract
The aim of the studies presented in this thesis was to study patients with diabetes and severe peripheral arterial disease (PAD) in regard to outcomes of foot ulcers, factors related to outcomes, and occurrences of new ulcerations and amputations following healing of the initial ulcer.

Patients with diabetes and a foot ulcer, consecutively presenting at a multidisciplinary foot centre, with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg, were prospectively included, followed up according to a predefined program, and offered vascular intervention when applicable. All patients had continuous follow-up until healing or death, irrespective of the vascular intervention.

In total (n=1,151), 36% of... (More)
The aim of the studies presented in this thesis was to study patients with diabetes and severe peripheral arterial disease (PAD) in regard to outcomes of foot ulcers, factors related to outcomes, and occurrences of new ulcerations and amputations following healing of the initial ulcer.

Patients with diabetes and a foot ulcer, consecutively presenting at a multidisciplinary foot centre, with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg, were prospectively included, followed up according to a predefined program, and offered vascular intervention when applicable. All patients had continuous follow-up until healing or death, irrespective of the vascular intervention.

In total (n=1,151), 36% of patients healed primarily, 16% healed after minor amputation, 13% healed after a major amputation, and 27% died unhealed. At the end of the study, there was a dropout rate of 5%, and 3% of patients were still in treatment. In patients considered not feasible for revascularization (n=602), 38% healed primarily, 12% healed after minor amputation, 17% healed after major amputation, and 33% died unhealed. Comorbidities, the severity of PAD, and the extent of tissue involvement were strongly related to a low probability for ulcer healing, irrespective of revascularization. Angioplasty or reconstructive vascular surgery increased the probability of healing. The time to revascularization after admittance to a diabetic foot centre was also related to the probability of healing without major amputation.

After healing from a previous ischaemic ulcer, 34% of patients developed a new ulceration in the same foot within the observation time. Twenty-two percent of patients who developed new ulcers had an amputation before healing from the new ulcers. Lesser maximal tissue destruction during the previous ulcer and open reconstructive vascular surgery were related to a lower risk of new ulcerations. Patients with diabetes and ischaemic foot ulcers had a median survival time of 33 months.

In conclusion, this thesis has shown that a substantial number of patients with diabetes, foot ulcers, and severe PAD can heal without a major amputation. The probability of ulcer healing was strongly related to comorbidity, the extent of tissue involvement, and the severity of PAD. Patients with diabetes and ischaemic foot ulcers not feasible for revascularisation are not excluded from healing without major amputation. Not only revascularization per se, but also the timing of revascularization increased the probability of healing without a major amputation. Following healing, these patients had a high risk of developing new ulcers. The extent of tissue involvement of a previous ulcer and reconstructive vascular surgery affected the risk of developing new ulcers. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Adjunct professor Wahlberg, Eric, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
organization
publishing date
type
Thesis
publication status
published
subject
keywords
outcomes, PAD, Diabetic foot ulcers
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
2014:99
pages
94 pages
publisher
Diabetes and Endocrinology
defense location
Lilla aulan, Jan Waldenströms gata 5, SUS, Malmö
defense date
2014-09-23 09:00
ISSN
1652-8220
ISBN
978-91-7619-028-9
language
English
LU publication?
yes
id
d7092093-9547-4e98-b945-bced698bb90e (old id 4612607)
date added to LUP
2014-09-02 12:02:29
date last changed
2016-09-19 08:44:45
@phdthesis{d7092093-9547-4e98-b945-bced698bb90e,
  abstract     = {The aim of the studies presented in this thesis was to study patients with diabetes and severe peripheral arterial disease (PAD) in regard to outcomes of foot ulcers, factors related to outcomes, and occurrences of new ulcerations and amputations following healing of the initial ulcer. <br/><br>
Patients with diabetes and a foot ulcer, consecutively presenting at a multidisciplinary foot centre, with a systolic toe pressure &lt;45 mm Hg or an ankle pressure &lt;80 mm Hg, were prospectively included, followed up according to a predefined program, and offered vascular intervention when applicable. All patients had continuous follow-up until healing or death, irrespective of the vascular intervention.<br/><br>
In total (n=1,151), 36% of patients healed primarily, 16% healed after minor amputation, 13% healed after a major amputation, and 27% died unhealed. At the end of the study, there was a dropout rate of 5%, and 3% of patients were still in treatment. In patients considered not feasible for revascularization (n=602), 38% healed primarily, 12% healed after minor amputation, 17% healed after major amputation, and 33% died unhealed. Comorbidities, the severity of PAD, and the extent of tissue involvement were strongly related to a low probability for ulcer healing, irrespective of revascularization. Angioplasty or reconstructive vascular surgery increased the probability of healing. The time to revascularization after admittance to a diabetic foot centre was also related to the probability of healing without major amputation.<br/><br>
After healing from a previous ischaemic ulcer, 34% of patients developed a new ulceration in the same foot within the observation time. Twenty-two percent of patients who developed new ulcers had an amputation before healing from the new ulcers. Lesser maximal tissue destruction during the previous ulcer and open reconstructive vascular surgery were related to a lower risk of new ulcerations. Patients with diabetes and ischaemic foot ulcers had a median survival time of 33 months.<br/><br>
In conclusion, this thesis has shown that a substantial number of patients with diabetes, foot ulcers, and severe PAD can heal without a major amputation. The probability of ulcer healing was strongly related to comorbidity, the extent of tissue involvement, and the severity of PAD. Patients with diabetes and ischaemic foot ulcers not feasible for revascularisation are not excluded from healing without major amputation. Not only revascularization per se, but also the timing of revascularization increased the probability of healing without a major amputation. Following healing, these patients had a high risk of developing new ulcers. The extent of tissue involvement of a previous ulcer and reconstructive vascular surgery affected the risk of developing new ulcers.},
  author       = {Elgzyri, Targ},
  isbn         = {978-91-7619-028-9},
  issn         = {1652-8220},
  keyword      = {outcomes,PAD,Diabetic foot ulcers},
  language     = {eng},
  pages        = {94},
  publisher    = {Diabetes and Endocrinology},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Outcome of Ischaemic Foot Ulcers in Patients with Diabetes, with or without Revascularization},
  volume       = {2014:99},
  year         = {2014},
}