Peripheral Vascular Disease in Patients With Diabetes Mellitus

Abstract

The concomitant occurrence of atherosclerotic peripheral vascular disease in patients with diabetes mellitus is a major factor in the progression of diabetic foot pathology. The rate of lower extremity amputation in the diabetic population is 15 times that seen in the nondiabetic population (1). This increased rate is a result of a number of factors present in the diabetic population that leads to foot pathology in a synergistic fashion. These factors include peripheral neuropathy, which leads to structural and sensory changes within the foot; microvascular changes, nonocclusive changes in the microcirculation leading to the impairment of normal cellular exchange; infection, often aggressive and polymicrobial and macrovascular disease, atherosclerosis of the peripheral arteries. Although the underlying pathogenesis of atherosclerotic disease in diabetics is similar to that noted in nondiabetics, there are several significant differences. Of note, the diabetic foot is more susceptible to moderate changes in perfusion than the nondiabetic foot, which results in a greater sensitivity to atherosclerotic occlusive disease. Compounding this scenario is the fact that diabetics have a fourfold increase in the prevalence of atherosclerosis, and a propensity for an accelerated form of atherosclerosis. This chapter reviews the pathobiology and anatomic distribution of diabetic peripheral arterial occlusive disease, its clinical presentation and the various diagnostic modalities of use in its evaluation. It concludes with a diagnostic and treatment protocol that can be used in patients presenting with this multifactorial disease process.