d i a b e t e s

Evidence-Based Management 42
Vascular disease and foot
assessment in diabetes
Paul Burland discusses the importance of foot assessments in patients with diabetes
and the treatment options available for peripheral arterial disease

A
vascular surgeon once his/her own? blocked further along the more prevalent in the diabetic
wrote in a set of The temptation can be to arterial tree. limb and tends to occur at a
patient’s notes, go for the more advanced Studies since then have younger age (Boulton et al,
‘without an adequate blood dressings and treatments shown this not to be the case 2002). In a survey carried out
supply this wound will never which are readily available, and although microvascular in the US, a staggering 84%
heal’. This may seem an without fully assessing the disease occurs, it rarely causes of people with diabetes were
obvious statement, but on vascular supply. This article complete occlusion of the found to have evidence of
further examination of the will explore the issue of blood supply (LoGerfo and peripheral arterial disease.
notes it could be seen that this peripheral arterial disease in Gibbons, 1996). Therefore, in (Lucas et al, 2004).
basic fact had been diabetes and discuss the patients with diabetes, the use
overlooked. methods of assessment and of angioplasty, arterial stents Atherosclerosis
The body needs a tenfold treatment available to and bypass surgery can The onset of atherosclerosis in
increase in blood supply to maintain an adequate blood improve the vascular supply people with diabetes occurs in
heal an ulcer but arterial supply to the foot. to the foot thus helping heal much the same way as in
disease prevents this from chronic ulcers (Mercer and people without. Endothelial
occurring (Heuser and Henry, Peripheral arterial Berridge, 2000). damage and platelet
2004). The patient with disease Peripheral arterial disease is aggregation leads to lipid
diabetes which this statement Diabetic vascular disease in strongly associated with older accumulation and plaque
concerns, had experienced a the lower limb can be divided age. In the general population formation (Figure 1).
multitude of costly and time into peripheral arterial disease it is estimated that the disease However, the distribution of
consuming treatments for foot and microvascular disease. develops in (NHS Choices, these plaques is different in
ulcers, including larvae and Microvascular disease causes 2010): individuals with diabetes, as
topical negative pressure structural and physiological the vessels below the knee are
therapy, before finally being abnormalities of the capillary ➤➤2.5% of people under 60 often blocked. Earlier
referred for vascular network. Peripheral arterial ➤➤8.3% of people aged calcification of the tunica
assessment. If such an disease, also referred to as 60–69 media is often seen in people
oversight can happen on a peripheral vascular disease, is ➤➤19% of people over 70. with diabetes, resulting in
hospital ward where a a large vessel disease caused hardening of the elastic
vascular specialist is present, by atherosclerosis of the Peripheral arterial disease is arterial walls.
how often can it happen in a major arteries.
busy general practice where Of the two conditions,
the practitioner has to act on peripheral arterial disease is
Artery with
the main cause of foot cholesterol
build-up
Paul Burland is podiatrist at York ulcerations in someone with
Hospital, specializing in wound care diabetes. Goldenberg et al
Submitted 16 January 2012; (1959) stated that in diabetes
accepted for publication following peer there is another microvascular Artery wall
Artery with
review 8 February 2012 condition characterized by cholesterol
small vessel atherosclerosis, build-up Plaque
Key words: Atherosclerosis, diabetes, foot
causing occlusion of the
assessment, smoking Blood clot
capillary network. Therefore,
Endothelium
Series Editor: Anne Phillips is senior it was commonly thought that Artery wall
lecturer in diabetes care, Alcuin C College, any repair of large vessel
Department of Health Sciences, University of
obstructions would be futile Figure 1. Endothelial damage andPlaque
platelet aggregation leads to lipid
York, Heslington, York YO10 5DD
as the supply would be accumulation and plaque formation.
Blood clot
Endothelium
187 Practice Nursing 2012, Vol 23, No 4
 One of the major differences reasonable to assume that
seen in the ischaemic leg in vascular disease is present.
people with diabetes is Foot pulses need to be
impaired development of checked as part of a patient’s
collateral circulation. When an annual diabetes review.
artery is occluded, a Practice nurses should refer
reasonable blood supply is patients with absent foot
maintained to the foot, despite pulses to the foot protection
the blockage, by the team (i.e. podiatry) to consider
enlargement of these smaller further vascular review.
connective arteries (Figure 2a). The palpation sites for the
However, in individuals with dorsalis pedis and posterior
diabetes the ability to develop tibial pulses are shown in
these arterial ‘rat runs’ is Figure 3. The sites can be
reduced. Therefore occlusions difficult to locate as the
are more common in people position of these arteries can
with diabetes, and owing to vary between individuals. The
reduced collateral circulation, use of a hand-held doppler
more difficult to overcome. can help to identify the level
Angioplasty and stenting can of disease process in a
resolve this problem pulseless foot. Most people
(Figure 2b). with peripheral arterial
disease will have some arterial
Foot assessment flow to the foot. Therefore,
The palpation of pulses in the the mere presence of an
foot is a simple but highly audible pulse is not
effective diagnostic procedure necessarily a sign that all is
(National Institute for Health well. It is rather the nature of
and Clinical Excellence the signal which will indicate
(NICE), 2004). If the pedal the state of the disease
pulses cannot be found, it is process. Healthy arteries will

Figure 2a. Left femoral artery Figure 2b. Left femoral artery
before angioplasty after stenting

188 Practice Nursing 2012, Vol 23, No 4

have a definite triphasic or peripheral arterial disease
biphasic pulse. A dampened, (Aerden et al, 2011).
monophasic sound indicates a A more accurate alternative
diseased artery which requires is to take a toe brachial index,
further investigation. using a toe cuff, but since this
Ankle brachial pressures requires time, experience and
indices can help detect the equipment, the technique is
severity of any blockage. In considered unsuitable for
people without diabetes, the primary care (SIGN, 2006).
use of ankle brachial
pressures indices is a reliable Claudication
tool to assess suspected Intermittent claudication, such
peripheral arterial disease, as muscle pain brought on by
with a value of >0.9 exercise and relieved by rest,
suggesting the presence of is a classic symptom of
disease, and >0.5 associated peripheral arterial disease.
with critical ischaemia (SIGN The Fontaine Classification
2006). However, in the (Fontaine et al, 1954) is an
calcified arteries of people old but simple scheme which
with diabetes there is doubt classifies chronic peripheral
about the reliability of ankle ischaemia (Table 1).
brachial pressures indices In individuals without
(Aerden et al, 2011). Finding diabetes who have ischaemia
a very low ankle brachial by the time a foot ulcerates,
pressure (>0.7) or a very high stages 3 or 4 have usually
reading (>1.3) will provide developed. Whereas, in
overwhelming evidence that people living with diabetes,
significant disease is present. ischaemic ulcers may occur at
However finding a ‘normal’ stages 1 or 2, which can lead
ankle brachial pressure cannot to a delay in referral for
rule out the presence of vascular assessment (Mercer

a b

Figure 3.The palpation sites for (a) dorsalis pedis and (b) posterior tibial
pulses.The pulse are palpable at the site marked with a cross, Doppler
signals may be audible at any point along the line of the artery

Table 1. The Fontaine classification system

Stage 1 No symptoms
Stage 2 Intermittent claudication subdivided into:
2a Without pain on resting, but claudication greater than 200 metres
2b Without pain on resting, but claudication less than 200 metres
Stage 3 Nocturnal and/or resting pain
Stage 4 Necrosis and/or gangrene in the limb
From: Fontaine et al, 1954

Practice Nursing 2012, Vol 23, No 4 189

d i a b e t e s
Evidence-Based Management 42

and Berridge, 2000). Early in ischaemic ulcers, where issue may appear too over 40 years who are at risk,
intervention and treatment is infected wounds in particular, complex, but a failure to should be prescribed statin
paramount in preventing the will fail to heal (EURODIALE address it will mean a failure therapy (unless
development of ulceration. Study, 2008). to fully treat the wound. It contraindicated) to help lower
The incidence of cannot be stressed enough their cholesterol. People over
intermittent claudication is Smoking how much smoking cessation 50 years should undertake
4–5 times higher in people The link between smoking and can improve the prospects of antiplatelet therapy to help
with diabetes than in those peripheral arterial disease has wound healing. reduce the risk of thrombus
without. This ratio would be been recognized for decades formation. Where indicated, an
even higher if it were not for (Mernie and Sidawy, 2006). Critical ischaemia angiotensin-converting enzyme
the fact that with diabetes, The risk of atherosclerosis in Critical ischaemia is (ACE) inhibitor is the first-line
claudication is sometimes people with diabetes who characterized by rest pain and drug to lower blood pressure
masked by peripheral smoke is 16 times that of non- failure of trivial foot injuries and prevent cardiovascular
neuropathy. It should be diabetic non-smokers. Former to heal, leading to ulceration events (NICE, 2009).
remembered that peripheral smokers remain up to 7 times and eventual gangrene (SIGN, Cilostazol is a drug that has
arterial disease is not the most more likely to develop the 2006) (Table 2). These signs both antiplatelet and
common cause of foot condition (Fielding, 1985). are a result of poor vasodilatory effects and can
ulceration in diabetes, The additional effect that circulation and reduced be used for relieving early
constituting only about a smoking has on wound nourishment to the tissues, claudication in Fontaine
quarter of all cases (Edmonds healing can be catastrophic, with obvious changes, stage 2b (SIGN, 2006).
and Foster, 2008). leading to amputation rates especially to the skin, nails,
Neuropathy, which does 2–3 times higher in smokers hair, and muscles. Glycaemic control
constitute the main underlying than non-smokers (Mernie In critical ischaemia, the Reports provide evidence that
cause, has its own particular and Sidawy, 2006). foot is cool and pulseless and improving haemoglobin A1c
set of problems and challenges. As illustrated in Case the colour can vary depending (HbA1c) can reduce the risk of
However, once these are Study 1, people may appear on the position of the leg. A diabetes-related death
addressed, neuropathic ulcers ignorant of the effect that positive Buerger’s postural test (Stratton et al, 2000).
will heal. This is not the case smoking tobacco has on the demonstrates this well; when Although no direct link
lower limb. Much publicity is elevated, the leg is drained, between improved glycaemic
given to the effects of smoking causing it to blanch. Bringing control and wound healing is
on the health of the heart and the foot to the floor allows evident, it would appear
lungs, and the increased risk blood to drain back. However, logical that improving control
of stroke and cancer. However, owing to the lack of sufficient will contribute to healing (UK
the detrimental effect of arterial blood, the colour Prospective Diabetes Study
smoking on wound healing is becomes ruddy and cyanotic. (UKPDS), 1998).
not well known. This is known as a ‘sunset
When dealing with non- foot’ and may be mistaken for Exercise
healing foot ulceration in infection in the person who Regular exercise can help
people with diabetes the fact has severe ischaemia improve vascular supply and
that the patient smokes can (Figure 7). However, an extend claudication distances.
be difficult to discuss between infected foot will not blanch It is also noted that supervised
the patient and the practice when elevated. Critical exercise is more beneficial
Figure 7. The sunset foot nurse. The task of tackling the ischaemia requires urgent than unsupervised (Leng et al,
referral (within 24 hours) to a 2000). When encouraging
Table 2. Characteristics of an ischaemic foot vascular surgeon via the patients to increase exercise,
Cold, legs and/or feet which may be pale or blue multidisciplinary foot care care must be taken to check
Reduced or absent pulses in the legs and/or feet team (NICE, 2004). their feet for risk factors such
Dry, thin and brittle skin and nails as neuropathy or deformity.
Loss of hair on legs and feet Treatment Regular foot checks must be
Muscle wasting Drug management continued as foot ulcers can
Prevention and delaying the easily occur when activity is
Positive Buerger’s sign
progression of peripheral increased.
Ulcers are commonly seen on the margins of the foot
arterial disease requires early
There may be limb swelling, secondary to cardiac failure
intervention in people with Surgical intervention
From: Edmonds et al, 2008 diabetes (NICE, 2008). People The two main therapeutic

190 Practice Nursing 2012, Vol 23, No 4

d i a b e t e s
Evidence-Based Management 42

CASE STUDY 1

A 50-year old male presented at his cramps in his leg at night and had was no other option but to perform a
practice complaining of pain in his left recently stubbed his toe. The area had below knee amputation.
leg when walking 300 yards. He had developed into a dry necrotic ulcer The effect of smoking on this
recently been diagnosed with type 2 and the foot was red (Figure 4) individual’s outcome can only be
diabetes and had been prescribed During examination, no pedal pulses speculated upon. However, if he had
metformin, simvastatin, low dose were palpable and if elevated, the foot been a non-smoker, his chances of
aspirin, and ramipril. blanched. Doppler investigation success would have been considerably
The patient smoked about 30–40 reported a weak monophasic signal in higher than they were.
cigarettes a day. He was suffering from the posterior tibial artery.
He was urgently referred by
podiatry to a vascular surgeon for an
angiogram. The images showed a large
blockage in the femoral artery which
was angioplastied and a stent applied
to keep the vessel open. With a
restored blood supply, the ulcer healed
and the patient’s leg became pain free.
Figure 4. Left foot on presentation He also agreed to stop smoking.
Two years later the patient returned
to the podiatrist with ulcers over the
lateral side of his foot, and a trauma
injury to the dorsum (Figure 5). The
pain and claudication had returned.
He had not been able to give up
smoking and the stent had become
occluded (Figure 6). He was admitted
to hospital and a femoral posterior
tibial bypass was performed. This
relieved the symptoms and the wounds
began to heal. He cut down on his
cigarettes but was unable to fully cease
smoking. The bypass lasted only
5 weeks before occluding and there
Figure 5. Re-ulceration 2 years later Figure 6. The stent occluded

options for peripheral arterial then the radiologist will sections of artery at either side disease process should not be
disease are endovascular proceed to an angioplasty. of the blockage. Synthetic underestimated. It is
treatment (angioplasty and This involves passing a wire tubing can be used if the important for the practice
arterial stenting) and bypass across the blockage and patient’s veins are not available. nurse to intervene with
surgery. Where surgical inflating a balloon to open the smoking cessation advice in
intervention is indicated, an artery. Occasionally, on Conclusions order to help the patient stop
angiogram is usually deflation of the balloon, the Complications of peripheral smoking, especially if the
performed first to identify the area collapses and a metal arterial disease can occur at an patient is at risk of
nature and extent of the stent is left in place to keep early stage in people with ulceration.
disease. In people with renal the artery open. diabetes. Practice nurses have a In line with NICE
failure, where the contrast Bypass surgery is a more vital role in the early guidelines (2004), practice
agent is potentially harmful, a complex invasive procedure. identification and treatment, nurses should refer any
magnetic resonance It involves bypassing the and this can help prevent, patients with absent foot
angiogram (MRA) may be diseased artery, usually by potentially limb-threatening, pulses to the foot protection
performed instead. grafting a segment of long ulceration. team. If the ulcer is active, the
If the stenosis is suitable saphenous vein to healthy The role of smoking in the patient will require referral to

192 Practice Nursing 2012, Vol 23, No 4

the multidisciplinary foot care disorders] [in German]. Helvetica Diabetic Foot Lower Extremity
Chirurgica Acta 21: 499–533 Arterial Disease and Limb
team within 24 hours (NICE,
Salvage. Lippincott Williams and
Key Points
2004). Goldenberg SG, Alex M, Joshi RA
et al (1959) Nonatheromatous Willkins, Philadelphia: 129–134
peripheral vascular disease of the National Institute for Health and
Conflict of interest: none declared lower extremity in diabetes Clinical Excellence (2004) Type 2 ➤➤ The body needs a tenfold
Mellitus. Diabetes 8:261–73 Diabetes: Prevention and
Management of Foot Problems. increase in blood supply to
Heuser R, Henry M, eds (2004)
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Fontaine R, Kim M, Kieny R (1954) Merine KM, Sidawy AN (2006) Group (1998) Tight blood referral within 24 hours
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