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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 448-455

Role of arterial duplex of both lower limbs in the evaluation of diabetic foot


Department of Radiodiagnosis, Al Azhar University, Cairo, Egypt

Date of Submission10-Jun-2020
Date of Decision18-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication2-Oct-2020

Correspondence Address:
BSc Yasmin A El-Sayed
Department of Radiodiagnosis, Al Azhar University, Cairo, 12211
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_68_20

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  Abstract 


Introduction Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycemia and dyslipidemia. Abnormalities in nutrient metabolism and vascularity resulting from DM lead to lower limb arterial diseases and ischemia, and this leads to infection, foot ulcers, and impairment of wound healing. Color Doppler ultrasound is a widely available noninvasive technique in the assessment of arterial affection of lower limbs that occur with DM. Color Doppler ultrasound has lots of advantages over other diagnostic imaging modalities; it is a feasible modality available in nearly all hospitals, being cheap, accurate, and safe.
Aim The aim was to highlight the role of arterial duplex to better delineate vascular anatomy, localize the obstruction, assess the severity of stenosis, and detect the presence of collaterals, and distal runoff in patients with diabetic foot disease.
Materials and methods Ultrasound color and Doppler examinations were performed to 20 patients previously diagnosed to have DM; the arterial supply of lower extremities was divided into these segments: common iliac artery, external iliac artery, common femoral artery, superficial femoral artery, profunda femoris artery, popliteal artery, anterior tibial artery, posterior tibial artery, peroneal artery, and dorsalis pedis. Arterial lesions were located by changes in vessel caliber, changes in color flow patterns, and broadening of Doppler waveform, quantified by measuring the peak systolic velocity (PSV) ratio across a lesion and by comparing the PSV within stenosis with that proximal to the lesion; this ratio was independent of individual variations in blood pressure, vascular compliance, and cardiac function.
Results In all, there were 20 patients (400 segments), 35 segments showed significant stenosis (luminal narrowing ≥50% of artery diameter and PSV ratio ≥2), 21 segments were occluded, eight of them were with no distal collateral refilling, and 100 segments showed nonsignificant stenosis (luminal narrowing <50% of artery diameter and PSV ratio <2). Of 400 examined arterial segments, 297 arterial segments showed normal triphasic flow, 95 segments showed monophasic flow, eight segments had no flow indicating there was no distal refill in these segments. Of 400 arterial segments, 104 segments had low PSV (which were measured at the distal part of each segment).
Conclusion Duplex ultrasound is an accurate easily acquired noninvasive diagnostic modality in diabetic foot patients. There was very high incidence of atherosclerosis in diabetic foot patients with more affection in below-knee arteries.

Keywords: diabetes mellitus, diabetic foot, duplex ultrasound


How to cite this article:
El-Sayed YA, Hak MT, Mostafa AM. Role of arterial duplex of both lower limbs in the evaluation of diabetic foot. Sci J Al-Azhar Med Fac Girls 2020;4:448-55

How to cite this URL:
El-Sayed YA, Hak MT, Mostafa AM. Role of arterial duplex of both lower limbs in the evaluation of diabetic foot. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 28];4:448-55. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/448/296955




  Introduction Top


Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycemia and dyslipidemia. Abnormalities in nutrient metabolism and vascularity resulting from DM lead to lower limb arterial diseases and ischemia, and this leads to infection, foot ulcers, and impairment of wound healing. Diabetic lower limb ischemia often leads to limb necrosis [1].

Lower limb arterial disease resulting from long-standing DM is an important health problem of the present time. DM is a common pathological condition with a higher prevalence rate in developing countries. Egypt is included among the countries with the highest prevalence of diabetes [2].

Color Doppler ultrasound is a widely available noninvasive technique in the assessment of arterial affection of lower limbs that occur with DM. Color Doppler ultrasound has lots of advantages over other diagnostic imaging modalities; it is a feasible modality available in nearly all hospitals, being cheap, accurate, and safe [3].

It also uses nonionizing radiation, and hence is safe in all cases with no limitations. Color Doppler ultrasound technique is not used with contrast agents, and hence it has no hazards of allergic or nephropathic effects [4]. Color Doppler ultrasound competes with magnetic resonance angiography, and some studies show same or better results compared with magnetic resonance angiography, but with much less cost [5].

Color Doppler ultrasound technique can identify the condition of arterial wall, whether healthy or diseased, atheromatous plaques, and calcification through gray scale. Areas of stenosis, turbulence, and defect of blood flow can be seen with the help of color. Moreover, a major advantage for Doppler ultrasound over other imaging modalities is that it can identify hemodynamic changes that occur with arterial stenosis [6].


  Materials and methods Top


This study is a prospective observational cohort study conducted on 20 patients presented to the Radiology Department in the Diabetes Mellitus Institute with diagnosis of diabetic foot during the period from July 2018 to August 2019.

The study was approved by the Ethics Committee and informed consent was obtained from all patients.

Exclusion criteria

Recent lower limb trauma and recent vascular surgery.

All patients were subjected to full detailed history, clinical examination with special emphasis on lower limb for signs of diabetic foot and routine laboratory investigations (fasting blood glucose level and glycosylated hemoglobin).

Ultrasound color and Doppler examinations were performed using Toshiba Xario 200 ultrasound machine (Toshiba, Akasaka, Minato-ku, Tokyo Japan), which can combine a real-time B-mode imaging system with pulsed and continuous wave Doppler facilities together with the availability of color coding of signals.

Patients were asked not to eat for 8 h before examination to diminish the bowel gases and enhance visualization of the abdominal aorta and common iliac arteries. The arterial supply of lower extremities was divided into these segments: common iliac artery, external iliac artery, common femoral artery, superficial femoral artery, profunda femoris artery, popliteal artery, anterior tibial artery, posterior tibial artery, peroneal artery, and dorsalis pedis. Iliac segments were examined with a 3–5 MHz probe with the patient supine. A 4–7 MHz probe was used for femoropopliteal segments, which were examined with the legs relaxed in mild external rotation. Examination of popliteal arteries and the origins of the tibial arteries was performed in lateral or prone position with the knees partially flexed. Infrapopliteal arteries were similarly scanned using a 4–7 MHz probe with the patient lying prone or in lateral position. Each segment was examined first using a gray scale ultrasound for the detection of atheromatous plaques and then using color flow imaging transversely and longitudinally to size the colored flow in the lumen with respect to the arterial wall and to detect areas of flow disturbances or increased velocity.

Arterial lesions were located by changes in vessel caliber, changes in color flow patterns, and broadening of Doppler waveform, quantified by measuring the peak systolic velocity (PSV) ratio across a lesion and by comparing the PSV within stenosis with that proximal to the lesion; this ratio was independent of individual variations in blood pressure, vascular compliance, and cardiac function. The segment was considered normal if no stenotic lesion or Doppler spectral changes were found. The stenotic lesion was considered hemodynamically significant if there was doubling of the PSV ratio or more across the lesion (PSV ratio). Therefore, the stenosis was considered hemodynamically significant if the PSV ratio is greater than or equal to 2, whereas the stenosis was considered hemodynamically nonsignificant with a PSV ratio of 1–2. Occlusions were diagnosed when no color flow or Doppler spectral signal was detected despite the variations in sensitivity by increasing the Doppler gain, decreasing the scale, and increasing the sample volume size in order to detect any slow flow within the lesion.

Ethical considerations

The study was approved by the Ethics Committee and informed consent was obtained from all patients. All patients were informed about the technique, and they were ensured that their anonymity will be carefully protected.

Statistical analysis

Data were coded and entered using the Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corp., Armonk, New York, USA). Data were summarized using mean, SD, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data.


  Results Top


Our study showed that all patients have atherosclerotic changes and calcified atheromatous plaques with different degrees; nine of our patients had right lower limb affection; seven patients had bilateral affection; and four patients had left lower limb affection ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).
Figure 1 Occluded segment of right popliteal artery.

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Figure 2 Calcific right anterior tibial artery with the tardus parvus pattern and low peak systolic velocity.

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Figure 3 Occluded right posterior tibial artery with no distal refill.

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Figure 4 Stenotic segment of left superficial femoral artery (3 cm) with PSVR 1.6.

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Figure 5 Significant stenosis in left posterior tibial artery with PSVR 3.4.

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Figure 6 Significant stenosis in left anterior tibial artery with PSVR 2.3.

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Of the 400 examined arterial segments, 35 segments showed significant stenosis (luminal narrowing ≥50% of artery diameter and PSV ratio≥2), 21 segments were occluded, eight of them were with no distal collateral refilling and 100 segments showed nonsignificant stenosis (luminal narrowing <50% of artery diameter and PSV ratio <2).

Of the 400 examined arterial segments, 297 arterial segments showed normal triphasic flow; 95 segments showed monophasic flow; and eight segments had no flow indicating there was no distal refill in these segments.

Of 400 arterial segments, 104 segments had low PSV (which were measured at the distal part of each segment).

The study focused on the detection of segments with occlusion or significant arterial stenosis (luminal narrowing ≥50% of artery diameter), as these lesions are of clinical importance and may need intervention, and smaller lesions are mainly of no major clinical importance and usually need no intervention.

In our study, we found that infragenicular arteries were by far more affected than supra-genicular arteries; anterior and PTAs were the most common arteries having arterial insufficiency in the form of significant stenosis or occlusion We also noticed that common iliac and external iliac arteries were rarely affected ([Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6]).
Table 1 Age distribution

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Table 2 Sex distribution

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Table 3 Comorbidities

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Table 4 Symptomatology

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Table 5 Assessment of all segments regarding flow, stenosis, and peak systolic velocity

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Table 6 Distribution of arterial segmental affection by means of duplex examination

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Case 1

A 58-year-old diabetic woman presented with nonhealing ulcer in the dorsum of the right foot and trophic changes.

Case 2

A 53-year-old diabetic man presented with left lower limb pain at rest and nonhealing ulcer in the medial aspect of the left foot and trophic changes.


  Discussion Top


**Peripheral vascular disease is a major cause of mortality and morbidity affecting especially the elderly population. The prevalence of peripheral vascular disease is multifold higher in patients with DM compared with and sex-matched nondiabetic subjects. This may be because of hyperglycemia, hypertension, hyperlipidemia, platelet factors, and other factors, which are increased in diabetic patients. WHO estimates show that India already has the largest number of people suffering from diabetes mellitus [7],[8].

Since patients usually do not present early with symptoms of peripheral arterial disease, changes of chronic arterial insufficiency like poor wound healing are the presenting features. Acute embolic events originating from more proximal arterial lesions, such as from either ulcerated plaques or thrombosed popliteal aneurysms can cause extensive tissue loss, including loss of affected limb, unless intervention is performed [9].

In patients with diabetes, the incidence of small arteriolar disease especially involving more peripheral tibioperoneal arteries is more common. The main investigation now used to investigate the location and extent of disease is duplex sonography [10],[11]. It is good at identifying occlusions, discriminating between and grading large (>50%) and small (<50%) stenosis. As compared with arteriography, duplex sonography has a sensitivity of 71–98% and specificity of 91–100% for grading of stenosis. In routine clinical practice, duplex scanning has reduced the need for arteriography in the management of patients including those requiring interventional procedures [12],[13].

Doppler studies provide direct information about the arterial disease by analyzing the hemodynamically significant arterial stenosis changes in arterial flow velocity, velocity pulse wave contour, disruption of laminar flow, and turbulence [14].

The objective of our study was to evaluate lower limb arteries (including external and internal iliac arteries, common femoral, superficial femoral, profunda femoris, popliteal artery, anterior tibial, posterior tibial, peroneal and dorsalis pedis arteries) by color doppler sonography in diabetic patients for the evaluation of degree of sufficiency.

Regarding the presence of atherosclerotic changes

Our study included a total of 20 patients presenting with diabetic foot disease with variable degrees of symptoms, which ranged from pain to ulcer or gangrene; we performed duplex evaluation for 400 arterial segments in 40 limbs.

All examined patients showed different degrees of atherosclerotic changes, which ranged from mild nonsignificant stenosis to complete arterial occlusion. In our results, we found that 100 (25%) arterial segments had mild nonsignificant stenosis, 35 (8.8%) arterial segments showed signs of significant stenosis (luminal narrowing ≥50% of artery diameter and PSV ratio ≥2); 21 (5.3%) segments had total occlusion; and eight (2%) of them had no distal collateral refilling.

In 2014, Das et al. [15] conducted a study to evaluate the value of color duplex in the assessment of lower limb arteries in diabetic patients. In agreement with our results, they found all patients had atherosclerotic changes.

In 2014, He et al. [16] performed a comparative study between diabetics and nondiabetics as regards incidence of lower extremity atherosclerosis; in agreement with our results they found much higher incidence of atherosclerosis in diabetics.

Regarding anatomical distribution and commonly affected arteries

In our study, anterior and PTAs are the most frequently affected followed by superficial femoral artery.In contrast to our findings, Das et al. [15] showed that the dorsalis pedis artery was the most frequently affected artery followed by anterior and PTAs.

In 2010, Shaheen et al. [17] conducted a study under the name of Doppler-based evaluation of peripheral lower limb arterial insufficiency in DM. They also found that the dorsalis pedis artery was most frequently affected in diabetic patients.

Regarding demographic data

In our study, female patients were more than men in contrast to the study conducted by Das et al. [15] which revealed male predominance.

We noticed in our trial that the mean age of patients was 58 years, in agreement with other studies performed by Das et al. [15] and Zeinab et al.[18], which showed the same mean age of affection with diabetic foot.

Study limitations

  1. The study is a single-center trial on a limited number of patients that should be validated by large cohort studies.
  2. Arterial duplex was operated to all patients by a single operator.
  3. We used a single diagnostic modality without correlation to other modalities.



  Conclusion Top


  1. Duplex ultrasound is an accurate easily acquired noninvasive diagnostic modality in diabetic foot patients.
  2. Very high incidence of atherosclerosis in diabetic foot patients with more affection in below-knee arteries.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Schaper NC, Andros G, Apelqvist J, Bitunjac M. Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot. Diabetes Metab Res Rev 2012; 20(Suppl 1):218–224.  Back to cited text no. 3
    
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Hunt CH, Hartman RP, Hesley GK. Frequency and severity of adverse effects of iodinated and gadolinium contrast materials: retrospective review of 456, 930 doses AJR Am J Roentgenol 2009; 193:1124–1127.  Back to cited text no. 4
    
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Newman JD, Rockman CB, Kosiborod M, Guo Y, Zhong H, Weintraub HS et al. Diabetes mellitus is a coronary heart disease risk equivalent for peripheral vascular disease. Am Heart J 2017; 184:114–120.  Back to cited text no. 7
    
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He C, Yang J-G, Li Y-M, Rong J, Du F-Z, Yang Z-G, Gu M. Comparison of lower extremity atherosclerosis in diabetic and non-diabetic patients using multidetector computed tomography, BMC Cardiovasc Disord 2014; 14:125.  Back to cited text no. 16
    
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Shaheen R, Sohail S. A Doppler-based evaluation of peripheral lower limb arterial insufficiency in diabetes mellitus. J Coll Physicians Surg Pak 2010; 20:22–25.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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