Diabetic Foot Ulcer Treatment &
Management | How a Vascular Surgeon can help

If you have diabetes, having too much glucose (aka sugar) in
your blood for a long time can cause some serious complications, including foot
ulcers/foot problems.

A diabetic foot is a long-term (or “chronic”)
complication which affects directly from Peripheral Arterial Disease (PAD)
and/or sensory neuropathy related to diabetes.

What Are Some Common Foot Problems With
Diabetes?

·        
Athlete’s foot

·        
Fungal infection of nails

·        
Calluses

·        
Corns

·        
Blisters

·        
Bunions

·        
Dry skin

·        
Diabetic ulcers

·        
Hammertoes

·        
Ingrown toenails

·        
Plantar warts

Magnitude of the problem in India

·        
Diabetic population : 30 million

·        
Foot complications : 39 %

·        
Compromised blood circulation : 6-16 %

·        
Neuropathy : 30 – 50 %

·        
15 % of Diabetics would develop foot ulcers in their
lifetime.

How diabetic foot problems develop

High or unstable blood sugar levels, the hallmark of diabetes, can
cause the arteries to change, which can choke off or damage nerves. This is
known as diabetic neuropathy, and it initially feels like a tingling or
pins-and-needles sensation, then burning, and finally numbness and lack of
feeling in the foot.

Diabetic foot ulcers are usually the result of minor trauma, such as a blister or
callus. They often appear under bony
pressure areas, such as the heel or bottom of the foot.
Normally, a person who develops one of these on their foot would feel pain and
walk differently or wear different shoes to avoid putting additional pressure
or friction on it. But if you have diabetic neuropathy, you won’t feel that
pain. You’ll keep wearing the same shoes and walking on it just as you always
do, leading it to turn into a more serious wound.

Unfortunately, we often don’t see people with diabetic foot ulcers
until the wound is advanced and an infection has begun to set in. They may not
have felt the pain of the wound, but the infection is now making them sick,
causing fever, chills and swelling or redness in the leg.

You may be able to avoid getting to this point by practicing some
simple foot care techniques and seeing your doctor as soon as a problem
develops.

Who are at Highest risk for developing Diabetic foot problems?

·        
Uncontrolled Diabetes

·        
Neglected foot care

·        
Cracks/cuts/corns in foot

·        
Diabetes associated Neuropathy

·        
Peripheral Arterial Disease/smoking

Warning Signs of Diabetic Foot Problems

·        
Wound / ulcer development

·        
Foot swelling / redness

·        
Foot Pain

·        
Leg Cramps

·        
Blue nails / Black color of toes

·        
Tingling / numbness / burning in feet

How do a vascular surgeon treat
diabetic foot problems?

Vascular assessment is important part for ulcer healing process.

·        
Wound cleaning procedure + Antibiotics

·        
Complete non-weight bearing of the
involved extremity (Special footwear)

·        
Dedicated diabetic foot wound dressing
/ VAC dressing

·        
Teaching Foot care to patients

·        
Revascularisation (ANGIOPLASTY / BYPASS) for non-healing wounds when needed.

Myths about Diabetic foot treatment

Myths

·        
 Technically not feasible to
perform

·        
 High chances for failure of
treatment

·        
 Very costly

·        
 Limb amputation is inevitable

·        
 Good quality artificial legs are
better for life style

Truth

·        
 Routinely performed by experts

·        
 Very good success rate

·        
 It’s a cost-effective treatment

·        
 Rarely required if treated timely

·        
 Nothing is comparable to one’s
own legs

Role of improving blood circulation in
diabetic foot

Why?: To save the foot, leg.

Goal: To Maximize foot blood circulation
for wound healing

Preventive measures to be taken

Along with treating diabetic foot conditions, there are other
things we can do to prevent further problems. If you’ve had foot or vascular
surgery to correct a problem, we’ll monitor you over the months and years
after.

If we determine at some point down the road that there’s a new
area of pressure developing, we may be able to correct it before it becomes a
problem. Surgical examples include tendon lengthening or osteotomy, in which we
cut or reshape a bone to relieve pressure.

We also may be able to avoid surgery with a non-invasive
procedure. If, for example, you have hammertoe, in which the toe bends downward
causing repeated ulcers on the tip of the toe, we could perform a percutaneous
needle tenotomy. In this procedure, we use a needle to release part of the
tendon from the bone.

Diabetes care doesn’t stop at controlling blood sugar. If you or a
loved one has diabetes, get in the habit of practicing proper foot care,
scheduling regular check-ups, and seeking early treatment for problems to
prevent serious diabetic foot complications, including amputation.

Regular Foot Care

·        
Wash Dry Moisturize your feet daily to
avoid skin dryness & cracks.

·        
Regularly check your feet
(self-examination) for warning signs.

·        
If you have difficulty with your
vision, ask a family member to check for you.

·        
Get your feet assessed annually once by
your doctor.

·        
Cut your toe nails straight across, not
at corners. Gently file if any sharp edges present.

·        
Avoid removing callous/corns on your
own, it may cause injury to your feet.

·        
Avoid walking bare feet.

·        
Don’t wear tight socks/shoes

·        
Avoid direct heat application on feet
with hot water bag/electric heating pads.

·        
If you find any injury/redness/crack;
immediately:- Wash and dry your feet, apply antiseptic solution
e.g. Betadine & see your diabetic foot ulcers specialist/doctor.

DVT Awareness Month

March is celebrated world-wide as blood clot awareness month.

Blood clots can happen to anyone, but they are preventable.

Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. Deep vein thrombosis can cause leg pain or swelling but can also occur with no symptoms.

You can get DVT if you have certain medical conditions that affect the blood clotting mechanism of your body. A grume in your legs also can happen if you do not move for an extended time, like after you’ve got surgery or an accident, when you’re traveling a long distance, or when you’re on bed rest.

Deep vein thrombosis is often very serious because blood clots in your veins can break loose, travel through your bloodstream and find stuck in your lungs, blocking blood flow (pulmonary embolism). However, embolism can occur with no evidence of DVT.

When DVT and embolism occur together, it’s called venous thromboembolism (VTE).

Symptoms

DVT signs and symptoms can include:

• Swelling in the affected leg. Rarely, there’s swelling in both legs.
• Pain in your leg. The pain often starts in your calf and may result in cramping or soreness.
• Red or discolored skin on the leg.
• A feeling of warmth in the affected leg.
• Deep vein thrombosis can occur without noticeable symptoms.
• Obesity

Causes

Anything that stops your blood from flowing or clotting normally can cause a blood clot. The main causes of DVT are damage to a vein from surgery or trauma and inflammation due to infection or injury.

Risk Factors

Many things can increase your risk of developing DVT. The more risk factors you have, the greater your risk of DVT.

• Being older than 60 increases your risk of DVT, though it can occur at any age.
• Sitting for long periods of time (E-thrombosis), such as when driving or flying (Traveler’s thrombosis). When your legs remain still for hours, your calf muscles don’t contract. Muscle contractions normally help blood circulate.
• Prolonged bed rest, such as during a long hospital stay, or paralysis. Blood clots can form in the calves of your legs if your calf muscles don’t move for long periods.
• Fracture/Injury or surgery. Injury to your veins or surgery can increase the risk of blood clots.
• Pregnancy increases the pressure in the veins in your pelvis and legs. Women with an inherited clotting disorder are especially at risk. The risk of blood clots from pregnancy can continue for up to six weeks after you have your baby.
• Birth control pills (oral contraceptives) or hormone replacement therapy. Both can increase your blood’s ability to clot.
• Being overweight or obese. Being overweight increases the pressure in the veins in your pelvis and legs.
• Smoking affects blood clotting and circulation, which can increase your risk of DVT.
• Some forms of cancer increase substances in your blood that cause your blood to clot. Some forms of cancer treatment also increase the risk of blood clots.
• Heart failure. This increases your risk of DVT and pulmonary embolism. Because people with heart failure have limited heart and lung function, the symptoms caused by even a small pulmonary embolism are more noticeable.
• Inflammatory bowel disease. Bowel diseases, such as Crohn’s disease or ulcerative colitis, increase the risk of DVT.
• A personal or family history of DVT or PE. If you or someone in your family has had one or both of these, you might be at greater risk of developing DVT.
• Some people inherit genetic risk factors or disorders, such as factor V Leiden, that make their blood clot more easily. An inherited disorder on its own might not cause blood clots unless combined with one or more other risk factors.
• No known risk factor. Sometimes, a blood clot in a vein can occur with no apparent underlying risk factor. This is called an unprovoked VTE.

Complications

Complications of DVT can include:

• Pulmonary embolism (PE). PE is a potentially life-threatening complication associated with DVT. It occurs when a blood vessel in your lung becomes blocked by a blood clot (thrombus) that travels to your lung from another part of your body, usually your leg. It’s important to get immediate medical help if you have signs and symptoms of PE. Sudden shortness of breath, chest pain while inhaling or coughing, rapid breathing, rapid pulse, feeling faint or fainting, and coughing up blood may occur with a PE.

• Postphlebitic syndrome. Damage to your veins from the blood clot reduces blood flow in the affected areas, causing leg pain and swelling, skin discoloration and skin sores.
• Treatment complications Complications may result from blood thinners used to treat DVTs. Bleeding (hemorrhage) is a worrisome side effect of blood thinners. It’s important to have regular blood tests while taking such medications.

Diagnosis of DVT

• It is usually a clinical diagnosis based on the symptoms and signs.
• Your doctor may order a blood test (d-Dimer) to check the presence of blood clotting in the body, but it’s a less specific test.
• Venous duplex ultrasound scan is the best confirmatory test to diagnose DVT.

How Is DVT Treated?

Your doctor will want to stop the blood clot from getting bigger or breaking off and heading toward your lungs. They’ll also want to cut your chances of getting another DVT.

This can be done in one of three ways:

• Blood thinners are the most common medications used to treat DVT. They cut your blood’s ability to clot. You may need to take them for 6 months. If your symptoms are severe or your clot is very large, your doctor may give you a strong medicine to dissolve it. These medications, called thrombolytics, have serious side effects like sudden bleeding. That’s why they’re not prescribed very often.
• Inferior vena cava (IVC) filter. If you can’t take a blood thinner or if one doesn’t help, your doctor may insert a small, cone-shaped filter inside your inferior vena cava. That’s the largest vein in your body. The filter can catch a large clot before it reaches your lungs.
• Thrombolysis procedure(clot removal from veins): Thrombolysis is used to remove a large burden of blood clots from veins in patients with DVT.Clot removal will clear the passage for return of impure blood from your legs. This procedure should be done within 7 to 10 days after diagnosis of DVT.

Advantages

• Minimal invasive latest technique, recommended as per recent guidelines
• Immediate reduction in leg swelling, pain
• Reduced late complications like-Recurrence, leg wounds development

Catheter-directed thrombolysis is done by doing a small puncture in vein behind the knee, guidewire along with the Angiojet (clot suctioning device) is introduced inside the vein. Clots are removed from vein & blood flow is again normalized in the limb.

• Avoid sitting still. If you have had surgery or have been on bed rest for other reasons, try to get moving as soon as possible. If you’re sitting for a while, don’t cross your legs, which can block blood flow. If you’re traveling a long distance by car, stop every hour or so and walk around.
• If you’re on a plane, stand or walk occasionally. If you can’t do that, exercise your lower legs. Try raising and lowering your heels while keeping your toes on the floor, then raising your toes with your heels on the floor. Don’t smoke. Smoking increases your risk of getting DVT.
• Exercise and manage your weight. Obesity is a risk factor for DVT. Regular exercise lowers your risk of blood clots, which is especially important for people who sit a lot or travel frequently.
• Compression stockings. These special socks are very tight at the ankle and get looser as they reach your knee. This pressure prevents blood from pooling in your veins. You can buy some types at the drugstore. But your doctor might prescribe a stronger version that can be fitted by an expert.

What to do next if I am suspecting DVT in my legs?

Consult a Vascular Surgeon immediately for assessment. Doctor will perform an Ultrasound Doppler test of your legs & will explain to you further the course of treatment.

Raise your voice to increase blood clot awareness,share life saving information with your dear ones.

The vascular system of humans is made up of the vessels that carry blood and lymph through the body and it is also called “the circulatory system”. The arteries and veins carry blood throughout the body, delivering oxygen and nutrients to the body tissues and taking away waste matter from tissues.

The lymph vessels carry lymphatic fluid (a clear, colorless fluid containing water and blood cells). The lymphatic system helps protect and maintain the fluid environment of the body by filtering and draining lymph away from each region of the body.

The vessels of the blood circulatory system/Vascular System include:

• Arteries:Blood vessels that carry oxygenated blood away from the heart to the body.
• Veins:Blood vessels that carry blood from the body back into the heart.
• Capillaries:Tiny blood vessels between arteries and veins that distribute oxygen-rich blood to the body.
• Blood moves through the circulatory system as a result of being pumped out by the heart. Blood leaving the heart through the arteries is saturated with oxygen. The arteries break down into smaller and smaller branches to bring oxygen and other nutrients to the cells of the body’s tissues and organs. As blood moves through the capillaries, the oxygen and other nutrients move out into the cells, and waste matter from the cells moves into the capillaries. As the blood leaves the capillaries, it moves through the veins, which become larger and larger to carry the blood back to the heart.
• In addition to circulating blood and lymph throughout the body, the vascular system functions as an important component of other body systems.
• The health of your veins are often suffering from a variety of conditions, like obesity, heart condition or diabetes causing various vascular diseases. Even genetics play a vital role in whether you’re vulnerable to vascular problems.

What is vascular disease?

A vascular disease is a condition that affects the arteries and veins of your circulatory system. Vascular disease affects the regular flow of your blood in the body, either by blocking, narrowing or weakening blood vessels, or by damaging the valves that are found in veins. Various vital organs and other body parts get damaged due to vascular disease/ poor vascular health which is caused usually due to decreased or completely blocked blood flow.

What causes vascular disease?

• Atherosclerosis

Atherosclerosis (a buildup of plaque, which may be a deposit of fatty substances, cholesterol, cellular waste products, calcium, and fibrin within the inner lining of an artery) is the main culprit for vascular disease. It’s yet unknown exactly what causes atherosclerosis. Atherosclerosis may be a slow, progressive, vascular disease. However, the disease has the potential to progress rapidly. It’s generally characterized by the buildup of fatty deposits along the innermost layer of the arteries. If the disease process progresses fast, plaque may form. This thickening narrows the arteries and may decrease blood flow or completely block the flow of blood to organs and other body tissues and body parts.

• Blood clots

A vessel could also be blocked by an embolus (a tiny mass of debris that moves through the bloodstream) or a thrombus (a blood clot).

• Inflammation

Generally, inflammation of blood vessels is also known as vasculitis, which causes a variety of vascular disorders. Inflammation may cause narrowing and blockage of blood vessels.

• Trauma or injury

Trauma or injury involving the blood vessels may cause inflammation or infection, which may damage the blood vessels and cause narrowing and blockage.

• Genetic

Certain vascular conditions of the system are inherited and present in genes.

How to take care of your blood vessel health?

It is imperative to strengthen veins and arteries to keep your vascular health sound & maintain healthy blood circulation in the body.

Tips for Maintaining Healthy Blood Vessels

• Don’t Smoke or Use Tobacco:The chemicals in tobacco smoke can deoxygenate and thicken blood. Additionally, nicotine causes vascular hardening and narrowing.
• Eat a Healthy Diet:Fruits and vegetables are great for circulation and the health of vein walls.
• Maintaining a Healthy Weight:Carrying around extra weight puts extra pressure on your veins, deteriorating your blood vessel health.
• Take Frequent Walks:Physical activity gets your blood pumping, which helps your veins move blood upwards and helps in proper blood circulation.
• Don’t Cross Your Legs:Crossing legs for a longer period of time increases problems with circulation.
• Focus on staying active:If you’ve got a desk job, wake up early regularly and take a walk to keep the blood pumping.
• Stay hydrated:When you’ve had a lot of water, your blood is thinner and flows better. Thicker blood due to dehydration can make vein insufficiency problems worse.
• Use compression:If you’re vulnerable to venous insufficiency, whether by genetics, pregnancy, chronic conditions like obesity or heart condition, or work/lifestyle habits, then wear compression socks. They help contract muscles round the veins to assist blood withdraw up toward the guts. It would even be a great idea to place your feet up a couple of times each day (higher than hip level) to offer your circulation a lift.
• Seek treatment:If you start noticing symptoms such as fatigue, heaviness and swelling, then it would be a good time for an evaluation from a vascular expert near you.

Dr. Kushan Nanavati (MBBS, MS, DNB) is an eminent, MCI recognized Consultant Vascular Surgeon practicing in Vadodara, Gujarat since 2019. He is associated with VINS Hospital, Vadodara & also attached with the majority of corporate/multispecialty hospitals across the city. Dr. Nanavati is dedicated exclusively towards the care of veins & artery diseases related to the Blood Circulatory System.