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The Need for Arteriography in Diabetic Patients With Gangrene and Palpable Foot Pulses

The Need for Arteriography in Diabetic Patients With Gangrene and Palpable Foot Pulses Abstract • A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status. (Arch Surg 1984;119:1260-1263) References 1. Edwards AE, Cohen NR, Kaplan MM: Effect of exercise on the peripheral pulses . N Engl J Med 1959;260:738-741.Crossref 2. DeWeese JA: Pedal pulses disappearing with exercise: A test for intermittent claudication . N Engl J Med 1960;262:1214-1217.Crossref 3. Strandness DE Jr, Bell JW: An evaluation of the hemodynamic response of the claudicating extremity to exercise . Surg Gynecol Obstet 1964;119:1237-1242. 4. Kempczinski RE: Peripheral arterial atheroembolism , in Miller DC, Roon J (eds): Diagnosis and Management of Peripheral Vascular Disease . Reading, Mass, Addison-Wesley Publishing Co Inc, 1982, pp 135-149. 5. Walden R, Adar R, Mozes M: Gangrene of toes with normal peripheral pulses . Ann Surg 1977;185:269-272.Crossref 6. Morris-Jones W, Preston FE, Greaney M, et al: Gangrene of the toes with palpable peripheral pulses: Response to platelet suppressive therapy . Ann Surg 1983;193:462-466.Crossref 7. Porter JM, Taylor LM Jr, Baur GM: Nonatherosclerotic vascular disease , in Moore WS (ed): Vascular Surgery: A Comprehensive Review . New York, Grune & Stratton Inc, 1983, pp 55-97. 8. West KM: Epidemiology of Diabetes and Its Vascular Lesions . New York, Elsevier North Holland Inc, 1978. 9. Sizer JS, Wheelock FC Jr: Digital amputations in diabetic patients . Surgery 1972;72:980-989. 10. Effeney DJ, Goldstone J: Chronic arterial insufficiency of the lower extremities , in Miller DC, Roon J (eds): Diagnosis and Management of Peripheral Vascular Disease . Reading, Mass, Addison-Wesley Publishing Co, 1982, pp 254-269. 11. Wheelock FC: Transmetatarsal amputations and arterial surgery in diabetic patients . N Engl J Med 1961;264:316-320.Crossref 12. Vincent DG, Salles-Cunha SX, Bernhard VM, et al: Noninvasive assessment of toe systolic pressures with special reference to diabetes mellitus . J Cardiovasc Surg 1983;24:22-28. 13. Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputations . Orthop Clin North Am 1973;4:31-42. 14. Barnes RW, Thornhill B, Nix L, et al: Prediction of amputation wound healing: Role of Doppler ultrasound and digit photoplethysmography . Arch Surg 1981;116:80-83.Crossref 15. Schwartz JA, Schuler JJ, O'Connor RJA, et al: Predictive value of distal perfusion pressure in the healing of amputation of the digits and forefoot . Surg Gynecol Obstet 1982;154:865-869. 16. Bone GE, Pomajzl MJ: Toe blood pressure by photoplethysmography: An index of healing in forefoot amputations . Surgery 1981;89:569-574. 17. Franzeck UK, Talke P, Bernstein EF, et al: Transcutaneous PO2 measurement in health and on peripheral arterial occlusive disease . Surgery 1982;91:156-163. 18. McFarland DC, Lawrence PF: Skin fluorescence: A method to predict amputation site healing . J Surg Res 1982;32:410-415.Crossref 19. Malone JM, Leal JM, Moore WS, et al: The 'gold standard' for amputation level selection: Xenon-133 clearance . J Surg Res 1981;30: 449-455.Crossref 20. Katsamouris A, Brewster DC, Megerman J, et al: Transcutaneous oxygen tension in selection of amputation level . Am J Surg 1984;147:510-517.Crossref 21. Pillay V, Robbins P, Schwartz F, et al: Acute renal failure following intravenous urography in patients with long standing diabetes mellitus and azotemia . Radiology 1970;95:633-636.Crossref 22. Brant-Zawadzki M, Gould R, Norman B: Digital subtraction cerebral angiography by intra-arterial injection: Comparison with conventional angiography . AJR 1983;140:347-353.Crossref 23. Levin ME, O'Neal LW: The Diabetic Foot . St Louis, CV Mosby Co, 1973, p 262. 24. Wheelock F Jr, in discussion, Katsamouris A, Brewster DC, Megerman J, et al: Transcutaneous oxygen tension in selection of amputation level . Am J Surg 1984;147:510-517.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

The Need for Arteriography in Diabetic Patients With Gangrene and Palpable Foot Pulses

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References (24)

Publisher
American Medical Association
Copyright
Copyright © 1984 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1984.01390230032007
Publisher site
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Abstract

Abstract • A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status. (Arch Surg 1984;119:1260-1263) References 1. Edwards AE, Cohen NR, Kaplan MM: Effect of exercise on the peripheral pulses . N Engl J Med 1959;260:738-741.Crossref 2. DeWeese JA: Pedal pulses disappearing with exercise: A test for intermittent claudication . N Engl J Med 1960;262:1214-1217.Crossref 3. Strandness DE Jr, Bell JW: An evaluation of the hemodynamic response of the claudicating extremity to exercise . Surg Gynecol Obstet 1964;119:1237-1242. 4. Kempczinski RE: Peripheral arterial atheroembolism , in Miller DC, Roon J (eds): Diagnosis and Management of Peripheral Vascular Disease . Reading, Mass, Addison-Wesley Publishing Co Inc, 1982, pp 135-149. 5. Walden R, Adar R, Mozes M: Gangrene of toes with normal peripheral pulses . Ann Surg 1977;185:269-272.Crossref 6. Morris-Jones W, Preston FE, Greaney M, et al: Gangrene of the toes with palpable peripheral pulses: Response to platelet suppressive therapy . Ann Surg 1983;193:462-466.Crossref 7. Porter JM, Taylor LM Jr, Baur GM: Nonatherosclerotic vascular disease , in Moore WS (ed): Vascular Surgery: A Comprehensive Review . New York, Grune & Stratton Inc, 1983, pp 55-97. 8. West KM: Epidemiology of Diabetes and Its Vascular Lesions . New York, Elsevier North Holland Inc, 1978. 9. Sizer JS, Wheelock FC Jr: Digital amputations in diabetic patients . Surgery 1972;72:980-989. 10. Effeney DJ, Goldstone J: Chronic arterial insufficiency of the lower extremities , in Miller DC, Roon J (eds): Diagnosis and Management of Peripheral Vascular Disease . Reading, Mass, Addison-Wesley Publishing Co, 1982, pp 254-269. 11. Wheelock FC: Transmetatarsal amputations and arterial surgery in diabetic patients . N Engl J Med 1961;264:316-320.Crossref 12. Vincent DG, Salles-Cunha SX, Bernhard VM, et al: Noninvasive assessment of toe systolic pressures with special reference to diabetes mellitus . J Cardiovasc Surg 1983;24:22-28. 13. Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputations . Orthop Clin North Am 1973;4:31-42. 14. Barnes RW, Thornhill B, Nix L, et al: Prediction of amputation wound healing: Role of Doppler ultrasound and digit photoplethysmography . Arch Surg 1981;116:80-83.Crossref 15. Schwartz JA, Schuler JJ, O'Connor RJA, et al: Predictive value of distal perfusion pressure in the healing of amputation of the digits and forefoot . Surg Gynecol Obstet 1982;154:865-869. 16. Bone GE, Pomajzl MJ: Toe blood pressure by photoplethysmography: An index of healing in forefoot amputations . Surgery 1981;89:569-574. 17. Franzeck UK, Talke P, Bernstein EF, et al: Transcutaneous PO2 measurement in health and on peripheral arterial occlusive disease . Surgery 1982;91:156-163. 18. McFarland DC, Lawrence PF: Skin fluorescence: A method to predict amputation site healing . J Surg Res 1982;32:410-415.Crossref 19. Malone JM, Leal JM, Moore WS, et al: The 'gold standard' for amputation level selection: Xenon-133 clearance . J Surg Res 1981;30: 449-455.Crossref 20. Katsamouris A, Brewster DC, Megerman J, et al: Transcutaneous oxygen tension in selection of amputation level . Am J Surg 1984;147:510-517.Crossref 21. Pillay V, Robbins P, Schwartz F, et al: Acute renal failure following intravenous urography in patients with long standing diabetes mellitus and azotemia . Radiology 1970;95:633-636.Crossref 22. Brant-Zawadzki M, Gould R, Norman B: Digital subtraction cerebral angiography by intra-arterial injection: Comparison with conventional angiography . AJR 1983;140:347-353.Crossref 23. Levin ME, O'Neal LW: The Diabetic Foot . St Louis, CV Mosby Co, 1973, p 262. 24. Wheelock F Jr, in discussion, Katsamouris A, Brewster DC, Megerman J, et al: Transcutaneous oxygen tension in selection of amputation level . Am J Surg 1984;147:510-517.Crossref

Journal

Archives of Surgery – American Medical Association

Published: Nov 1, 1984

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