Discussion
In the world, due to changes in the structure of people's diet, the incidence of diabetes has increased gradually and so has incidences of lower extremity disability caused by diabetic peripheral arterial disease. The Framingham study showed that there was a 3.5- and 8.6-fold excess risk among men and women, respectively, of developing PAD in patients with DM.
Diabetic peripheral arterial disease is a characteristic of arteriosclerosis of the lower extremity arteries. It often involves several arteries of the double lower extremities. Patients with diabetic peripathic arterial disease commonly show involvement of the arteries below the knee, especially at the tibial and peroneal arteries, and involvement of the profunda femoris. It is multi-seasonally distributed and most prevalent in the tibial and peroneal arteries of the calf, including anterior tibial artery, posterior tibial artery and peroneal artery.
Life style modifications are the first mode of therapy, and most of the studies have shown physical exercise improves exercise tolerance at least a doubling in walking distance. There is no conclusive evidence to suggest that optimal glycaemic control lowers the risk of PAD. The management of dyslipidaemia in patients with diabetic peripheral arterial disease is warranted and the primary aim is LDL-cholesterol levels < 2.6 mmol/l.
Due to the small diameter and the multi-branching of the arteries, the conventional treatment method of bypass surgery often has little effect on the stenosis or blockage. Furthermore, there was a high rate of postoperative restenosis and reblock, which is why the long-term outcome is not very satisfactory.
Therefore, with the constant updating of the treatment technology and equipment, the application of percutaneous transluminal angioplasty and luminal stenting surgery in the treatment of diabetes mellitus have caught the attention of surgeons at home and abroad. These techniques can radically improve the treatment of diabetic lower extremity arterial disease.
Since 2005, our department has carried out clinical research on endovascular treatment for diabetic peripheral arterial disease. Up until now, 81 patients have been treated. This study is currently in progress. The results showed that the clinical symptoms, vascular ultrasonic, and foot ulcer healing conditions of the observation group had significantly improved after the treatment. In contrast, the clinical symptoms, vascular ultrasonic, and foot ulcer healing conditions of the control group had no significant improvement after the treatment. There were no significant differences between the two groups before the treatment. Even if the observation group had a significant improvement compared with the control group after the treatment, all the above information showed only that endovascular treatment has a satisfactory short-term effect for diabetic lower extremity arterial disease. However, due to the limitation of the short follow-up time and the inadequate number of patients, the long-term efficacy of endovascular treatment remains unclear. It requires a long-term accumulation of information from a large sample.
Through this research, it can be concluded that endovascular treatment for diabetic peripheral arterial disease has many advantages: a) It has smaller chances of trauma and a faster recovery speed. It can also provide an immediate effect after the treatment; b) It has a high success rate and a low mortality rate. The current success rate of interventional therapy is up to 100%, while mortality rate is almost 0; c) It has a high rate of limb salvage. The diabetic foot ulcers caused by hypoxia-ischemia of patients who have undergone interventional treatment will gradually heal with the recanalization of blood vessels. As a result, the limb salvage rate was significantly higher than before; d) It is a kind of repeatable treatment. With a repeatable balloon dilatation, the restenosis of the lesion can be re-expanded with the same safety and effectiveness to improve the rate to save ischemic limbs; e) The intervention requires only local anesthesia, which has less side effects and is more suitable for elderly and frail patients.
One reported that patients with DM develop more symptomatic forms of PAD such as intermittent claudication, foot ulcers and critical limb ischaemia symptoms. But in the follow-up, we found that patients who received infrapopliteal artery balloon expansion surgery have high restenosis rate, but the limb ulcer have healed, and the clinical symptoms have disappeared. Thus, the endovascular treatment for diabetic peripheral arterial disease could rapidly improve the blood supply and provide time for the foot ulcer and sectional toe wound to heal. With the gradual formation of restenosis, the collateral compensatory circulation was also gradually established, thereby greatly increasing the limb-salvage rate. These are the clinical significance and value of the endovascular treatment for diabetic peripheral arterial disease.
Because in the small diameter intravascular stent can lead to the early thrombosis and late lumen lost, thus affecting support long-term patency rate. It still have considerable controversy for whether the infrapopliteal arteries stented. At present scholars do not recommend the infrapopliteal arteries conventional implant the drug-uncoated stents, and bare metal stents is limited to postoperative failure cases of balloon expansion as a remedial method. With the new technology and new method development, some surgeon try to have drug-coated stents in the infrapopliteal arteries. Our groups of patients of infrapopliteal arteries had a good treatment effect after balloon expansion and no vascular rupture cases, so there is no implant any stents.