Foot for thought


IT’S the usual story of a diabetes patient, one that starts with pain in the foot. Then, it’s the cramp in the calves. A little walking and the thighs begin to ache. Soon there is constant need to rest. As time goes by, little scratches on the feet turn into wounds that never heal.

Finally, the doctor warns: “If this continues we may need to amputate your foot.”

If this sounds familiar, don’t panic. With a new procedure that involves the use of stents, Dr Shaiful Azmi Yahya, consultant cardiologist at National Heart Institute says the doctor’s warning will remain a warning: You won’t necessarily have to lose a limb.

As he explains, arteries and veins transport blood to all parts of your body.

When there is an extensive build-up of fatty deposits on the inside of your artery walls, plaque and blood clots can form, obstructing blood flow.

If you feel pain after walking a short distance, your limbs are probably not receiving enough blood. This can be a sign that you’re suffering from a progressive systemic disorder called peripheral vascular disease’ (PVD).

PVD can appear in any major artery but is most common in the arteries of the lower limbs. Although the disease progresses slowly, the problem is that it is often under-diagnosed. This is particularly grave for diabetics as PVD can progress directly to a situation where there is a critical lack of blood supply to the legs.

When this happens, patients often experience pain, even during rest, suffer tissue loss or gangrene. If left untreated, it can result in amputation of limbs. Dr Shaiful estimates that 30 to 50 per cent of patients with diabetes have PVD. Indeed, the rate of major limb amputation is four times higher for them.

Whenever dead tissue is removed from the body, some healthy tissue surrounding the affected area must also be removed. With early diagnosis and treatment of PVD, the removal of such healthy tissue can be minimised.

“Our job is to enhance affected areas by getting more blood supplied to them.

Even if we have to amputate, we might just remove a few toes instead of removing the whole ankle,” he says.

The most noticeable symptom of PVD is pain, cramps or aches in the calves, thighs or buttocks that appear repeatedly when walking. This pain is relieved when the patient rests. Another symptom is that the colour of the feet takes over 40 seconds to return to normal after the feet have been elevated at 60 degrees for one minute.

Wounds on the feet will not heal and the patient suffers hair loss on his lower limbs, poor nail growth (brittle nails), dry and scaly skin. Dr Shaiful adds: “Any ulcer he develops is punched-out, painful and with little bleeding.”

To make a diagnosis, the doctor will first conduct a physical examination of the patient, paying special attention to the feet. Then, he will use a Doppler device to accurately calculate what’s called, ankle brachial index (ABI) — he will divide the highest systolic ankle pressure by the highest systolic arm pressure. If the ratio is between 0.50 and 0.90, the patient probably has mild to moderate PVD. If the ABI is less than 0.50, the patient probably has severe PVD.

Then, a range of diagnostic and imaging tests (such as magnetic resonance angiography and CT angiography) will be performed to confirm the diagnosis and determine exactly where the artery is blocked.

Those diagnosed with PVD are usually advised to change their lifestyles (stop smoking, maintain an ideal body weight and exercise), prescribed medication or asked to consider surgery.

Dr Shaiful’s preferred treatment option is a minimally invasive procedure which includes angioplasty and stent implantation — a catheter with a deflated balloon on its tip is passed into the narrow part of the artery. Then the balloon is inflated to open the blood vessel. The stent is permanently implanted to hold the diseased artery open and to restore blood flow. The balloon is deflated and removed.

The stent is a tiny cylindrical wire mesh tube made from a material called nitinol, a combination of nickel and titanium. It is malleable and, therefore, particularly useful for vessels in the lower limbs that need to flex, extend, compress and rotate.

Angioplasty and stent implantation certainly causes less scarring than surgery and has been effective in reducing disability in cases of PVD. The patient avoids the trauma and risks of surgery such as anaesthesia. Recovery is so fast that some patients return home the same day or the day after the procedure is completed.

The cost of angioplasty and stent implantation in cases of PVD can be anywhere between RM15,000 and RM20,000. Nevertheless, Dr Shaiful sees major benefits in diagnosing and treating those suffering from PVD.

In his words: “Diabetics already suffer from so many complications of the disease. With this procedure, we can help make their quality of life a little better and reduce the risk of amputation.”

THE risk factors for PVD are similar to those for coronary artery disease and cerebrovascular disease. Modifiable risk factors for PVD are:

RISK FACTORS

-Hypertension
-High cholesterol
-Smoking
-Obesity
-Sedentary lifestyle

Non-modifiable risk factors for PVD are:

-Age
-Male gender
-Diabetic
-Family history

SUMBER