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Question: What's the best way to treat peripheral vascular disease in a patient with type 2 diabetes?
Answer: Patients with both type 1 and type 2 diabetes can suffer from accelerated atherosclerosis, and peripheral arterial disease is twice as common in patients with diabetes than in patients without. Approximately 20% of patients with diabetes will develop either a foot infection or an ulceration or will suffer rest pain and will require hospitalization for the evaluation and treatment of these difficult issues.1
The single best treatment method for peripheral vascular disease is prevention. Patients clearly can improve their outcome via risk factor modification. One of the most effective ways to assist in slowing the process of atherosclerosis is to avoid tobacco use.2
For many asymptomatic patients, meticulous foot hygiene is of the utmost importance. Feet should be inspected, noting dry or fissured skin, calluses, or onychomycosis, which may lead to skin disruption and thus ulceration.3 Simple actions, such as moisturizing the feet every day to avoid cracking and wearing shoes that fit properly to prevent injury to the foot, serve to prevent the development of ulcers that will not heal without correcting decreased blood flow. An equally important step is to have a podiatrist trim the toenails to prevent injury to the surrounding skin. In one study examining 699 patients with a foot ulcer, 21% of ulcers were caused by footwear, 11% were due to injuries such as falls, and 4% were due to self-inflicted injuries such as trimming of toenails.4
Additionally, diabetic peripheral neuropathy may involve both the sensory and motor nerves and is a large factor contributing to pressure necrosis and ulceration. Therefore, it's important that patients with diabetes inspect their feet daily to identify areas of pressure before an ulceration develops.
Patients with diabetes also may present with intermittent claudication, defined as ischemic muscle pain secondary to inadequate blood flow. This lack of perfusion is due to proximal arterial stenoses leading to decreased blood flow to large muscle groups. In general, claudication pain should be treated conservatively, with a strict exercise program that includes walking. Again, risk factor modification is critical at this stage to alter the ultimate outcome. Patients who smoke should be counseled to stop. Hypertension and hypercholesterolemia should be managed aggressively. With medical management, roughly one-third of patients will have an improved walking distance, one-third will remain at a similar level of disability, and only one-third will progress to a limb-threatening problem.
The most critical peripheral vascular issue that patients with diabetes encounter is the development of an ulceration accompanied by infection, gangrene, or rest pain. All are limb-threatening problems that could lead to amputation if not treated urgently. Evaluation by a vascular surgeon is crucial. Typically, a vascular surgeon will perform a physical examination to document pulses and proceed to an arteriogram, which involves injecting a contrast agent into the femoral arteries of the leg to identify regions of blockages.
Balloon angioplasty with or without stent placement may be used to attempt to open the blocked arteries or surgery may be performed using a vein from the leg or arm to re-create a new conduit to take blood to the lower leg or foot. Vascular surgeons often are skilled in both modalities and can help individual patients decide on the most advantageous option.
For patients whose infection or ischemia is too severe to correct, amputation is the only option. If amputation is necessary, a prosthetic leg can be made to help the patient become ambulatory again.
The most important step patients can take is to assume responsibility for
their future by smoking cessation and meticulous foot care. Patients with
claudication pain still have the ability to improve their walking distance
through exercise and control of lipids. However, if ulceration, gangrene,
infection, or rest pain develops, it is imperative that blood flow be restored
to the leg to prevent limb loss. Involving a vascular surgeon early is always
a good idea. 
Footnotes
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References
2. Willigendael EM, Teijink JA, Bertelink ML, et al.: Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg 40:1158–1165, 2004.[Medline]
3. Boike AM, Hall JO: A practical guide for examining and treating the
diabetic foot. Cleve Clin J Med 69: 342–348, 2002.
4. Macfarlane RM, Jeffcoate WJ: Factors contributing to the presentation of diabetic foot ulcers. Diabet Med 14: 867–870, 1997.[Medline]
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