“Diabetes patients have a much greater incidence of blockages in the legs,” says Clinton Atkinson, M.D., a vascular surgeon with Pinehurst Surgical. “In particular, they tend to get blockages in the smaller vessels, and those are often harder to treat.”

The main goal of treatment is to restore adequate blood flow to prevent serious problems, such as infections and gangrene, which can lead to amputation.

“Treatment can be more challenging in diabetics, because they often have blockages in a number of vessels,” says Jonathan Hasson, M.D., a vascular surgeon in Rockingham.

Diabetics are particularly susceptible to leg and foot infections. Sometimes these are due to a type of nerve condition called diabetic neuropathy, which can cause either pain or numbness. But even when diabetic neuropathy is involved, infections and other complications are often made worse by poor circulation.

Vascular disease in the legs is sometimes diagnosed after a person develops a sore on the lower leg or foot that won’t heal. (See accompanying story on wound care.) Or someone might notice he isn’t able to walk as far as he used to without having leg fatigue or cramps.

“When that happens, people automatically tend to restrict their activity level, which is bad for the heart, bad for weight gain and, in turn, really bad for controlling their diabetes,” Dr. Atkinson says.

If minimally invasive procedures aren’t successful, or if they aren’t appropriate for a given patient, conventional surgery is almost always an option.

“When someone has multiple blockages in an artery, then bypass surgery becomes the first choice,” Dr. Atkinson says. “The technology for minimally invasive procedures has dramatically improved, but it hasn’t completely replaced the traditional methods.”

In bypass surgery, a healthy vein from elsewhere in the body is used to replace a diseased artery in the leg or foot.

Interventional radiology
Radiologists and vascular surgeons often complement each other in diagnosing and treating clogged blood vessels. They use many of the same tools and techniques.

To check for diseased arteries in the leg, physicians typically begin by feeling the pulse in the patient’s ankle. If the pressure feels weak, it can be compared to the pressure of the pulse in the patient’s arm.

“Most of the time, that will tell us if the patient is not getting enough blood flow to the lower legs,” says John Hoy, M.D., an interventional radiologist with Pinehurst Radiology Group. If blood flow seems to be restricted, additional tests can be done to locate the area of disease and find out how serious it is. Sometimes this can be done with ultrasound, which is non-invasive. In many cases, physicians now use minimally invasive radiological imaging techniques.

John Hoy, M.D.

“Historically, we had to put a large tube into a vessel and inject dye,” Dr. Hoy says. “Now we are able to put a small IV into a small vein in the arm, inject some contrast material and use either MR angiography or CT angiography to take images of vessels supplying any part of the body. At Moore Regional, we have developed a cardiac and vascular MR and CT advanced imaging program that is nationally recognized.”

There are actually two ways that blood flow can be restricted in the arteries of diabetics. In addition to plaque building up inside the vessels, the walls of the vessels themselves can become rigid with calcium deposits. This makes the arteries less elastic and less able to propel blood downstream, says Noel McDevitt, M.D., of Pinehurst Plastic Surgery Specialists.

Dr. McDevitt often treats foot and leg problems caused by poor circulation.

“It isn’t unusual to take an X-ray of the leg of a diabetic and see the entire arterial system outlined in calcium,” he says.

Tending to wounds

Numbness, lack of sensation, inability to feel pain—these are symptoms of an especially insidious effect of diabetes called diabetic neuropathy.

Not everyone with diabetes has it, but many do. If you are one of them and a sore develops on your foot, you might not know it—because you can’t feel it—until it has become seriously infected.

You might even lose the foot.

“I can’t tell you how many times I’ve had people come in with a big ulcer on the bottom of their foot, and it turns out they have a roofing nail sticking through the sole of their shoe,” says Noel McDevitt, M.D., of Pinehurst Plastic Surgery Specialists. “It’s also common to see patients with an abscess in their foot and, when we take an X-ray, we find that a sewing needle or straight pin has worked its way in.”

Diabetic neuropathy causes leg and foot pain in some people, numbness in others. It is easy for them to scald their feet in bath water, because they can’t feel how hot it is, or to blister their feet by walking on hot sand.

But most of the serious foot problems that people with diabetes have aren’t so dramatic. They often start with a small cut or crack in the skin or an ingrown toenail that provides an opening for a bacterial or fungal infection. Once infection sets it, it can literally eat its way through soft tissue, tendons and even bone. Depending on the extent of damage, amputation of a toe or the entire foot may be the only option.

That is why foot care—inspecting the feet, cleaning them and protecting them—is so important.

“People with diabetes should never walk barefoot, inside or outside,” Dr. McDevitt says, “and they should always feel inside their shoes before putting them on to make sure nothing has gotten in them. They also need to keep their toenails clipped and their feet clean and dry, and they should inspect their feet every day.”

Sores on the ankle and lower leg are another frequent complication of diabetes. A sore can develop when the soft tissue in a particular area doesn’t get enough blood because of clogged arteries.

“We often see big, open ulcers around the ankle or just above the heel that can be very difficult to treat,” Dr. McDevitt says. “First, we clean them and remove the dead tissue. We dress the wound with topical antibiotics and, if it appears there is an invasive infection, we will get a culture to find out exactly what it is and then give the patient an oral antibiotic.”

Some sores are so large or deep that they have to be covered with skin grafts, which require a long time for healing and rehabilitation. But most sores heal with proper cleaning and dressing.

Ann Poplin, R.N., is a certified wound care specialist who sees both inpatients and outpatients at FirstHealth Moore Regional Hospital. She says different types of diabetic sores require different dressings.

“Some dressings are impregnated with collagen, which helps the tissue rebuild itself,” Poplin says.

Proper nutrition also promotes wound healing.

“Getting adequate vitamins, minerals and protein is very important,” says Poplin. “And the better someone controls their diabetes, their blood sugar level, the faster they are going to heal.”