背景:糖尿病足周围动脉病变的诊断并发糖尿病及其晚期并发症。已发现糖尿病足可分为动脉狭窄和非动脉狭窄,两者在血流动力学特征上有显著差异。
目的:使用高频彩色多普勒超声(HFCDU)和激光多普勒流量计评估非动脉狭窄和胫骨横向运输(TTT)治疗的糖尿病足患者的早期血流动力学变化。
方法:25例Wagner3-5级糖尿病足溃疡患者接受TTT治疗,记录创面愈合时间和愈合率。根据术前下肢超声检查结果对患者进行分组。任何股骨狭窄≥50%的病例,腿部,胫骨后端,胫骨前,患肢的腓骨动脉被归类为动脉狭窄组(n=16);否则,他们被归类为非动脉狭窄组(n=9).手术前和手术后一个月,采用HFCDU评估患者下肢动脉病变程度及血流动力学变化。股动脉粥样硬化性狭窄的程度,下膝关节流出道血管狭窄和闭塞的程度,并对内侧动脉钙化程度进行评分;将三个评分相加,得到下肢动脉病变的总评分。PeriScanPIM3,一种激光多普勒流量计系统,用于检测手术前和手术后1个月足底微循环的变化。比较两组创面愈合情况及血流动力学指标。
结果:非动脉狭窄组糖尿病足创面愈合时间明显短于动脉狭窄组(47.8±13vs85.8±26,P<0.05),两组创面愈合率均为100%。无动脉狭窄组术前总下肢动脉病变评分低于动脉狭窄组(18.89±8.87vs24.63±3.52,P<0.05)。非动脉狭窄组术前pop动脉(POA)血流量高于动脉狭窄组(204.89±80.76cc/minvs76.75±48.49cc/min,P<0.05)。与基线(手术前)相比,非动脉狭窄组术后患肢POA血流量在术后1个月下降(134.11±47.84cc/minvs204.89±80.76cc/min,P<0.05),而动脉狭窄组增加(98.44±30.73cc/minvs61.69±21.70cc/min,P<0.05)。尽管动脉狭窄组术后1个月POA血流明显改善,仍低于非动脉狭窄组(98.44±30.73cc/minvs134.11±47.84cc/min,P<0.05)。无动脉狭窄组术前足底微循环高于动脉狭窄组(56.1±9.2vs33.2±7.5,P<0.05);动脉狭窄组术后1个月足底微循环明显改善(51.9±7.2,P<0.05),而非动脉狭窄组减少(35.9±7.2,P<0.05)。
结论:根据术前HFCDU检查结果,糖尿病足患者可分为两类:非动脉狭窄和动脉狭窄,术后早期血流动力学变化有明显差异。在TTT之后的早期阶段,与基线相比,非动脉狭窄的糖尿病足受累肢体的血流量和速度以及足底微循环灌注下降。而糖尿病足动脉狭窄的患者与基线相比有显著改善,虽然两者均顺利治愈糖尿病足溃疡。
BACKGROUND: The diagnosis of peripheral arteriopathy in the diabetic foot is complicated by diabetes and its advanced complications. It has been found that diabetic foot can be categorized into arterial stenosis and non-arterial stenosis, both of which have significant differences in hemodynamic characteristics.
OBJECTIVE: To evaluate the early hemodynamic changes in diabetic foot patients with nonarterial stenosis and arterial stenosis treated by tibial transverse transport (TTT) using high-frequency color Doppler ultrasonography (HFCDU) and a laser Doppler flowmeter.
METHODS: Twenty-five patients with Wagner grades 3-5 diabetic foot ulcers were treated with TTT, and the wound healing time and rate were recorded. Patients were grouped according to the results of preoperative lower-extremity ultrasonography. Cases with ≥ 50% stenosis in any of the femoral, popliteal, posterior tibial, anterior tibial, and peroneal arteries of the affected limb were classified as the arterial stenosis group (n = 16); otherwise, they were classified as the nonarterial stenosis group (n = 9). Before and one month after surgery, HFCDU was used to evaluate the degree of lower limb artery lesions and hemodynamic changes in patients. The degree of femoral-popliteal atherosclerotic stenosis, the degree of vascular stenosis and occlusion of the lower-knee outflow tract, and the degree of medial arterial calcification were scored; the three scores were added together to obtain the total score of lower extremity arteriopathy. PeriScanPIM3, a laser Doppler flowmeter system, was used to detect alterations in plantar microcirculation before and 1 mo after surgery. Wound healing and hemodynamic indices were compared between the two groups.
RESULTS: The wound healing time of the diabetic foot was significantly shorter in the nonarterial stenosis group than in the arterial stenosis group (47.8 ± 13 vs 85.8 ± 26, P < 0.05), and the wound healing rate of both groups was 100%. The preoperative total lower extremity arteriopathy scores were lower in the nonarterial stenosis group than those in the arterial stenosis group (18.89 ± 8.87 vs 24.63 ± 3.52, P < 0.05). The nonarterial stenosis group showed higher preoperative popliteal artery (POA) blood flow than the arterial stenosis group (204.89 ± 80.76 cc/min vs 76.75 ± 48.49 cc/min, P < 0.05). Compared with the baseline (before surgery), the postoperative POA blood flow of the affected limb in the nonarterial stenosis group decreased one month after surgery (134.11 ± 47.84 cc/min vs 204.89 ± 80.76 cc/min, P < 0.05), while that in the arterial stenosis group increased (98.44 ± 30.73 cc/min vs 61.69 ± 21.70 cc/min, P < 0.05). Although the POA blood flow in the arterial stenosis group was obviously improved one month after surgery, it was still lower than that in the nonarterial stenosis group (98.44 ± 30.73 cc/min vs 134.11 ± 47.84 cc/min, P < 0.05). The nonarterial stenosis group had higher preoperative plantar microcirculation than the arterial stenosis group (56.1 ± 9.2 vs 33.2 ± 7.5, P < 0.05); compared with the baseline, the plantar microcirculation in the arterial stenosis group was significantly improved one month after surgery (51.9 ± 7.2, P < 0.05), while that in the nonarterial stenosis group was reduced (35.9 ± 7.2, P < 0.05).
CONCLUSIONS: Based on preoperative HFCDU findings, diabetic foot patients can be divided into two categories: Those with nonarterial stenosis and those with arterial stenosis, with obvious differences in hemodynamic changes in the early postoperative period between them. In the early stage after TTT, the blood flow volume and velocity and the plantar microcirculation perfusion of the affected limb of the diabetic foot with nonarterial stenosis decreased compared with the baseline, while those of the diabetic foot with arterial stenosis improved significantly compared with the baseline, although both had smoothly healed diabetic foot ulcers.