Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice

Abstract

Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.

Prospective study on microangiopathy in type 2 diabetic foot ulcer

“…Another new finding was that microangiopathy was absolutely equal in neuroischaemic and neuropathic patients. The fact that all our ischaemic patients were also neuropathic should not be misleading and or even considered a bias as, in our experience [14] and in the literature [15][16][17], it is becoming increasingly clear that the population of patients with ischaemic diabetic foot corresponds exactly to these characteristics. There are conflicting reports about skin capillary blood flow in the diabetic foot.…”

Ischemic Ulcer Healing: Does Appropriate Flow Reconstruction Stand for All That We Need?

“…To date, the prevalence of purely neuropathic, ischemic, and combined neuro-ischemic foot ulcers in patients with diabetes was estimated at 35, 15, and 50% rates, respectively [57][58][59].…”

“…Reported DFS singularities include (1) the regular tibial trunks calcifications [2,30,31,57] that match the extent of local neuropathy [25,31], (2) the "end-artery occlusive disease" (EAOD) concept [59], (3) an impaired arterio-and angiogenesis [60], (4) a specific collateral deprivation following chronic inflammation and septic thrombosis of small vessels [31,35,[57][58][59], (5) intrinsic vascular or matrix impaired regeneration [61], and (6) characteristic neuro-ischemic compartmental hyper pressure foot syndromes [62].…”

“…Thus, chronic hyperglycemia may enhance at the mitochondrial-level expanded free radicals production, altering normal metabolic and cellular activity [63]. This malfunction affects more particularly normal regeneration at the microcirculatory level (vasa-vasorum and vasa-nervorum) also the tissue binding matrix [58,[59][60][61].…”

“…Modern diabetic ulcer understanding builds a complete design of multifaceted and potentially devastating CLI effects in these patients [2,31,[57][58][59][60][61][62].…”