Venous Distension in the Diabetic Neuropathic Foot (Physical Sign of Arteriovenous Shunting)

Ward, J. D.; Boulton, A. J. M.; Simms, J M; Sandler, DavidA.; Knight, Graham

doi:10.1177/014107688307601206

Cited by 81 publications

(42 citation statements)

References 8 publications

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“…Neuropathic oedema decreases when patients are given ephedrine [21] and it is possible that nutritive blood flow, impaired by arteriovenous shunting, might be improved. Many patients and physicians know that pain can be diminished by cooling the feet [9,22] and unsatisfactory attempts have been made in the past to reduce blood flow [23]. Evidence from the present investigation suggests that reduction of blood flow might alleviate pain.…”

Section: Discussionmentioning

confidence: 67%

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Blood flow patterns in painful diabetic neuropathy

1984

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Summary.Peripheral blood flow is known to be qualitatively increased in diabetic patients with neuropathy. We have measured the actual blood flow in the feet of diabetic patients with neuropathy using non-invasive mercury strain gauge plethysmography and Doppler sonogram techniques and shown that it is increased on average five times above normal at an ambient temperature of 20 ~ -22 ~ Moreover, reduction of this high flow by sympathetic arousal stimuli proved possible in those with severe painful neuropathy contrasting strongly with failure to reverse it in those with severe non-painful sensory neuropathy. Reduction of blood flow was associated with reduction in neuropathic pain. We studied 22 diabetic patients with severe sensory neuropathy and eight with painful neuropathy. High resting foot blood flows were demonstrated in both groups with neuropathy. The big toe flow in those with severe sensory neuropathy was 29.3 + 9.2 ml. rain-1. 100m1-1 (mean+-SD) and in the painful neuropathy group, 25.9+_7.5, compared with 5.2+2.4ml.min -1. 100m1-1 in the non-diabetic control subjects (p<0.001). High foot skin temperatures were also recorded in the groups with neuropathy, reflecting the high blood flow. The subjects with painful neuropathy retained the ability to constrict peripheral blood vessels in response to arousal stimuli, and reduce peripheral flow on average by 32% compared with the patients with sensory neuropathy who responded on average by only 10%. The demonstration of a peripheral sympathetic defect, responsible for the high blood flow and the potential reversal of such flow in painful neuropathy may be important in our further understanding of the aetiology of such pain and its treatment.Key words: Diabetes mellitus, peripheral blood flow, sensory neuropathy, painful neuropathy, peripheral sympathetic neuropathy.During the nineteenth century, the feet of diabetic patients with peripheral neuropathy were observed to be hot and erythematous [1] and the blood flow in such feet was considered to be increased. This increase is now thought to be due to the dilation of denervated arteriovenous shunts [2-9] normally controlled by sympathetic nerves.Measurement of actual blood flow in diabetic neuropathic feet has only been undertaken in one previous study [10]. Blood flow was not found to be increased in neuropathic subjects probably because the studies were conducted by waterbath plethysmography at 32~ causing vasodilatation and increased flow in the control subjects.The aim of this study was to measure the magnitude of resting foot blood flow in a group of diabetic patients with severe sensory neuropathy and to discover whether the hot, burning foot, so characteristic of distal painful neuropathy, also has a high resting flow resulting from a peripheral sympathetic defect. In addition, the sympathetic responses of both types of neuropathy were tested to discover whether either retained the ability to reduce peripheral flow by vasoconstriction, and whether any benefits might result from this. Subjects and metho...

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Section: Discussionmentioning

confidence: 67%

“…This increase is now thought to be due to the dilation of denervated arteriovenous shunts [2][3][4][5][6][7][8][9] normally controlled by sympathetic nerves.…”

Section: Resultsmentioning

confidence: 99%

Blood flow patterns in painful diabetic neuropathy

1984

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“…It is well established that there is arterio-venous shunting in the diabetic neuropathic leg which leads to distended, "arterialised" veins [39][40][41][42] that have elevated oxygen ten-sion [42]. The presence of epineurial arterio-venous shunts in the neuropathic subjects and the reduced intensity of fluorescence has led us to speculate that similar mechanisms may be taking place at the surface of the nerve leading to a "steal" effect rendering the endoneurium ischaemic.…”

Section: Discussionmentioning

confidence: 99%

Impaired blood flow and arterio-venous shunting in human diabetic neuropathy: a novel technique of nerve photography and fluorescein angiography

et al. 1993

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Summary. New techniques of sural nerve photography and fluorescein angiography which are able to provide an index of nerve blood flow have been developed. Under local anaesthetic, 3 cm of sural nerve was exposed at the ankle using an operating microscope. Without disturbing the epineurium, vessels were identified and photographed at a standard magnification ( x 30). These were independently graded by an ophthalmologist not otherwise involved with the study. Fluorescein angiography was then carried out on the exposed nerve. The fluorescein appearance time and intensity of fluorescence were quantified, using computer analysis of digitised images. Thirteen subjects with chronic sensory motor neuropathy, five non-neuropathic diabetic and nine normal control subjects were studied. The mean epineurial vessel pathology score of the neuropathic group was significantly higher than the combined normal control and non-neuropathic diabetic groups (p < 0.01). Direct epineurial arteriovenous shunting was observed in six neuropathic and one non-neuropathic diabetic patients and not in any of the normal control subjects. The nerve fluorescein appearance time was significantly delayed in subjects with chronic sensory motor neuropathy (51.5 + 12 s) compared to both normal (34.7 _+ 9 s, p < 0.01) and non-neuropathic diabetic subjects (33.4 + 11 s,p < 0.025). The mean intensity of fluorescence at 96, 252 and 576 s, was significantly lower in subjects with chronic sensory motor neuropathy compared with both of the other groups (p < 0.05). The epineurial vessel pathology score was significantly related to reduced sural (p < 0.01) and peroneal (p < 0.001) nerve conduction velocities, elevated vibration (p < 0.01) and thermal (p < 0.001) perception and the severity of retinopathy (p < 0.002). The fluorescein appearance time was significantly related to reduced sural sensory (p <0.02) conduction velocity, elevated vibration (p < 0.01) perception and epineurial vessel (p < 0.002) pathology score, but it failed to relate to peroneal motor (p = 0.06) conduction velocity, thermal (p = 0.1) perception and the severity ofretinopathy (p = 0.3). Intensity of fluorescence was significantly related to fluorescein appearance time (at 96 s,p < 0.001; at 576 s,p < 0.05) but did not relate to measures of neuropathic severity. These techniques have enabled us to observe that epineurial vessel anatomy is abnormal and that nerve blood flow is impaired in subjects with chronic sensory motor neuropathy. In addition epineurial arterio-venous shunting may be a feature of diabetic neuropathy. These techniques may further be applied to study nerve blood flow in early diabetic neuropathy.

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“…The failure of sympathetic control results in a vasodilatation with increased flow through the A-V shunts and therefore an increased total peripheral blood flow [6]. This could be associated with a reduced flow in nutritional capillaries (capillary steal) and explain the coexistence of increased peripheral skin blood flow and of cutaneous ulceration in patients with autonomic neuropathy [7]. According to this line of reasoning the low TcPO 2 values observed in diabetic patients might be the consequence of peripheral autonomic neuropathy.…”

Section: Resultsmentioning

confidence: 97%

“…The consequence of a sympathetic dysfunction is a vasodilatation and an increased flow through the A-V shunts [34], which results in an increased oxygen content in the foot venous blood and therefore in an increased SI [35,36]. Related to this a "capillary steal" phenomenon has been hypothesized [7]. This could explain the reduced foot TcPO 2 values in diabetic patients without PVD.…”

Section: Discussionmentioning

confidence: 99%

Autonomic neuropathy and transcutaneous oxymetry in diabetic lower extremities

et al. 1994

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Transcutaneous oxygen tension is a useful method with which to assess the functional status of skin blood flow. The reduced values observed in diabetic patients have been interpreted as a consequence of peripheral vascular disease. However, diabetic patients show lower transcutaneous oxygen tension values than control subjects with equivalent degrees of peripheral vascular disease, suggesting that additional factors are involved. Since the autonomic nervous system influences peripheral circulation, we studied the relationship between autonomic neuropathy and foot transcutaneous oxymetry in non-insulin-dependent diabetic (NIDDM) patients without peripheral vascular disease. The following age-matched patients were selected and evaluated: control subjects, C, (n = 20), NIDDM patients without autonomic neuropathy, D, (n = 16) and with autonomic neuropathy, DN, (n = 20). All diabetic patients showed lower transcutaneous oxygen tension values than control subjects, while no differences were observed between the diabetic patients with and without autonomic neuropathy. In addition the saturation index that increases in the presence of autonomic neuropathy does not correlate with foot TcPO2. In conclusion autonomic neuropathy does not influence foot TcPO2 and therefore it is unlikely that it contributes to development of foot lesions during induction of foot skin ischaemia

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Venous Distension in the Diabetic Neuropathic Foot (Physical Sign of Arteriovenous Shunting)

Cited by 81 publications

References 8 publications

Blood flow patterns in painful diabetic neuropathy

Blood flow patterns in painful diabetic neuropathy

Impaired blood flow and arterio-venous shunting in human diabetic neuropathy: a novel technique of nerve photography and fluorescein angiography

Autonomic neuropathy and transcutaneous oxymetry in diabetic lower extremities

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