Author: veinmaster

Specialist Vascular Surgeon Canterbury New Zealand

New Diabetic Foot Guidelines

NICE (National Institute for health and Care Excellence), a UK body tasked with the assessment and review of new and established treatments based on robust clinical evidence, have just released their latest guidelines (aimed at delivery of care in the NHS) on diagnosis and management of primary diabetes in adults, diagnosis and management of both primary and secondary in children and ‘young people’, and the prevention and management of diabetic foot problems.

The introduction of the latter highlights the problems of the diabetes epidemic within the UK, and reflected all over the world. Diabetes is on an inexorable rise (at least 50% in the past 6 years), and with it comes a host of acute and chronic medical problems, and the consequences are an earlier death in those with diabetes often through prolonged, chronic, debilitating illness.

The key to avoidance of complication is sugar control to as normal a level as possible. This needs proactive care and patient collaboration, equity of provision and education.

As societies, there needs to be a rethink about nutrition – the most important cause of diabetes. Irrespective of your genetic make-up, if you eat too much and exercise too little you increase the risk of developing secondary diabetes. More information on the types and causes are found on the NIDDK website.

The diabetic foot comes to my attention as a vascular surgeon increasingly frequently. It is the major cause of non-traumatic amputation and is usually associated with a preexisting, inadequately treated, diabetic foot ulcer. Early and effective treatment of a foot ulcer can prevent major amputation. Late intervention can result in disfigurement, dysfunction and limb loss. Prevention is cheap, intervention (and the sequalae) is expensive. Treatment is multidisciplinary with specialist physicians, surgeons and podiatrists essential components of care but the key member of the team is the person with diabetes themselves; without self motivated and managed care the attrition will continue.

The KEY RECOMMENDATIONS:

Care within 24 hours of diagnosis (Early intervention)

Across all settings (Pathways to incorporate community, specialist clinics, and in-patient services)

Preemptive risk assessment and risk management (Foot protection service)

Rapid referral pathways for acute diabetic foot problems (Early initiation of treatment under specialist teams)

Patient education (Critical engagement and self determination)

Establish local treatment guidelines for established disease (Specialist team direction and resource support)

Research (the effects of monitoring on outcome, what care pathways work, impact of education and psycho-behavioral management, which dressings are most effective, how best to manage the Charcot foot)

To these recommendations I’d add that there is little that can be achieved by them or the research targets if there is no way of effectively reporting outcomes in a reliable and comparable way. There has been progress in this with the introduction of the WIFI (Wound, Ischaemia, Foot Infection) scheme for stratification of diabetic foot. This should have been incorporated into the new recommendations as a core standard of reporting, and in that omission there has been a significant missed opportunity to really push both the research and care of the diabetic foot forward.

No stitches please

The diabetic foot. The biggest non-traumatic cause of limb amputation; some would say the biggest AVOIDABLE cause of lower limb amputation. It’s a battle, and a global one at that. As diabetes becomes more prevalent it is going to become more of a problem unless the multiple disciplines of medicine and surgery develop a solution to the lethal triad of  ischaemia, infection and neuropathy. Two events prompted this blog post (well three but the third is simply the fact I’ve not posted recently anything remotely medical). Firstly, a recent article in Vascular News (http://tinyurl.com/oyoalug) about a new pan European trial for  assessing the efficacy of minimally invasive attempts at revascularisation using software developed by Phillips. The assumption is that revascularisation leads to limb preservation. Not unreasonable, but there’s much debate among vascular surgeons at least on what the outcome measurement outcome should be for treatment of diabetic foot  disease. Wound healing? Resumption of ADLs? The traditional ‘amputation free survival’? Besides, we’re not even sure that the assumption holds true. There are plenty of diabetic feet that are surgically amputated with clinically, and radiographically, normal vascular supply (that is not to say normal vascularity), or supply that has been restored optimally without any discernible benefit. I think the trialists will find that the software predicts tissue perfusion, but I believe the results for clinical success by limb salvage, or however it is measured, will be disappointing. There are just too many other variables to consider, the other two prongs of the triad at least. The second reason for posting is a recent case; and this is part of the problem in the real world of clinical management of the diabetic foot. A patient with neuropathy, decent vascular supply who presented with an infected necrotic toe a few months ago had the toe amputated and sutured closed. Just one stitch to approximate the edges and speed the skin closure. He was even seen to have (mostly) healed his wound in the wound clinic three weeks later. The tell tale was in the notes. The wound review described a well healed wound with a small non-healed edge at one side exuding a small amount of fluid. Two weeks later I see this in the clinic and the remnant bones of the amputated and ‘healed’ toe have decomposed on X-ray. 

    

In this case the foot was saved by further debridement and removal of the infected tissues and bone and the WOUND LEFT OPEN to drain; to heal by secondary intention. A week down the line and the situation could have been considerably worse with a septic patient and a limb threatened and threatening. 

Attempts to close these wounds must be avoided. I bang on about this but it is still done, and the inevitable recurrent infection still occurs. The wounds look clean but they are not and, particularly in diabetic patients, the microcirculation, the immune response, and the awareness is inadequate to prevent adequate primary healing. So, while new software might give us reassurance that the pictures are good, it’s the people on the ground doing the work and owning the disease that need to learn both how to prevent the initial insult and how to prevent deterioration, and recurrence, that will make the biggest impact on how frequently diabetic foot disease will lead to major amputation. One positive aspect to this sea of defeatist talk is the fact that for the first time to my knowledge a major player in the health industry is investing in diabetic foot research, albeit perhaps recognizing it as an area of growth and potential profit, and it is likely now that others will follow. Hopefully on the back of big pharma money there will be a multi pronged approach to the epidemic that is approaching rather than tinkering at the high tech (high return) edges

In the meantime, for those with an interest who might find themselves with a suture in hand and a lovely looking toe amputation wound begging to be closed my measage is: just don’t, please. 

Laser, Surgery, Radiofrequency (RF) or Foam for treatment of varicose veins?

The short answer is that all types of treatment are effective, but it will depend on when and where they are used.

Foam sclerotherapy is almost completely painless, but frequently requires multiple visits and is more prone to recurrence than the other techniques. The chemical used to treat the vein is mixed with air (usually) into a foam before injection. When it is injected into the vein the foam fills it, replacing the blood temprarily to allow the chemical to contact and destroy the cells lining the vein (this is the crucial part of any of the vein treatments). The foam dissolves and the vein collapses. Over time the collapsed vein scars up and shrinks so is unable to fill with blood. The technique is most suited to smaller, isolated, veins although it can be effective for larger and longer veins, particularly for those that are just under the skin and are extremely wobbly.

Surgery is the most common and traditional form of treatment. The results are dependent on the expertise of the surgeon, their knowledge of the disease and, to avoid the more common complications, precise technique. It usually involves being put to sleep, and often multiple surgical woulds, albeit small ones. The vein is disconnected from the body and stripped away, this removes the whole vein, and with it the lining cells. Blood fills the space left and this ultimately is absorbed by the body leaving only internal, invisible scar tissue. In expert hands surgery is highly effective and durable, but it is dependent on the surgeons expertise. See a specialist vascular surgeon of the best results.

The down-side of surgery is that it requires a hospital admission usually, and the wounds are prone to infection, bleeding, significant bruising, ooze and numbness; this can continue for several weeks or months after the initial surgery. It is also a relatively painful recovery initially.

The desire to avoid the surgery related complications of varicose vein operations has provided the impetus for the development of so called minimally invasive techniques; laser and RF ablation.

Both techniques are similar in the method of treatment and outcomes, but differ in patient experience. Lasers and RF catheters are introduced to the vein through a needle inserted into the vein. The patient is usually awake, and the procedure can be performed in an ‘office’ setting. Laser treatment requires the use of specially equipped rooms to prevent dangerous laser light causing unwanted injury outside of the operative area. Both techniques involve accurate positioning inside the vein using a live ultrasound scan image. This means that the surgeon can see exactly which vein he or she is treating for its full length (not the case with traditional surgery). Both techniques require the injection of an anaesthtising fluid around the vein – again under scan image guidance. The difference between the techniques lies in the intensity of the treatment. Lasers vapourise the cells lining the vein (them again) at extremely high temperatures of upto 700 Celsius in a continuous ‘pull through’, RF ablation uses heat at 120 Celsius over a length of 3 or 7 cm over a 20 second period, effectively ‘poaching’ the cells within the vein.

Studies have shown that RF ablation is the gentlest of the surgical techniques. It has superb durability with the least pain for the patient.

In summary, all techniques have their advantages and disadvantages and no single technique fits all veins. For the best treatment of varicose veins one needs a full expert assessment by a specialist in vascular surgery capable of delivering the spectrum of treatments. Many surgeons and medical practitioners will provide varicose vein treatments but, to avoid disappointment, and to reduce the chance of recurring veins and complications, please ensure the one that you see is a vascular specialist.

Complications

Modern minimally invasive venous treatments are safe. Safer than the more traditional surgery with knives, clips, hooks and strippers. Despite their inherent safety it is important to know that NO medical intervention is completely safe. The most concerning complication for endovenous therapy is deep vein thrombosis. It is rare, probably less than 1-2% of cases, made rarer by getting the patient up and walking within minutes of completing the procedure and encouraging mobility throughout the following 2-3 weeks.

This was highlighted to me recently after performing an ablation on a patient under general anaesthetic, at the patients request. All straightforward, as was the recovery. However, the tendency, after GA, is to spend time recovering in bed. Its a kind of tradition that is hard to culturally shake off. It makes people groggy for quite a period afterwards and subdues natural activity. Patients are dehydrated. All of this contributes to a pro coagulant state already present following surgery.

It was probably a combination of all these factors, and body habitus, an hot holiday weather in the weeks following that caused a DVT. Luckily, the patien has recovered well but it has delayed recovery for some months.

The lesson for me is to not try to please people all the time. Either it’s ambulatory surgery or it’s not, and if not then all the usual tools for thromboprophylaxis should be used. That said, I’ll refer you right to the top of the piece. There is nothing that one does in medicine that is completely safe.

Endovascular Today – Blunt Thoracic Aortic Injury: Current Issues and Endovascular Treatment Paradigms September 2014

The 2011 SVS TEVAR for BTAI clinical guidelines raised a number of unanswered questions.How have they been resolved since then?

via Endovascular Today – Blunt Thoracic Aortic Injury: Current Issues and Endovascular Treatment Paradigms September 2014.

this is a really good article on the current status of the treatment of Blunt Thoracic Aortic Injury. Frequently fatal at scene, these injuries are considered rare, but are increasingly diagnosed as imaging technology improves and prehospital treatment gets better at delivering survivors of major trauma.

The chances of survival have increased as a result of the shift in management from heroic, frequently futile and complicated open surgery only performed by a handful of heroic surgeons. You would be lucky to have your injury and survive to get such expertise dealing with you. Now most major trauma centres will be within reach, experienced in endovascular techniques and be easily capable of performing a thoracic stent insertion for traumatic injury.

The issues resolved in this article will help even those centres who do relatively few of these procedures to deliver care with safety.

Sweaty hands and pits

I’ve recently had a query from a patient of mine that I ‘adopted’ from another colleague. They have hyperhidrosis, excessive sweating and periodically has Botox injections for relief. This is a really good and very safe treatment for what can be an incredibly embarrassing and almost socially debilitating problem. The alternatives are varied. Strong antiperspirants, obviously, something called Iontophoresis, and a surgical procedure called thorascopic sympathectomy.
Iontophoresis is essentially tap water electrolysis. There’s no consensus on how it actually works and despite the notion that electricity and water is generally regarded as dangerous in combination, in this situation it seems to have benefit for some. It involves putting your hands into shallow basins of water with a controlled current running. It has to be controlled to have a therapeutic, as opposed to fatal, effect so please do not connect your kitchen sink to the mains without first consulting your doctor.
Iontophoresis is probably an under-utilised method because of its dubious evidence (doctors love evidence to cite or refute in support or otherwise of a cause) but it is cheap and effective for some.
Thorascopic sympathectomy is the destruction of a set of nerves that form a chain inside the chest alongside the backbone. It is very effective too. It requires a general anaesthetic, the patients lungs to be deflated on either side and for a heat probe to be passed through a telescope to destroy the nerves where they communicate. The nerves, known as the sympathetic chain are a primitive bunch that involve themselves in auto regulation. That is to say reflex responses to changes in the environment. Sympathectomy is a more or less indiscriminate ablation of the sympathetic chain. You can’t predict where the actual nerves that control sweating in the hand or armpit are, so you burn a number of areas in succession, more or less hoping that there’ll be the desired effect on completion. There are adverse side effects. Pain after the procedure for a week or so, and a lung that usually needs re-inflating (not usually a problem provided it hasn’t been injured during the procedure). The most common and problematic side effect is ‘compensatory sweating’ in areas that haven’t been treated. So the torso, back and face can start to sweat more while the hands or armpits are dry. There can also be some effect on the appearance of the face with a drooping of the eyelid and dilatation of the pupil ; horners syndrome. Thorascopic Sympathectomy is better for hands than it is for armpits, but provides the most complete and long lasting treatment for hyperhidrosis.

Botox is an alternative that provides good relief for a limited period, typically 6 to 9 months. The toxin is injected in small amounts just deep to the skin throughout the affected area. This can be pretty painful as anyone might imagine. Anaesthetic creams are used to alleviate the pain but are of dubious efficacy. Personally, I’d use a regional anaesthetic block at the wrist to numb the area for a few hours before the injections. The Botox effect isn’t instant, the sweating reduces over a few days. The treatment is repeated when the effect begins to wear off. As more treatments are given, so the effect can reduce if the body establishes antibodies to the toxin molecule. It is an excellent treatment that has minimal down sides and certainly none of the risks of surgery. It just needs to be repeated and that might get expensive over a significant number of years.

New Blog

This new blog is to highlight the new and established evidence on vascular disease and it’s treatments.

I am a Specialist Vascular Surgeon providing services within both a state funded Tertiary Specialist Hospital, and as a private practitioner.

The blog will involve, predominantly, news, personal opinions on healthcare related subjects, and occasional anonymised case related commentaries. Other stuff too no doubt as it is develops.

Anyone interested in the information about vascular diseases and treatments can visit many websites throughout the web, my sites contain additional information and contact details. They are:

http://www.canterburyveinspecialist.com
And
Www.christchurchvascularsurgery.health.nz