| As many as 50% of diabetics, especially those with a long history of diabetes, have peripheral circulatory disorders. This term describes a host of disorders resulting from narrowing or occlusion of the blood vessels in the extremities (vascular disease). The vascular disease often is associated with significant impairment of the circulation to the legs and feet. This circulatory compromise often causes symptoms such as pain in the legs and feet during walking that is relieved with rest, known as intermittent claudication.
In addition to peripheral circulatory disorders, diabetics often have decreased sensation in their extremities (peripheral neuropathy) and increased susceptibility to infection. These factors complicate the peripheral vascular disease by increasing the risk of foot infections and ulcerations which leads to gangrene and possible amputation of part of the affected extremity. In fact, diabetes accounts for approximately half of all non-traumatic amputations in the US (Palumbo).Risk: Peripheral circulatory disorders tend to occur in those who have long-standing diabetes (greater than 10 years). These disorders are found in less than 20% of those who have been diagnosed with diabetes for less than 2 years, while it occurs in almost 40% of those who have had diabetes for 20 years (Palumbo). |
Source: Medical Disability Advisor
| History: Individuals may report altered sensation in the lower extremities, particularly the feet. This altered sensation may be described as "numbness" or a "burning sensation" in their feet. Often they complain of cramping pain in their calf, thigh, groin or buttocks. They may report that the pain is precipitated by walking activities and disappears during rest. This pain may be limited to one side, right or left, or be present in both lower extremities. Individuals may report a change in the color of their feet and/or legs. For many, the presence of blisters, slow healing wounds or black discoloration on their feet or lower extremities are what prompts them to seek medical attention. Physical exam: The physical exam may reveal decreased or absent pulses in the feet, ankles and sometimes lower leg. The affected limb or limbs may show decreased muscle size (atrophy), absence of hair, smooth, shiny skin and thickened, brittle toenails. If the circulation is severely reduced, the skin may be cool to touch and the limb may have an altered color such as redness, paleness or cyanosis (blue hue). Swelling (edema), as well as cracked skin, blisters or skin ulcers may be present. Skin ulcers that have associated tissue death (gangrene) may appear black and crusty or may have a crackling sound and feel when touched which is indicative of gas gangrene. Tests: An ankle brachial index (ABI), which measures the ratio of the systolic blood pressure measured at the ankle compared to the systolic blood pressure of the brachial artery (arm) is often used to determine the presence of peripheral circulatory disorders. This may be of limited value in diabetics who tend to have firm, calcified vessels which can distort the blood pressure measurement. Doppler ultrasound imaging uses an ultrasound probe (Doppler) which can record and measure the amplitude of blood flow through arteries. Recordings of diminished flow indicate peripheral vascular compromise. Conventional angiography can directly measure the degree and location of vascular occlusion. MRI of the arteries, called magnetic resonance angiography (MRA) may be used as a noninvasive means to visualize the vascular occlusion. |
Source: Medical Disability Advisor
| The objective for treatment of peripheral vascular disorders in diabetics is to re-establish circulation to the affected limb and limit the progression of the vascular obstruction. Mild peripheral vascular disorders may be treated medically, using a combination of diet, exercise and medications to maintain normal blood sugar levels and to enhance circulation. Medications may include antidiabetic agents, insulin, vasodilators and platelet inhibitors.
More advanced disease often requires invasive treatment. This may include surgical revascularization in which a surgically placed graft is implanted to bypass the affected vessel (i.e. femoral artery or popliteal artery) and restore adequate circulation. Balloon angioplasty is a minimally invasive interventional radiology procedure that is being done to restore circulation in uncomplicated peripheral vascular disorders. In this procedure, a catheter is introduced through a large leg vessel and directed to the site of vascular occlusion. A balloon of the catheter is inflated to open the blood vessel and re-establish blood flow. In some cases, a hollow, slightly rigid device called a stent is placed in the vessel to act as scaffold to hold the vessel open and maintain circulation. |
Source: Medical Disability Advisor
| The prognosis is dependent on the extent of vascular disease, the type of treatment required and the existence of comorbid conditions. Those who are treated with angioplasty have a 1 year patency (vessel opening) rate of 85%. Complications occur in approximately 4% to 6% of those receiving angioplasty. The long term (greater than 5 years) patency rate of those treated with surgical revascularization is slightly better than those who receive angioplasty intervention. However, surgical intervention requires a longer hospital stay and is associated with greater morbidity and mortality. |
Source: Medical Disability Advisor
| Complications associated with balloon angioplasty are infrequent and include thrombosis, vessel dissection, hematoma formation and formation of a false aneurysm. Some of these complications may require surgical intervention.
Complications associated with surgical revascularization include anesthetic risk, respiratory failure, hemorrhage, infection, circulatory shock and rarely death. |
Source: Medical Disability Advisor
| Prolonged sick leave may be required for inpatient therapy, and/or surgical treatment and recovery. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did the physical exam reveal diminished or absent pulses in the lower extremities?
-
Was an ABI done?
-
Was angiography done to confirm diagnosis?
-
Did the physical exam reveal skin abnormalities (redness, pallor, cyanosis) suggestive of advanced peripheral vascular disease?
-
Were ulcers, blisters or necrotic tissue present on the feet or lower extremities?
-
Has the individual had x-rays, CT scan, or MRI?
Regarding treatment:
- Was medical management and lifestyle changes tried?
-
Was balloon angioplasty with or without stent done?
-
Was surgical revascularization required?
-
Was the medical intervention successful in maintaining a normal blood glucose level?
Regarding prognosis:
- If amputation was necessary, is the individual active in a rehabilitation program?
-
Have blood sugars been controlled during hospitalization?
-
Is the individual's employer able to accommodate any necessary restrictions?
-
Does the individual have any comorbid conditions that may affect ability to recover?
-
Has the individual had any complications associated with the condition or treatment?
|
Source: Medical Disability Advisor
| Palumbo, P. J., and L. Joseph Melton. "Peripheral Vascular Disease and Diabetes." Diabetes in America. 2nd ed. Bethesda, MD: National Diabetes Data Group, 1995. 401-408. National Diabetes Information Clearinghouse (NDIC). National Institutes of Health (NIH). 23 Oct. 2004 <http://diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter17.pdf>. |
Source: Medical Disability Advisor