Wet Gangrene Of The Toes

A 54-year-old male patient with type 2 diabetes diagnosed at the age of 49 years was admitted to the Vascular Surgery Department because of wet gangrene involving the toes of his left foot. He had been treated with sulfonylurea over the previous 8 years which had led to acceptable diabetes control (HBA1c: 7.5%). The patient was an ex-smoker. During the last 10 years he had also suffered from hypertension which had been treated with an angiotensin converting enzyme inhibitor and a diuretic. He had typical intermittent claudication with pain in both calves while walking distances of 150 m.

On examination, wet gangrene was noted on the fourth and fifth toes of his left foot. An infected area of ischemic necrosis was also present on the dorsal aspect of his left third toe (Figure 7.21). The peripheral pulses were absent and the ankle brachial pressure index was 0.4 bilaterally; he also had findings of mild peripheral neuropathy. The patient was in quite severe pain, and he was treated with systemic analgesics and i.v. antibiotics (ticar-cillin-clavulanic acid and clindamycin). An angiogram revealed multifocal athero-matous lesions of both iliac and superficial femoral arteries (Figure 7.22), as

Superficial Femoral Artery And Angiogram
Figure 7.16 Digital subtraction angiography showing multiple sites of stenosis in both iliac and superficial femoral arteries (upper panel). Stent inserted in left superficial femoral artery (lower panel). (Courtesy of C. Liapis)

well as increased development of collateral vessels. A proximal stenosis was noted on both tibial and peroneal arteries. A femoral-popliteal bypass graft and, eventually, a ray amputation of the last two toes were carried out and the wound was left open for drainage.

Atherosclerotic lesions in diabetic patients occur at sites similar to those in non-diabetics (such as sites of arterial bifurcation), while more advanced disease is common in diabetic patients affecting even collateral vessels. The pathology of the affected arteries is similar in both diabetics and non-diabetics. Typical atherosclerotic lesions of diabetic patients with peripheral vascular disease include diffuse multifo-cal stenosis. In addition, diabetic peripheral vascular disease has a predilection for the tibioperoneal arteries. All tibial arteries may be occluded with distal reconstitution of a dorsal pedal or common plantar artery. Atherosclerosis begins at a younger age and progresses more rapidly in diabetics than in non-diabetics. While non-diabetic men are affected by peripheral vascular disease much more commonly than non-diabetic women (men-to-women ratio 30:1), the incidence among diabetic men is twice that observed among diabetic women.

Keywords: Peripheral vascular disease; wet gangrene; digital subtraction angiog-raphy

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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