Management of Diabetic Ulcers Due to Arterial Insufficiency

5 January 2022

Diabetes has emerged as one of the most significant health problems. About 10% of people are living with diabetes globally, including in the US. However, what is worrisome is that cases of diabetes continue to rise. Data shows that one-third of the US population is also living with prediabetes.

Diabetes causes numerous complications. It is especially bad for nerve and vascular health. Thus, diabetes causes complications like increased risk of cardiovascular diseases, peripheral vascular disorders, kidney disease, retinopathy, and diabetic ulcers.


Diabetic ulcers most commonly occur on the lower extremities (legs and feet). Poorly managed diabetic ulcers are the leading cause of amputations after trauma. If inadequately treated, ulcers penetrate the full skin thickness, get severely infected, and ultimately require amputation.


Understanding diabetic foot ulcers


Treating diabetic foot ulcers is quite complicated and requires a multidisciplinary team. It appears that there is a unique role of vascular surgeons and interventional radiologists in managing these ulcers and preventing amputations.


Studies show that there are two primary causes of foot ulcers in diabetes; purely neuropathic, purely ischemic (vascular issue), and mixed. It is estimated that just about 35% are purely neuropathic. Conversely, 65% of all ulcers are either purely ischemic/vascular or mixed.


Regretfully, for decades the role of peripheral arterial disease (PAD) was ignored in the diabetic foot. It may explain why the clinical outcomes were so bad. However, in recent years, the approach to the diabetic foot has changed. Most researchers now realize that PAD plays a significant role in the diabetic foot.


One of the most extensive studies to date, called The EURODIALE study, shows it is vital to differentiate diabetic ulcers based on the presence or absence of PAD. It is because those with PAD have a much lower healing rate. Moreover, such ulcers are at a greater risk of getting infected. But even worst, PAD ulcers are much more likely to end with food amputation.


How can doctors know if the diabetic ulcer is due to arterial insufficiency?


Thus, it is vital to differentiate between the neuropathic and PAD ulcers in diabetes. These are two quite different kinds of ulcers requiring different treatment approaches.


There are many ways of understanding arterial insufficiency. Some methods are non-invasive, and others are minimally invasive.


Color Doppler ultrasound (CDUS) is one of the excellent non-invasive says of visualizing the vascular blood flow. It provides a color map of blood flow through various blood vessels. It is one of the best methods in the way that it is safe, non-invasive, and doctors can check multiple arteries in a short time. However, it may be less sensitive in detecting minor arterial lesions, especially in smaller blood vessels.


Doctors may also use Multidetector-row computed tomography angiography (MD-CTA). It is minimally invasive and is a highly sensitive method. It is especially useful for small blood vessels of calves and other small blood vessels in the foot. In addition, it has a high resolution and is thus one of the most effective ways to diagnose the condition.

Contrast-enhanced magnetic resonance angiography (CE-MRA) is another highly useful and minimally invasive method.


Intra-arterial digital subtraction angiography is yet another way of diagnosing PAD. Doctors often do angiography in patients when they think that angioplasty or revascularization is needed. Thus, they may often carry out this procedure (or even other procedures) just before the intervention.


Thus, carrying out minimally invasive diagnostic procedures like angiography before revascularization has certain benefits. So, it is because doctors can use the same cut to introduce catheters for diagnostic reasons and treatment, thus improving the safety of the procedure and minimizing trauma.


Treatment of diabetic ulcer due to arterial insufficiency


Diabetic ulcers due to PAD must be treated with the help of either open surgery or endovascular revascularization. Needless to say, that less invasive methods like angioplasty are often preferred due to less trauma, faster healing, and much higher safety of the procedure.


Some individuals may ask if there is any need for revascularization in diabetic ulcers? Well, the studies show the clear advantage of revascularization. Comparative data from extensive studies show that revascularization may increase the healing rate by more than double. Not only that, revascularization may cut down the risk of amputation to half.


Since there is absolutely no doubt about the benefit of revascularization, the next question could be the choice of method. For most patients, the initial method of treatment could be balloon angioplasty. It is quite a safe procedure and is minimally invasive. Doctors use local anesthetics and introduce a catheter to blood vessels. Then, they use an x-ray monitor to visualize.


They use special instruments and catheters. These catheters have a balloon at their end. Once the catheter reaches the place where there is a plaque (as visible in the x-ray monitor), they inflate the balloon. This would reopen the artery, normalizing the blood flow.


However, quite often, dilation of the artery with a balloon is not enough. Thus, doctors would often put a metallic stent at the place. These stents support the artery wall, prevent their constriction. In addition, many stents are coated with medication to prevent the formation of plaques at that place in the future.


However, angioplasty and stents may not work in all. For example, some people are too prone to plaque formations. In such a case, doctors would need to carry out bypass surgery. As the name of the surgery suggests, it involves bypassing the occluded artery. For this, doctors would take some less needed artery from the patient’s body and use it to create a bridge that bypasses the plaque, thus restoring the blood flow.


To conclude, diabetic foot ulcer is a severe condition requiring a multidisciplinary team to treat the disease. It appears that interventional radiologists (those who carry out angioplasty or put stents in blood vessels) and vascular surgeons have a special place in improving healing rates and preventing foot amputation.


References


  1. National Diabetes Statistics Report, 2020 | CDC. Published September 28, 2020. Accessed December 24, 2021. https://www.cdc.gov/diabetes/data/statistics-report/index.html
  2. Brownrigg JRW, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ. Evidence-based Management of PAD & the Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2013;45(6):673-681. doi:10.1016/j.ejvs.2013.02.014
  3. Armstrong DG, Cohen K, Courric S, Bharara M, Marston W. Diabetic Foot Ulcers and Vascular Insufficiency: Our Population Has Changed, but Our Methods Have Not. J Diabetes Sci Technol. 2011;5(6):1591-1595.
  4. Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51(5):747-755. doi:10.1007/s00125-008-0940-0
  5. Schaper NC, Andros G, Apelqvist J, et al. Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes/Metabolism Research and Reviews. 2012;28(S1):218-224. doi:10.1002/dmrr.2255
30 January 2026
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Varicose Vein Management at Our Vein Clinic While varicose veins may seem cosmetic in nature, they often indicate venous insufficiency. When your vein valves don't function as intended, blood pools instead of returning efficiently back to your heart resulting in bulging veins with bulges, twists and other symptoms including acheiness, heaviness or skin changes resulting in bulging veins as a telltale sign. Our vein clinic can offer varicose vein management services so we can treat these veins effectively! An expert varicose vein specialist can assess and recommend treatment, which typically entails minimally-invasive approaches like endovenous laser therapy, radiofrequency ablation, Sclerotherapy injections and Ambulatory Phlebectomy as well as VenaSeal closure systems. These procedures typically occur in an outpatient setting, allowing you to quickly get treated and return home quickly with minimal downtime. 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No matter the condition affecting your veins, our team provides full spectrum care - be it deep vein thrombosis treatment, assistance with blood clots, evaluation for leg pain or any other aspect. Our wound care clinic specializes in complex wounds that won't heal; when necessary we offer intravenous infusion therapy; while our vein clinic offers modern varicose veins treatment without long recovery times. Board certification, years of experience, comprehensive services and an accessible location - these factors do not just play into outcomes and experiences as patients; they directly affect them! Schedule Your Vascular Specialist Consultation Are you feeling vascular symptoms or concerned about circulation? Call Advanced Veins and Vascular to schedule an evaluation Today - our team will determine the source of the issue while creating a treatment plan suited specifically for you! 
30 January 2026
Imagine this: you are walking through a parking lot when cramps hit your calf muscles. You stop, wait a moment, and it goes away, only for it to return three aisles later at your grocery store - in its familiar spot, intensity, and pattern! Leg pain may seem random at times, but in fact it could be your circulation sending a warning signal that should not be ignored. I have treated hundreds of patients who had this pattern of leg pain in Coldwater and Hillsdale County and know from experience that early action makes all the difference in outcomes. Vascular Claudication and Leg Pain Treatment Vascular claudication refers to leg cramping or pain triggered by activity and relieved with rest. It derives its name from Latin, where limp means discomfort - this makes sense when considering that many patients adjust their walking pace in response to it. What happens in your legs is this: due to plaque buildup, your arteries have narrowed, restricting blood flow. As long as you remain still or sitting still, your muscles can adapt with reduced oxygen delivery; but once walking begins and muscles contract more vigorously, their oxygen requirements increase rapidly - leading to cramped leg muscles and cramping symptoms. Patients tell me they can predict almost exactly when the pain will begin - possibly within one block, or perhaps after fifty feet. Predictability serves as a powerful diagnostic indicator. Why You Need to Seek Medical Help Most cases of vascular claudication result from Peripheral Artery Disease, or PAD. Atherosclerosis in your leg arteries - similar to heart attacks - causes plaque accumulation, which narrows them, cutting off blood flow to active legs muscles that need oxygen for activity. Without treatment from a PAD specialist, symptoms could worsen leading to leg cramps that prevent activities. Between 8-12 million Americans currently suffer from PAD. Many may not realize it because their symptoms can easily be dismissed as age or arthritis-related; but this condition is serious: when plaque builds up in leg arteries, chances are it is also building elsewhere - increasing your risk for heart attack and stroke significantly. At Advanced Veins and Vascular, we understand the importance of early evaluation and treatment for PAD can prevent progression while safeguarding overall cardiovascular health. At our center, we conduct comprehensive assessments in order to gain an accurate picture of what's happening with your circulation. For this reason, seeing a PAD specialist should never be considered optional. In fact, early evaluation is often successful at stopping further progression as early intervention reduces severity and progression rates over time. At our practice we start off with thorough assessments in order to diagnose what exactly is occurring within your circulation - or otherwise known as 'PAD specialist ' Warning Signs That Need a Vascular Specialist Cramping pain when walking is often your body's first warning sign, but other symptoms may also appear: Unusual tiredness or weakness in your legs even between episodes of coldness or numbness in lower legs or feet Color changes when elevating legs Shiny appearance to skin on legs Nails growing slower than usual Sores or cuts that take weeks to heal. Sluggish or absent pulses in your feet This red flag calls for immediate attention: pain during rest or night time restlessness is indicative of circulatory issues; if it hurts to try sleeping and causes leg cramping that makes sleeping impossible then immediate medical evaluation from a vascular specialist is warranted. Risk Factors for Leg Pain Treatment Patients Certain risk factors dramatically increase your chances of vascular claudication and PAD. Smoking tops the list; if you currently smoke or used to smoke, your risk increases exponentially; in my practice, I have observed the correlation between severe PAD and smoking as one of its effects, with quitting being one of the single most powerful interventions available to help your condition. Diabetes accelerates arterial disease. High blood sugar damages blood vessels over time, increasing your chances of PAD and often making symptoms more severe. If you're diagnosed with diabetes and experiencing leg pain when walking, do not hesitate to seek medical assistance immediately. Other major risk factors for PAD include high blood pressure and cholesterol levels as well as age over 50, family history of cardiovascular disease, as obesity (which contributes to PAD as well), and inactive lifestyle. Are you experiencing leg pain due to multiple risk factors and need a professional assessment? At Advanced Veins and Vascular in Hillsdale County and Coldwater, our team offers expert leg pain treatment solutions. Not Every Case of Leg Pain Should Point to Vascular Claudication Not every instance of leg pain points towards vascular claudication. Spinal stenosis may also produce similar neurogenic claudication symptoms; the difference being that spine issues often improve when you lean forward or sit, while vascular issues typically improve with rest regardless of posture or position. Deep Vein Thrombosis can present itself in various ways; sudden pain, significant swelling, warmth and redness could all be symptoms of DVT. When these symptoms emerge following surgery, long flights or pregnancy, medical attention must be sought immediately - not scheduled appointments later on. Venous insufficiency causes heavy, achy legs that worsen throughout the day and swelling that increases throughout the day. Since this issue involves veins rather than arteries, treatment options must differ accordingly. Finding a qualified leg specialist in Coldwater & Hillsdale County is key for diagnosing what's causing your symptoms accurately, leading to effective treatment plans and lasting solutions. How We Diagnose Vascular Claudication Treatment Needs At Advanced Veins and Vascular, when it comes to leg pain evaluation, we start with an in-depth discussion about your symptoms and medical history before moving on to objective testing. Ankle-brachial index tests are typically the starting point. We measure blood pressure in your ankle and compare it to that of your arm - all within 15 minutes, without discomfort - providing immediate information if circulation to your legs has become impaired. Ultrasound imaging allows us to see exactly what's happening inside your arteries at any moment in real time, providing us with real-time images that allow us to detect narrowing, measure blood flow velocities and pinpoint exactly where blockages exist. Sometimes we will have you walk on a treadmill while monitoring symptoms; recreating the problem in such a controlled setting helps confirm its diagnosis. For more precise imaging, we can use CT or traditional angiography. These three-dimensional maps of your arteries help us better plan an effective treatment approach. Effective Vascular Claudication Treatment Options Treatment for vascular claudication should focus on three goals. They are to relieve your symptoms so you can walk without pain; improve quality of life and independence; and stop PAD from progressing further to more serious complications. Lifestyle Changes That Actually Work Supervised walking programs are supported by robust research. Their approach may seem counterintuitive but is actually effective: Walk until pain sets in, rest until it has subsided, then walk again. Repeat several times each week until your body develops collateral vessels to bypass blockages more naturally. Ceasing smoking should not be negotiable. Your arteries will respond, and symptoms should improve even without further interventions. Diet changes designed to manage cholesterol are designed to promote better plaque prevention. By increasing vegetables, whole grains, and lean proteins while decreasing consumption of saturated fat and processed foods, your goal should be to prevent additional plaque buildup. Most patients diagnosed with PAD require medical management. Antiplatelet drugs like aspirin or clopidogrel help prevent blood clots from forming; statins reduce cholesterol while helping stabilize arterial plaque; while blood pressure medications keep this under control. Cilostazol may help some patients walk farther before experiencing pain, though there are restrictions (can't take it with heart failure), however when effective patients notice real improvement. Minimally Invasive Procedures When conservative measures don't do the trick, we offer minimally invasive solutions. An angioplasty uses a balloon to stretch open narrowed arteries. We may then place a stent (small mesh tube) to keep them propped open. Finally, atherectomy tools can remove plaque directly from within an artery wall. These procedures involve making a tiny puncture through which local anesthesia is administered to you while awake. Most patients can go home that same day, with recovery measured in days rather than weeks - one of the greatest advances in treating PAD over the last 20 years. Surgery May Be Necessary Bypass surgery remains an option for extensive blockages. We create a detour around it using healthy veins from elsewhere or synthetic grafts; although more involved than endovascular procedures, you'll spend at least one night in hospital while recovery takes longer. But sometimes surgery remains the best option for lasting results. Leg Pain Treatment Untreated claudication does not remain stable over time; rather, it worsens. At its worst stage, critical limb ischemia occurs when blood flow drops dangerously low even at rest; when this happens, you're faced with constant discomfort, non-healing wounds, and real risk of amputation. Leg ulcers caused by poor circulation require special care to heal properly and avoid infection, and Advanced Veins and Vascular offers wound care services as part of our practice. PAD also puts you at higher cardiovascular risk overall; people living with PAD tend to have increased rates of heart attack and stroke, making treatment for PAD about protecting all aspects of vascular system health rather than solely targeting legs. When to Visit a Vascular Specialist in Michigan Schedule an evaluation if any of the following symptoms exist in you: Predictable leg pain or cramping that begins with walking Nighttime leg pain that interferes with sleep Persistent swelling in legs Wounds or sores that won't heal normally Temperature changes in legs Numbness or weakness impeding your mobility Sudden leg pain combined with coldness or numbness should always be considered an emergency - it could indicate complete arterial blockage or an acute blood clot, prompting immediate action to seek medical advice at once. Seek emergency help immediately! Assuring the Best Leg Pain Treatment Vascular claudication can be managed effectively with proper treatment. Most of my patients see significant progress after starting with treatment - they walk farther, experience less discomfort and return to activities they had given up due to leg pain. But success requires staying engaged with treatment plans in order to experience lasting improvement. Regular follow-up appointments allow us to monitor your progress and adjust your treatment plan as necessary. Medication reviews must take place periodically, while exercise programs might need adjustments at times. In addition, symptoms can change rapidly; we need to stay ahead of any potential progression. Schedule Your Evaluation With Advanced Veins and Vascular Is leg pain limiting your activities? Advanced Veins and Vascular can assist. Our specialists specialize in diagnosing and treating peripheral arterial disease (PAD). We serve Hillsdale County and Coldwater residents in Michigan using cutting-edge diagnostic tools and minimally invasive treatment techniques. Our team has the expertise to quickly diagnose the source of your symptoms and devise an individualized treatment plan to address them. From medication management, minimally invasive procedures, or surgical interventions, all are provided under one roof at our center of excellence. Reach out to Advanced Veins and Vascular to schedule your consultation, where we will discover the cause of your leg pain and offer solutions that won't hinder living the life you want. Don't let circulation problems stop you from living the life you deserve!
by Designer Support 4 October 2024
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by Ela Support 30 July 2024
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