Research Article
The Effect of Charcot Neuroarthropathy on Limb
Preservation in Diabetic Patients with Foot Wound and
Critical Limb Ischemia after Balloon Angioplasty
Mehmet Burak Çilda
ğ and Ömer Faruk Kutsi Köseoğlu
Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, 09100 Ayd
ın, Turkey
Correspondence should be addressed to Mehmet Burak Çilda
ğ; mbcildag@yahoo.com
Received 12 May 2017; Revised 17 July 2017; Accepted 1 August 2017; Published 29 August 2017
Academic Editor: Andrea Flex
Copyright © 2017 Mehmet Burak Çilda
ğ and Ömer Faruk Kutsi Köseoğlu. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Objective. The aim of this article is to investigate one-year limb preservation rates after below-the-knee angioplasty in patients with
diabetic foot wound who only have critical limb ischemia (CLI) and those who have Charchot neuroarthropathy (CN)
accompanied by CLI. Methods. This single-center, retrospective study consists of 63 patients with diabetic foot wound who had
undergone lower extremity balloon angioplasty of at least 1 below-the-knee (BTK) vessel. Only those patients with
postprocedural technical success of 100% were selected from the database. All patients were classi
fied into two groups as
patients with CLI and CN and patients with CLI only without CN. The Kaplan-Meier method was used to compare the limb
preservation rates for the two groups. Results. There was no statistically signi
ficant difference between patient age, gender,
diabetic disease duration, and comorbid disease such as chronic renal insu
fficiency, hypertension, and coronary artery disease of
the two groups (
p > 0 05). Limb preservation in the 12 months was 59.1% in the CN group and 92.7% in the group without CN.
Also, limb preservation rates between the two groups displayed statistically signi
ficant differences (p < 0 005). Conclusion. This
study showed that CLI can accompany CN in patients with diabetes. Limb preservation rates with endovascular treatment in
diabetic patients with CLI only are better than in diabetic patients with CLI and CN.
1. Introduction
Peripheral artery disease (PAD) can be de
fined as a group of
disorders characterized by narrowing and obstruction of the
arteries that reduce blood
flow. Critical limb ischemia (CLI)
is a clinical condition characterized by PAD-related ischemic
tissue loss including incurable ulcers or gangrene and ische-
mic pain at rest. Within 1 year of CLI diagnosis, 30% of cases
undergo major amputation and 25
–30% die [1]. Patients who
develop CLI require early revascularization due to poor
prognosis. CLI is common in diabetic patients and below-
the-knee (BTK) arteries are usually a
ffected [2]. In recent
years, endovascular therapy has replaced surgical bypass
treatment as a revascularization method especially in BTK
arteries. Endovascular revascularization is now the
first
choice in CLI cases of BTK level [3, 4]. Also, Charcot neu-
roarthropathy (CN) is the other causative condition of limb
loss in patients with diabetes. CN is a progressive disease
involving the foot and ankle bones, joints, and soft tissues.
It occurs in 0.1
–7.5% of all patients with diabetes and 29%
of diabetes patients with peripheral neuropathy [5, 6]. Major
amputation rate increases especially in CN accompanied by
ulcers or osteomyelitis [7]. Apart from a few studies, the liter-
ature has insu
fficient studies reporting PAD or CLI incidence
in CN [8]. Due to the natural course of diabetes mellitus,
PAD and CLI can be expected in CN cases. According to
our clinical observations, the coexistence of CN and CLI is
not so rare. We sometimes even have di
fficulty in differenti-
ating whether it is due to ischemic or neuropathic origin
when a diabetic patient with CN develops a foot wound
and consider the case as neuroischemic. In addition, in cases
with foot wound and CN accompanied by CLI, delayed
wound healing after minor amputation and secondary infec-
tion may occur which ultimately may require major
Hindawi
Journal of Diabetes Research
Volume 2017, Article ID 5670984, 4 pages
https://doi.org/10.1155/2017/5670984
amputation. Although there are studies in the literature
showing the e
ffectiveness of endovascular treatment in cases
with diabetic foot wound and CLI, there are no studies
showing the e
ffectiveness of endovascular treatment in cases
with CN accompanied by CLI.
In this study, we investigated one-year limb preservation
rates after angioplasty in patients with diabetic foot wound
who only have CLI, and those who have CN accompanied
by CLI.
2. Material and Method
2.1. Study Population and Design. This is a retrospective,
single-center study based on the collected data of patients
with diabetic wound who had undergone lower extremity
percutaneous balloon angioplasty (PBA) of at least 1 BTK
vessel. After institutional review board approval, imaging
data between October 2014 and March 2016 were reviewed.
Inclusion criteria were the presence of diabetic foot
wound and CLI, patients who had plain radiography of a
damaged foot and patients who had undergone balloon
angioplasty for stenosis or occlusion of at least 1 BTK vessel
with distal runo
ff to the foot with technical success.
Exclusion criteria were planned major amputation before
angiography and unsuccessful PTA, patients whose data con-
stituted any intervention before angioplasty, who did not
have plain radiography of the foot, who had suspicion of
acute CN, and who had concomitant above-knee arterial
steno-occlusive lesions including the aortoiliac and femoro-
popliteal arterial lesions.
CN diagnosis was made based on clinical observations
such as foot deformities and direct graphy
findings such as
subluxation or dislocation and erosion or destruction of foot
and ankle joints. Screening was done by magnetic resonance
angiography before angioplasty in all patients to determine
the a
ffected BTK arteries. Interventions had been performed
by antegrade approach and with the use of 5F sheaths. The
ratio of balloon to vessel diameter had been planned to be
1 : 1. The balloons available during the study period had a
diameter of 2.5 to 3.0 mm and a length of 60 to 120 mm. In
case of
flow-limiting dissection or residual stenosis of
>30%, a prolonged dilation had been performed. Postinter-
vention dual antiplatelet therapy with 100 mg aspirin and
75 mg clopidogrel once daily had been given for at least one
month, and 100 mg aspirin had been given daily thereafter.
Technical success was de
fined as restoration of direct flow
in the target vessel with runo
ff to the foot and a residual ste-
nosis of
<30%. Once discharged, patients were followed-up
in a multidisciplinary, dedicated foot clinic to facilitate the
healing process and recovery of ambulatory function.
We chose 1 year prevention of amputation as the end
point of this study, and amputation was de
fined as limb loss
below or above the knee. All angiographic images and plain
radiographies transferred from the radiology database were
evaluated in the workstation by a radiologist with 14 years
of experience. All patients were classi
fied into two groups as
diabetic patients with CLI and CN and diabetic patients with
CLI only without CN.
2.2. Statistical Analysis. Statistical analyses were performed
using Statistical Package for the Social Sciences (SPSS) 17.0
statistical software for Windows (SPSS Inc., Chicago, IL,
USA). Comparisons between patients with and without
Charcot neuroarthropathy were performed using the t-test
for continuous variables and the
χ2 test for discrete variables.
Kaplan-Meier life table analysis was used to calculate limb
preservation of the two groups. The log-rank test was used
to compare the limb preservation rates of the groups with
CN and without CN and to determine statistically signi
ficant
levels.
p values < 0.05 were considered statistically significant.
3. Results
63 patients met inclusion and exclusion criteria during the
study period. Thus, the study consists of 63 patients with
diabetic foot. Of these patients, 44 (69.8%) were men and
19 (30.2%) were women with a mean age of 67.2 years
(ranging 51
–84). The mean disease (diabetes mellitus) dura-
tion of all patients was 22.2 years (ranging 8
–32). The most
common comorbid disease was chronic renal insu
fficiency
(34.9%). Baseline clinical characteristics were similar between
the study groups. Treated lesions had a high degree of
complexity in both study arms; 84.1% of the lesions were total
occlusions. None of the patients in either study arms under-
went in
flow lesion treatment. In 12 months, the overall limb
preservation rate was 81% (51/63), and the mean survival time
of limb preservation after PBA was 11.07 months (std
± 0.26).
3.1. Diabetic Patients with CLI and CN Group. 22 (34.9%)
patients with diabetic foot with CN underwent conventional
angiography. CN was in the right foot in 11/22; left foot, 10/22;
and bilateral, 1/22. In 12 months, limb preservation was 59.1%
(13/22). The mean survival time of limb salvage after PBA was
9.95 months (std
± 0.57).
3.2. Diabetic Patients with CLI and without CN Group. 41
(65.1%) patients with diabetic foot without CN underwent
conventional angiography. In 12 months, limb preservation
was 92.7% (38/41). The mean survival time of limb salvage
after PBA was 11.68 months (std
± 0.20).
There was no statistically signi
ficant difference between
patient age, gender, diabetic disease duration, and comorbid
disease such as chronic renal insu
fficiency, hypertension,
and coronary artery disease of the two groups (
p > 0 05).
Demographic characteristics of the patients are shown in
Table 1. Limb preservation rates between CN and without
CN group displayed statistically signi
ficant differences in
the 12 months (Figure 1). Also, there was a statistically signif-
icant di
fference between the two groups in mean limb salvage
time (
p < 0 005).
4. Discussion
CN is a condition associated with peripheral neuropathy
common in diabetic patients, characterized by joint and bone
fractures, dislocation, and foot deformities [9]. It can be diag-
nosed clinically and radiologically, and its treatment is
primarily conservative. The aim of the treatment is to create
a plantigrade foot which provides bone stability [10, 11]. A
2
Journal of Diabetes Research
stable plantigrade foot may reduce the development of foot
ulcers. Developing ulcers in CN increase the risk of major
amputation, and patients with diabetes and Charcot defor-
mity associated with PAD also have a major risk of ulceration
and infection [7]. CLI can be de
fined as a serious form of PAD
that describes patients with chronic ischemic rest pain or with
ischemic skin lesions, either ulcers or gangrene. Although
amputation rates are not clearly known in patients with CN,
patients with CN and accompanying foot ulcers have been
shown to be 12 times more likely to have amputation risk than
patients with CN alone [12]. Treatment of CLI in patients
with CN is important in patients with impaired ulcer healing
because patients with CN have a greater risk of infectious
complications after surgery. Although relative ischaemia is a
common contributing factor in complications of the foot in
diabetes, there was not su
fficient information between CN
and CLI. Arterial pathology is most commonly shown to
involve BTK arteries in patients with diabetes [13
–16]. Revas-
cularization in BTK arteries can be performed by surgical or
endovascular methods. In recent years, endovascular revascu-
larization, which is more comfortable, has been performed as
the
first choice treatment in elderly diabetic patients with
lower morbidity and mortality rates, who do not require gen-
eral anesthesia, especially with a high likelihood of having
comorbid diseases [3, 4]. Lida et al. [17] identi
fied diabetes
as one of the factors associated with major amputation after
endovascular therapy for patients with CLI due to isolated
below-the-knee lesions, and they found limb preservation
rate at 2 years to be 68% in patients with diabetes. Another
study by Ferraresi et al. [18] found a limb preservation rate
of 93% at a mean follow-up of 1048 days after infrapopliteal
angioplasty in diabetic patients with CLI. Ryu et al. [19] com-
pared clinical outcome after infrapopliteal angioplasty in CLI
patients with and without diabetes and reported that the pri-
mary patency rate is lower in patients with diabetes although
there was no signi
ficant difference in the limb preservation
rate. Recently, Tartaglia et al. [20] found a one-year limb
preservation rate of 84% after infrapopliteal angioplasty in
patients at high risk of diabetes. All these studies showed
the e
ffectiveness of angioplasty on limb preservation in
patients with diabetes and CLI, but there was no published
study about limb preservation after angioplasty in patients
with CN accompanied by CLI. In our study, the one-year
limb preservation rate in all patients with ischemic diabetic
foot wound who underwent endovascular treatment of
BTK arteries was found to be 81%. This rate was found to
be 92.7% in patients without CN and 59.1% in cases with
CN. Limb preservation rates in cases without CN are similar
to those in the studies in the literature. However, the lower
rates in cases with CN are considered to be due to the
accompanying ischemic neuropathy in these cases.
Survival functions
1.0
0.8
0.6
0.4
0.2
0.0
Cum sur
vival
0
2
4
6
8
10
12
Limb preservation time (month)
CN
‒
CN+
Figure 1: Kaplan-Meier graph comparing the limb preservation
rates after endovascular treatment in diabetic patients with only
CLI and in diabetic patients CLI with CN.
Table 1: Demographic characteristics and occlusive artery numbers of diabetic patients with Charcot neuroarthropathy and without Charcot
neuroarthropathy.
Overall patients
n: 63
Patients with CLI and CN
n: 22
Patients with CLI and without CN
n: 41
Gender (% male)
44 (69.8%)
14 (66%)
25 (61%)
p: 0.67
Age (years)
67.21 (std
± 8.30)
66.59 (std
± 8.87)
67.54 (std
± 8.07)
p: 0.59
DM disease duration (years)
22.2 (std
± 12.6)
23.4 (std
± 11.6)
21.2 (std
± 13.1)
p: 0.66
Comorbid (
n: 54)
Chronic renal insu
fficiency
24 (38%)
8 (36.3%)
16 (39%)
p: 0.73
Coronary artery disease
10 (15.9%)
4 (18.1%)
6 (14.6%)
Hypertension
10 (15.9%)
3 (13.6%)
7 (17.1%)
Patients with occlusion and stenosis
53
19 (86.3%)
34 (82.9%)
p: 0.65
Patients with stenosis only
10
3 (13.6%)
7 (17.1%)
p: 0.89
n: number; CN: Charcot neuroarthropathy; std: standard deviation; DM: diabetes mellitus.
3
Journal of Diabetes Research
Several limitations of the present study need to be
considered. Firstly, this was a retrospective study from a
single institution with a small number of patients. Secondly,
we did not perform follow-up angiography or use other
imaging modalities for patency of the treated vascular bed.
Thirdly, it is unclear whether the cause of amputation in
major amputation cases was ischemia or neuropathy.
In conclusion, this study showed that diabetic CN
patients may be accompanied by CLI and neuropathies may
accompany ischemia in nonhealing foot ulcers. Although
endovascular treatment has been shown to have higher limb
preservation rates in patients who only have CLI without CN,
major amputation rate is considered to be reduced with
evaluation of BTK arteries and additional endovascular
therapy in diabetic patients with CN. Even if surgery is
planned for CN, according to us, PBA treatment before
surgery is useful for limb preservation in diabetic patients
with CN accompanied by CLI. However, there is a need for
studies with a larger number of patients with CN.
Conflicts of Interest
The authors have no con
flict of interest.
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