This position paper is based on the current German and international guideline
recommendations [1]
[2]
[3] and serves as a short, clinically-oriented guideline for
the diagnosis and treatment of patients with diabetes mellitus and peripheral
arterial disease (PAD).
Peripheral circulatory disorders of the pelvic and leg arteries are one of the
complications patients with diabetic mellitus suffer from. The term covers stenoses,
occlusions and - to a lesser extent - aneurysmal vascular changes of the pelvic leg
arteries.
Arterial vascular lesions mostly occur in later life, however, people with diabetes
mellitus are often affected prematurely. In these patients, the time of the initial
manifestation also depends on the duration of the disease and the quality of
metabolic control. Only 25% of affected patients have symptoms.
Especially in patients with diabetes mellitus, atheroma of the peripheral vessels is
aggravated by chronic inflammatory vessel wall processes and hypercoagulability.
Second to nicotine abuse, diabetes is the most important risk factor for the
occurrence of PAD [4].
Patients with diabetes have a 2 to 4-time higher risk of developing PAD than patients
without diabetes.
Up to 30% of all patients with claudication and 50% of all patients
with critical limb ischemia (CLI) are people with diabetes mellitus [5].
PAD patients with diabetes have specific anatomical-morphological and clinical
characteristics which must be considered in the diagnostic and therapeutic approach.
Compared to people without diabetes mellitus, PAD in people with diabetes mellitus
develops earlier, progresses more rapidly and more frequently changes over to
critical limb ischemia (CLI). Anatomically-morphologically, a multi-segmental
manifestation with long, calcified stenoses/occlusions of the lower leg
arteries with insufficient collateral formation is typical. Clinically, people with
diabetes mellitus often first consult their doctors because of a critical ischemia,
in part because the intermittent claudication preceding a critical ischemia and the
pain at rest can remain masked for a long time by the diabetic sensory
polyneuropathy. The prognosis regarding a life without amputations is poor for
people with diabetes mellitus. This is due, on the one hand, to the high ischemia
and ulcer recurrence rates and the associated minor and major amputations, on the
other hand it results from the high rate of comorbidities and co-prevalence of
terminal organ damage such as cardiac and renal insufficiency, each of which on its
own increases mortality.
The most significant consequences of diabetic peripheral circulatory disorders are
foot lesions (ulcers and gangrene) and minor and major amputations as a result of
ischemic or neuro-ischemic diabetic foot syndrome (DFS) ([Table
1]).
WHAT DOES IT MEAN?
-
The number of patients with PAD and diabetes is constantly
increasing.
-
The risk of amputation in people with diabetes mellitus is significantly
increased in the presence of PAD.
-
Timely detection of PAD reduces the amputation and cardiovascular event
rates if treatment is in accordance with guidelines.
-
Interdisciplinary cooperation and rapid revascularization are crucial in
critical limb ischemia.
Table 1 Classification of PAD according to Fontaine and
Rutherford.
Fontaine
|
Rutherford
|
Stage
|
Clinical picture
|
Degree
|
Category
|
Clinical picture
|
I
|
Asymptomatic
|
0
|
0
|
Asymptomatic
|
IIa
|
Walking distance>200 m
|
I
|
1
|
Mild IC
|
IIb
|
Walking distance<200 m
|
I
|
2
|
Moderate IC
|
I
|
3
|
Severe IC
|
III
|
Ischaemic pain at rest
|
II
|
4
|
Ischaemic pain at rest
|
IV
|
Ulcer, gangrene
|
III
|
5
|
Small patches necrosis
|
III
|
6
|
Large patches necrosis
|
IC=Intermittent claudication.
Diagnostics of PAD in People with Diabetes Mellitus
Diagnostics of PAD in People with Diabetes Mellitus
Non-invasive hemodynamic vascular function diagnostics in people with diabetes
mellitus allows conclusions to be drawn about the severity of the circulatory
disorder and provides prognostic information on the spontaneous course,
cardiovascular risk and/or wound healing.
Targeted diagnostics facilitate choosing the appropriate therapy and enable
monitoring of the course of the disease during and after vascular treatment.
VASCULAR DIAGNOSTICS FOR PEOPLE WITH DIABETES MELLITUS
VASCULAR DIAGNOSTICS FOR PEOPLE WITH DIABETES MELLITUS
-
Clinical examination including recording of pulse status and capillary
pulse as well as a qualitative comparison of skin colour and
temperature
-
Ultrasound ankle or toe pressure measurement (ABI; TBI)
-
Colour-coded duplex sonography with pulse curve analysis
-
Pulse oscillography of the digital arteries (DPO or LRR)
-
Transcutaneous oxygen measurement (tcPO2)
In people with diabetes mellitus, these non-invasive diagnostic procedures should
be used liberally if there is a suspicion of PAD, or if a foot lesion is present
or is not healing.
In the clinical examination, it is important to examine the reactive skin
circulation of the feet (capillary pulse) as well as perform palpation of the
foot pulses. Although pulse examination of the lower extremities is helpful, the
frequency of PAD is overestimated in the absence of pulses. Conversely, palpable
foot pulses do not rule out the presence of PAD.
The capillary pulse as a reactive filling of the skin after pressure indicates
the presence of a critical circulatory problem.
People with diabetes mellitus with PAD should have a regular clinical foot
examination
Ankle-brachial index (ABI) is determined using non-invasive doppler ultrasound to
measure blood pressure at rest and/or after exertion and is a suitable
test for detecting PAD.
Decreased peripheral pressure values are evidence of the presence of PAD and
indicate the cardiovascular risk in the patient. The ABI value with the lowest
ankle artery pressure is decisive for the diagnosis of PAD. An ABI value at rest
below 0.9 is deemed confirmation of the presence of PAD.
In the presence of media sclerosis (ABI>1.3), the pulse curve analysis,
pulse oscillography of the digital arteries and toe pressure measurement with
determination of the TBI (toe-brachial index) are of particular importance and
are used for the confirming PAD [1]
[2].
ABI measurement important for confirming PAD and risk stratification
A vascular physician must be consulted if an ABI<0.7, systolic toe
pressures<40 mmHg, systolic ankle
pressures<70 mmHg or a tcPO2 value<30 mmHg is
determined in patients with diabetes [3]. In such
cases, the risk of developing a foot ulcer is increased ([Table 2]).
Table 2 Severity and prognosis of PAD based on Doppler values
[1]
[2]
[3].
|
ABI
|
Ankle pressure (mmHg)
|
Toe pressure (mmHg)
|
PAD
|
<0.9
|
|
|
Media sclerosis
|
>1.3
|
|
|
CLI
|
|
<50
|
<30
|
Lack of wound healing
|
<0.7
|
<70
|
<40
|
Regional foot ischemia may also be present with palpable foot pulses or almost
normal toe pressure values (example: heel lesion in people with diabetes
mellitus who require dialysis).
Non-invasive hemodynamic functional examinations of the leg vessels are required
to assess severity, course and therapy stratification in patients with PAD.
Imaging procedures (ultrasound sonography, MR angiography, CT angiography, i.a.
DSA) should be performed on symptomatic or at-risk patients only with
therapeutic consequences.
Due to the co-morbidity of people with diabetes mellitus (kidneys, eyes, heart),
interdisciplinary diagnostics and therapy planning are indicated.
-
Colour-coded duplex sonography
-
MR angiography of the pelvic leg arteries
-
CT angiography of the pelvic leg arteries
-
Intra-arterial angiography with CA or CO2
IMAGING DIAGNOSTICS
-
Colour-coded duplex sonography
-
MR angiography of the pelvic leg arteries
-
CT angiography of the pelvic leg arteries
-
Intra-arterial angiography with CA or CO2
Colour-coded duplex sonography is of particular importance as a non-invasive
method. It combines hemodynamic results with morphological findings and thus
allows statements to be made on the localization and morphology of vascular
lesions.
If there are unclarities, cross-sectional imaging using CE-MR angiography or CT
angiography is recommended, however, it is important to take consideration of
contraindications and side effects.
An intra-arterial angiography (non-selective angiography or selective
high-resolution angiography) must be used to aid in determining whether a
vascular segment can be grafted; the angiography can also be planned in
intervention readiness, if necessary.
The often-limited kidney function in people with diabetes mellitus plays a
special role in the administration of contrast agents, whereby contrast
agent-induced nephropathy with the low or iso-osmolar contrast agents commonly
used today is significantly rarer. Hydration, co-morbidity and medication of the
patients must be taken into account.
CO2 angiography can be specifically used in intervention procedures
and offers a possibility for reducing contrast-induced renal dysfunction. In
lower leg imaging, it is supplemented by the targeted administration of a few
millilitres of a contrast agent containing iodine.
The indication for further radiological diagnostics should be made on an
interdisciplinary level.
Therapy of PAD in People with Diabetes Mellitus
Therapy of PAD in People with Diabetes Mellitus
Basic principles of therapy
The therapy of PAD in people with diabetes mellitus has 2 basic goals: the
improvement of peripheral blood flow in symptomatic patients as well as the
therapy of vascular risk factors and concomitant diseases with special
consideration of coronary and cerebrovascular vascular diseases ([Tables 3]
[4]).
Table 3 Treatment goals.
Goal
|
Stage
|
Therapy
|
Inhibition of PAD progression
|
Fontaine stage I–II Rutherford 1–3
|
-
Therapy of risk factors
-
Walking training
|
Risk reduction of cardiovascular events
|
Fontaine stage I–IV Rutherford 0–6
|
-
Therapy of risk factors
-
Walking training
|
Improvement of walking performance and quality of life as
well as pain reduction
|
Fontaine II Rutherford 2–4
|
|
Risk reduction of peripheral vascular events
|
Fontaine II–IV Rutherford 3–6
|
|
Salvaging the leg
|
Fontaine III–IV Rutherford 4–6
|
|
Table 4 Stage-adapted therapy methods. Source: [1].
|
Fontaine stage
|
Measure
|
III
|
III
|
IV
|
Risk factor management: giving up nicotine, diabetes
therapy, statins, blood pressure treatment
|
+ +
|
+
|
+
|
Platelet aggregation inhibitors: ASA or
clopidogrel
|
+
|
+
|
+
|
Physical therapy: structured vascular
sports/sport for people with diabetes mellitus
|
+ +
|
|
|
Drug therapy: cilostazol or naftidrofuryl
|
+
|
|
|
Structured wound treatment
|
|
|
+
|
Intervention therapy
|
+*
|
+
|
+
|
Operative therapy
|
+*
|
+
|
+
|
+Recommendation; *in case of excessive patient suffering
and suitable vascular morphology.
The basic treatment up to Fontaine stage IIb includes structured walking training
(e.g. also in sports groups for people with diabetes mellitus). Arm ergometric
exercise treatments for walking contraindications or limitations (e.g.
orthopaedic problems, PNP, DFS, etc.) are just as effective as walking training.
In addition to vascular sports, weight reduction in cases of obesity, giving up
nicotine in smokers and the treatment of arterial hypertension,
hypercholesterolemia and diabetes mellitus are recognised therapeutic
measures.
Conservative treatment in people with diabetes mellitus with symptomatic PAD
includes the administration of platelet aggregation inhibitors (ASA
100 mg or clopidogrel 75 mg daily), the administration of
statins and a structured vascular sports programme [3]
[4].
Anticoagulant therapy for PAD
Patients with symptomatic arteriosclerosis require platelet aggregation
inhibition with ASA or clopidogrel as a secondary prophylaxis. Clopidogrel has
demonstrated its superiority to ASA in symptomatic PAD patients [6]. ASA should not be routinely prescribed to patients
with healthy cardiovascular systems [7]
[8]
[9], this is also valid for
asymptomatic PAD patients [2]. Dual therapy with ASA
and clopidogrel does not present any advantages over monotherapy with ASA [10], nor does therapy with ticagrelor compared to
clopidogrel [11]. For patients with stable symptomatic
PAD after invasive revascularization and a high risk of ischemic events, a
combined therapy with rivaroxaban and ASA could show a reduction of the MACE
(myocardial infarction, stroke, cardiovascular death) and MALE (major adverse
limb event, severe circulatory disturbance/amputation) endpoints [12]. This is equally valid for patients with diabetes
mellitus.
Therapy of hypertension in patients with PAD
In general, all patients with arterial hypertension benefit from a reduction in
blood pressure [13], and patients with PAD
(=high-risk patients) in particular have an improved cardiovascular
prognosis. In patients with PAD, RR<120 mmHg
and>160 mmHg result in more leg events [14]. For this reason, blood pressure should not be set too low in PAD
patients. Renin-angiotensin system inhibitors are the drugs of choice for PAD
patients. PAD patients with cardiac comorbidity can also be treated with
beta-blockers for intermittent claudication and critical limb ischemia.
RECOMMENDATION FOR ANTICOAGULANT THERAPY IN PAD
Primary prevention
No indication for platelet aggregation inhibitors (PAI)
Secondary prevention
-
Asymptomatic PAD: no clear indication for PAI
-
Symptomatic PAD: clopidogrel 75 mg better than ASA
100 mg
-
High risk for ischemic events: rivaroxaban 2 ×
2.5 mg+ASA 100 mg
RECOMMENDATION RR-TARGETS FOR PATIENTS WITH PAD
RR target in PAD patients:
-
18-65 years<130 mmHg
-
65 years<140 mmHg
-
Overall>120 mmHg
Renin-angiotensin system inhibitors are the drugs of choice for PAD
patients.
Lipid therapy for diabetes and PAD
Statins and Ezetrol
There is general consensus that cholesterol-lowering therapy has a positive
effect on all-cause mortality and cardiovascular events in diabetic patients
with PAD, but the outcome of studies on PAD-related endpoints is
significantly weaker in diabetic patients. Existing recommendations result
more from subgroup analyses of large endpoint studies and observational
studies on coronary heart disease and cerebral angiopathy than from
prospective randomized studies on PAD. Few studies suggest a reduction in
the amputation rate [15] and an improvement in the
pain-free walking distance. According to a current evaluation of the
Veterans Affairs study, this applies both to the superior intensified
therapy (e.g. atorvastatin 40–80 mg) and low-dose therapy
(e.g. atorvastatin 10–20 mg or simvastatin
10–40 mg) [16]. Although there are
good indications for a reduction of the amputation and all-cause mortality
rates, there are also smaller studies with no significant effect on the
improvement of walking distance. On average, an improvement in the walking
distance of approx. 160 m can generally be achieved in PAD patients
[17].
The recommended target values for LDL cholesterol in PAD patients are an
absolute LDL cholesterol target<70 mg/dl or
1.8 mmol/l or a reduction of more than 50 % for an
initial LDL-C of 70–135 mg/dl or
1.8–3.5 mmol/l [2].
For Ezetrol, there are no robust statistics available on PAC.
Fibrates
Technically, fibrates lower triglycerides and increase HDL-C more than
statins. Subgroup analyses (tertiary endpoint), e.g. of the FIELD study,
show an absolute reduction of the microcirculation-related amputation rate
by a relative 36 % in people with diabetes mellitus. The rate of
major amputations and in patients with macroangiopathy was not different
[18].
PCSK9 inhibitors
Subgroup analyses of the FOURIER study show a 42% reduction in
PAD-related events (acute limb ischemia, amputation, or urgent peripheral
revascularization) for patients with or without PAD at the beginning of the
study [19]. This allows PCSK-9 inhibitors to be
used in patients with progressive PAD on statin therapy or in patients with
statin intolerance within the scope of the statutory health insurance
funds' prescription ability and subject to the proviso of high
therapy costs.
CONCLUSION
-
In the case of confirmed PAD, a statin therapy
with the maximum tolerable dosage for the patient (both with
and without existing coronary heart disease) should be
chosen to reduce the amputation and mortality
risks.
-
Target values for PAD: LDL
cholesterol<70 mg/dl or lowering by
more than 50 % (with an initial LDL cholesterol
level of
70-135 mg/dl).
Antidiabetics for PAD
Biguanide
Metformin is also the oral antidiabetic of choice for people with diabetes
and PAD. This is true even though the data is meagre in this respect. A
recently published study again proves the positive effect on CV survival,
but not on salvaging extremities and openness rate after peripheral
revascularisation [20].
Sulfonylureas and glinides
For both substance groups, no robust statistics on PAD are available. They
should generally only be used in justified exceptional cases when costs
determine the therapy. Due to the relatively high risk of hypoglycaemia and
the presumably unfavourable effects in patients with pre-existing coronary
heart disease, these substance groups are of little relevance [21].
Thiazolidinediones (PPAR-γ agonists)
For the only thiazolidinedione pioglitazone still available in Germany,
positive endpoint studies for cardiovascular survival in patients with type
2 diabetes and prediabetic patients are available with the PROACTIVE and
IRIS studies [22]
[23]
[24]
[25]
[26].
In the PROACTIVE study, amputations were also considered a primary endpoint.
However, no significant advantage over the control group could be observed
here. TZDs are contraindicated for existing heart failure.
DPP4 inhibitors
The cardiovascular endpoint studies SAVOR-Timi 53, EXAMINE, TECOS and
CAROLINA show a non-inferiority of DPP-4 inhibitors to the investigated
endpoints CV death, non-fatal myocardial infarction or stroke compared to
placebo or glimepiride. In the SAVOR-Timi-53 study, however, significantly
more frequent hospitalization with saxagliptin due to heart failure was
observed, which is why this substance should be used with caution in
patients with known heart failure. Cardiovascular superiority or advantages
in cases of simultaneous PAD have not been proven [27]
[28]
[29]
[30]
[31].
GLP-1 agonists
It was possible to demonstrate a positive effect on cardiovascular events
such as fatal and non-fatal myocardial infarction and non-fatal stroke
compared to placebos liraglutide, dulaglutide and semaglutide in endpoint
studies [32]
[33]
[34]. However, semaglutide in combination with
insulin shows an increased rate of microvascular eye complications, which is
why this GLP-1 agonist should not be used in patients with uncontrolled
diabetic retinopathy in combination with insulin for the time being [33]. With regard to PAD, however, no endpoint data
are available for this substance group either.
SGLT-2 inhibitors
The EMPAREG-outcome study, the DECLARE-TIMI study and the CANVAS study
provide data on the positive influence of the substances empagliflozin,
dapagliflozin and canagliflozin on cardiovascular endpoints such as
cardiovascular death, fatal and non-fatal myocardial infarction and stroke
[35]
[36]
[37]
[38]. The EMPAREG
outcome study and the DECLARE-TIMI study showed no increased amputation
rate. For canagliflozin, which is not on the market in Germany, the
amputation rate was significantly increased in the CANVAS study. In the
recently published CREDENCE study, however, this was not observed [39]. The use of canagliflozin in patients with type
2 diabetes and PAD is not currently recommended.
Basal insulin
There are no endpoint studies available for basal insulin therapy for
patients with PAD. No reduction of cardiovascular endpoints could be
demonstrated for insulin degludec or, in the ORIGIN study, for insulin
glargine. However, there was no increased incidence of cardiovascular
complications meaning that the therapy can be considered safe for the
cardiovascular system [40]
[41].
Insulin should be used in people with type 2 diabetes mellitus especially in
the presence of cardiovascular complications - except in the initial
adjustment phase – as far as possible, only after optimized oral or
GLP-1-based subcutaneous antidiabetic therapy.
CONCLUSION
-
The data regarding antidiabetic therapy and PAD outcome is
meagre.
-
Metformin is also the oral antidiabetic of choice for people with
diabetes and PAD.
-
If PAD is confirmed, the next step should be to add an SGLT-2
inhibitor or a GLP-1 agonist.
-
According to current data, the use of empagliflozin and
dapagliflozin is safe. Canagliflozin, on the other hand, has
shown an increased risk of amputation in a large outcome study
(albeit in retrospective subgroup analysis).
-
Therapy with basal insulin analogues is safe, but a reduction of
cardiovascular events has not been proven.
Principles of interventional therapy
The interventional therapy of PAD depends on the stages of the disease and the
affected vascular segments, which also applies for people with diabetes
mellitus.
Intermittent claudication
In Fontaine stage IIb claudication, the therapy goal is an improvement of
walking distance and quality of life. An initial intervention with
subsequent structured walking training [42] has
had the greatest success.
For aortoiliac disease, the primary openness rate 5 years after percutaneous
intervention is – generally - stent implantation in over 90%
[43]. For iliofemoral lesions with involvement
of the femoral artery, a hybrid procedure should be considered. An
intervention can also be considered even in femoropopliteal stenosis with
lifestyle-limiting PAD, even if the restenosis rates are significantly
higher. None of the guidelines recommend infrapopliteal, invasive therapy in
the stage of intermittent claudication [44]
[45].
Femoropopliteal surgery for short-stretch lesions with a length of less than
5 cm is still the indication for balloon dilatation only. Only from
a lesion length of more than 10 cm do studies show a clear advantage
of the additional implantation of self-expanding Nitinol stents [46]. Stents are also used in cases of recoil or
dissection, even for shorter lesions. Paclitaxel-coated drug-eluting
balloons (DEB) and stents (DES) showed a significant advantage over
conventional PTA in multiple randomized controlled trials with postoperative
monitoring periods of up to 5 years by reducing the restenosis rate [47]
[48].
In December 2018, Katsanos published a meta-analysis using pooled data from 3
studies, including both DEB and DES, 2–5 years after implantation in
which he determined a statistically significant higher all-cause mortality
compared to patients treated with uncoated systems [49]. In January 2019, for the first time, the US Food and Drug
Administration (FDA) published recommendations in which it recommended
preventive health protection by carefully weighing the benefits and risks of
the use of paclitaxel-coated balloons and stents. It was strongly
recommended to inform affected patients before the intervention that the use
of paclitaxel-coated devices can lead to an increased probability of death
as of 2 years after implantation. This recommendation was endorsed by both
the Federal Institute for Drugs and Medical Products/Bundesinstitut
für Arzneimittel und Medizinprodukte (BfArM) and the affected German
professional associations [50]. The most recent
FDA publication on this subject appeared in August 2019 [51]. Our own analyses also confirm the increased mortality signal
after 5 years with the use of paclitaxel-coated balloons and stents. At the
same time, the missing data on possible mechanisms, the weakness of
meta-analyses of very different studies with limited case numbers and the
high effectiveness of paclitaxel-coated balloons and stents in preventing
restenosis are also pointed out. However, the recommendations remain for the
time being. In the meantime, these meta-analyses of three relatively small,
differently designed randomised trials, which were not powered by mortality,
are contradicted by analyses from large insurance data. A recently published
analysis of US-American insurance data for a total of 83 225
PTA-treated patients with PAD of which 29% of whom received
medication-coated balloons, showed that patients treated with
paclitaxel-coated balloons had significantly lower all-cause mortality,
hospitalization and amputation rates after one year [59]. In a current health insurance data-based analysis from
Germany with 64 771 patients (107 112 procedures,
23 137 of which with paclitaxel coating) and taking into account
relevant, patient-related risk factors, no correlation was found between the
use of paclitaxel-coated devices and increased mortality, neither for coated
stents nor for coated balloons (Freisinger et al. Eur Heart J), both in the
short term (30 days) and in the long term (up to 11 years). Even after
repeated use of paclitaxel-coated devices in the course of the disease,
there was no correlation between paclitaxel and mortality. Similar results
have been obtained in further published studies [60]
[61]. In patients with recurrent
restenosis, complex stenosis, critical limb ischemia or multiple concomitant
diseases who are already at an increased mortality risk and for whom every
reintervention increases this risk, the use of medication-coated balloons
should be carefully considered.
Critical limb ischemia
If a circulatory disorder is present with acute danger to an extremity,
initial revascularization should be sought in addition to treating the
accompanying infection. Here the "Endovascular first"
strategy has gained in importance and is also recommended in the current
German S3 guideline [44]. In the treatment of the
aortoiliac and femoropopliteal segments, there is no difference in the
intervention strategy compared to intermittent claudication.
Various techniques are available for infrainguinal endovascular
recanalization. In principle, angioplasty is to be preferred in intraluminal
procedures. In designated centres, an infrapopliteal leg salvaging rate of
over 90% can be achieved after percutaneous angioplasty [52].
Although a significant advantage of medicine-coated stents compared to
balloon angioplasty could be demonstrated in small randomized controlled
trials in terms of amputation-free survival after 5 years, the benefit of
medicine-coated balloons cannot yet be conclusively evaluated [53]
[54].
A further option is the possibility of gradual revascularisation [55]. Retrograde recanalization is successful in
more than 80% of cases of critical limb ischemia without antegrade
revascularization [56]. However, these complex
procedures increase the duration of the intervention and the radiation
exposure for the patient and the examiner. The previously prevailing opinion
that the revascularisation results for diabetic feet are worse has been
rendered obsolete. According to literature research, only the subgroup of
people with diabetes mellitus requiring dialysis shows significantly poorer
results both in the openness and the leg salvaging rate at each
50-70% after 1 year, with a tendency towards a higher mortality rate
[57]. In general, for people with diabetes
mellitus and impaired kidney function and still functioning residual renal
function, CO2 should be used as a negative intravascular contrast
agent for angiography and interventional therapy for nephroprotection
whenever possible [58].
Acute limb ischaemia
Interventional endovascular approaches are local catheterisation, mechanical
thrombectomy by aspiration or special thrombectomy catheterisation. Modern
concepts show 6-month amputation rates of less than 10% with the
best outcome at an occlusion duration of less than 14 days [43].
Care after vascular interventions
After peripheral vascular interventions, the administration of platelet
aggregation inhibitors for secondary prophylaxis is absolutely
necessary.
Statins are also indicated for secondary prophylaxis (independent of the LDL
value). This not only improves clinical survival, but also significantly
improves the bypass openness rate and walking ability.
The benefits of further drug treatments for people with diabetes mellitus are
unclear.
Structured vascular training improves walking ability and clinical outcome
even after revascularizing procedures.