Stimulation TcPO2 Testing Improves Diagnosis of Peripheral Arterial Disease in Patients With Diabetic Foot

Vladimíra Fejfarová, Jiří Matuška, Edward Jude, Pavlína Piťhová, Milan Flekač, Karel Roztočil, Veronika Wosková, Michal Dubský, Alexandra Jirkovská, Robert Bém, Jitka Husáková, Věra Lánská, Vladimíra Fejfarová, Jiří Matuška, Edward Jude, Pavlína Piťhová, Milan Flekač, Karel Roztočil, Veronika Wosková, Michal Dubský, Alexandra Jirkovská, Robert Bém, Jitka Husáková, Věra Lánská

Abstract

Background: All diagnostic procedures of peripheral arterial disease (PAD) in diabetic foot (DF) are complicated due to diabetes mellitus and its late complications.The aim of our study is to enhance diagnosis of PAD using a novel transcutaneous oximetry (TcPO2) stimulation test.

Methods: The study comprised patients with mild-to-moderate PAD(WIfI-I 1 or 2) and baseline TcPO2 values of 30-50 mmHg.TcPO2 was measured across 107 different angiosomes. Stimulation examination involved a modification of the Ratschow test. All patients underwent PAD assessment (systolic blood pressures (SBP), toe pressures (TP), the ankle-brachial indexes (ABI) and toe-brachial indexes (TBI), duplex ultrasound of circulation). Angiosomes were divided into two groups based on ultrasound findings: group M(n=60) with monophasic flow; group T(n=47) with triphasic flow. Large vessel parameters and TcPO2 at rest and after exercise (minimal TcPO2, changes in TcPO2 from baseline (Δ,%), TcPO2 recovery time) measured during the stimulation test were compared between study groups.

Results: During the TcPO2 stimulation exercise test, group M exhibited significantly lower minimal TcPO2 (26.2 ± 11.1 vs. 31.4 ± 9.4 mmHg; p<0.01), greater Δ and percentage decreases from resting TcPO2 (p=0.014 and p=0.007, respectively) and longer TcPO2 recovery times (446 ± 134 vs. 370 ± 81ms;p=0.0005) compared to group T. SBPs, TPs and indexes were significantly lower in group M compared to group T. Sensitivity and specificity of TcPO2 stimulation parameters during PAD detection increased significantly to the level of SBP, ABI, TP and TBI.

Conclusion: Compared to resting TcPO2, TcPO2 measured during stimulation improves detection of latent forms of PAD and restenosis/obliterations of previously treated arteries in diabetic foot patients.

Clinical trial registration: ClinicalTrials.gov [https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009V7W&selectaction=Edit&uid=U0005381&ts=2&cx=3j24u2], identifier NCT04404699.

Keywords: PAD - peripheral arterial disease; TcPO2 and TcPCO2 measurement; diabetic foot; diagnosis; microcirculation.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Fejfarová, Matuška, Jude, Piťhová, Flekač, Roztočil, Wosková, Dubský, Jirkovská, Bém, Husáková and Lánská.

Figures

Figure 1
Figure 1
Distribution of angiosomes in the lower limb. 1- Angiosomes supplied by: anterior tibial artery (ATA); 2 - dorsalis pedis artery (DPA); 3 –medial plantar artery; 4 - calcaneal branch of the posterior tibial artery (PTA) (angiosomes 3 and 4 are supplied by the PTA); 5 - lateral plantar artery.
Figure 2
Figure 2
Modified Ratschow test.
Figure 3
Figure 3
Record of TCPO2 measurement during stimulation test Evaluated parameters: Resting TcPO2; maximal decline of TcPO2 during stimulation test, minimal TcPO2 during stimulation test; TcP02 differences in absolute numbers (△ =resting TcPO2 minus minimal TcPO2 during the stimulation test) and in percentages; TcPO2 recovery time.
Figure 4
Figure 4
Sensitivity and specificity of individual macrovascular assessment in relation to monophasic arterial flow supplying the relevant angiosome. ABI, ankle-brachial index; DPA, dorsalis pedis artery; PTA, posterior tibial artery; TBI, toe-brachial index; p, significance; CI, confidence interval; mm, Hg-millimetres of mercury; the highest sensitivity and specificity for individual measurements are highlighted in bold circles.
Figure 5
Figure 5
Sensitivity and specificity of microvascular assessment and TcPO2 stimulation parameters in relation to monophasic arterial flow supplying the relevant angiosome. TcPO2, transcutaneous oxygen measurement;△ -difference of TcPO2 counted as resting TcPO2 minus minimal TcPO2 detected during the stimulation test; %-percentage; p-significance; CI, confidence interval; mmHg, millimetres of mercury; the highest sensitivity and specificity for individual measurements are highlighted in bold circles.

References

    1. Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, et al. . High Prevalence of Ischaemia, Infection and Serious Comorbidity in Patients With Diabetic Foot Disease in Europe. Baseline Results From the Eurodiale Study. Diabetologia (2007) 50(1):18–25. doi: 10.1007/s00125-006-0491-1
    1. Morbach S, Furchert H, Groeblinghoff U, Hoffmeier H, Kersten K, Klauke G-T, et al. . Long-Term Prognosis of Diabetic Foot Patients and Their Limbs. Diabetes Care (2012) 35(10):2021–7. doi: 10.2337/dc12-0200
    1. Almuhannadi H, Ponirakis G, Khan A, Malik RA. Diabetic Neuropathy and Painful Diabetic Neuropathy: Cinderella Complications in South East Asia. J Pak Med Assoc (2018) 68(1):85–9.
    1. Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral Arterial Disease in Diabetic and Nondiabetic Patients: A Comparison of Severity and Outcome. Diabetes Care (2001) 24(8):1433–7. doi: 10.2337/diacare.24.8.1433
    1. Jörneskog G. Why Critical Limb Ischemia Criteria Are Not Applicable to Diabetic Foot and What the Consequences Are. Scand J Surg (2012) 101(2):114–8. doi: 10.1177/145749691210100207
    1. Criqui MH, Aboyans V. Epidemiology of Peripheral Artery Disease. Circ Res (2015) 116(9):1509–26. doi: 10.1161/CIRCRESAHA.116.303849
    1. Lange S, Diehm C, Darius H, Haberl R, Allenberg JR, Pittrow D, et al. . High Prevalence of Peripheral Arterial Disease and Low Treatment Rates in Elderly Primary Care Patients With Diabetes. Exp Clin Endocrinol Diabetes (2004) 112(10):566–73. doi: 10.1055/s-2004-830408
    1. Aziz ARA, Alsabek MB. Diabetic Foot and Disaster: Risk Factors for Amputation During the Syrian Crisis. J Diabetes Complications (2019) 26:107493. doi: 10.1016/j.jdiacomp.2019.107493
    1. Fejfarová V, Bém R, Dubský M, Wosková V, Němcová A, Hazdrová J, et al. . Novinky V Angiologii. Kazuistiky v diabetologii (2018) 16(suppl 1):S23–28.
    1. Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. . 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral, Mesenteric, Renal, Upper and Lower Extremity Arteries. Endorsed by the European Stroke Organization (ESO) and the Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J (2018) 39(9):763–816. doi: 10.1093/eurheartj/ehx095
    1. Mills JL, Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. . Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk Stratification Based on Wound, Ischemia, and Foot Infection (WIfI). J Vasc Surg (2014) 59(1):220–34.e1-2. doi: 10.1016/j.jvs.2013.08.003
    1. Halliday A, Bax JJ. The 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg (2018) 55(3):301–2. doi: 10.1016/j.ejvs.2018.03.004
    1. Available at: .
    1. Furuichi K, Shimizu M, Hara A, Toyama T, Wada T. Diabetic Nephropathy: A Comparison of the Clinical and Pathological Features Between the CKD Risk Classification and the Classification of Diabetic Nephropathy 2014 in Japan. Intern Med (2018) 57(23):3345–50. doi: 10.2169/internalmedicine.1132-18
    1. IWGDF Guidelines .
    1. Martini R, Abraham P. Transcutaneous PO2 Measurements. In: VAS European Book on Angiology/Vascular Medicine. Aracne; (2018).
    1. Urban M, Fouasson-Chailloux A, Signolet I, Colas Ribas C, Feuilloy M, Abraham P. Comparison of Two Devices for Measuring Exercise Transcutaneous Oxygen Pressures in Patients With Claudication. Vasa (2015) 44(5):355–62. doi: 10.1024/0301-1526/a000454
    1. Nirala N, Periyasamy R, Kumar A. Noninvasive Diagnostic Methods for Better Screening of Peripheral Arterial Disease. Ann Vasc Surg (2018) 52:263–72. doi: 10.1016/j.avsg.2018.03.018
    1. Alexandrescu V, Hubermont G. The Challenging Topic of Diabetic Foot Revascularization: Does the Angiosome-Guided Angioplasty may Improve Outcome. J Cardiovasc Surg (Torino) (2012) 53(1):3–12.
    1. Moosa HH, Peitzman AB, Makaroun MS, Webster MW, Steed DL. Transcutaneous Oxygen Measurements in Lower Extremity Ischemia: Effects of Position, Oxygen Inhalation, and Arterial Reconstruction. Surgery (1988) 103(2):193–8.
    1. Puricelli C, Tajana A, Kuntner A. [The Ratschow Test: Critical Study and Clinical Experiences]. Arch Ital Chir (1967) 93(1):673–96.
    1. Karetová D, Staněk F. Angiologie Pro Praxi. Praha: Maxdorf (2001), 28–46.
    1. Grouiller F, Jaquinandi V, Picquet J, Souday V, Saumet JL, Abraham P. Validation of a New Device for Transcutaneous Oxygen Pressure Recordings in Real and Simulated Exercise Tests. Int Angiol (2006) 25(2):190–6.
    1. Brownrigg JR, Hinchliffe RJ, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, et al. . Performance of Prognostic Markers in the Prediction of Wound Healing or Amputation Among Patients With Foot Ulcers in Diabetes: A Systematic Review. Diabetes Metab Res Rev (2016) 32 Suppl 1:128–35. doi: 10.1002/dmrr.2704
    1. Wang Z, Hasan R, Firwana B, Elraiyah T, Tsapas A, Prokop L, et al. . A Systematic Review and Meta-Analysis of Tests to Predict Wound Healing in Diabetic Foot. J Vasc Surg (2016) 63(2 Suppl):29S–36S.e1-2. doi: 10.1016/j.jvs.2015.10.004
    1. Yang C, Weng H, Chen L, Yang H, Luo G, Mai L, et al. . Transcutaneous Oxygen Pressure Measurement in Diabetic Foot Ulcers: Mean Values and Cut-Point for Wound Healing. J Wound Ostomy Continence Nurs (2013) 40(6):585–9. doi: 10.1097/WON.0b013e3182a9a7bf
    1. Hamburg NM, Creager MA. Pathophysiology of Intermittent Claudication in Peripheral Artery Disease. Circ J (2017) 81(3):281–9. doi: 10.1253/circj.CJ-16-1286
    1. Jeffcoate WJ, Rasmussen LM, Hofbauer LC, Game FL. Medial Arterial Calcification in Diabetes and Its Relationship to Neuropathy. Diabetologia (2009) 52(12):2478–88. doi: 10.1007/s00125-009-1521-6
    1. Available at: .
    1. Boyko EJ, Ahroni JH, Stensel VL, Smith DG, Davignon DR, Pecoraro RE. Predictors of Transcutaneous Oxygen Tension in the Lower Limbs of Diabetic Subjects. Diabetes Med (1996) 13(6):549–54. doi: 10.1002/(SICI)1096-9136(199606)13:6<549::AID-DIA126>;2-R
    1. Puricelli C, Tajana A, Kuntner A. The Ratschow Test: Critical Study and Clinical Experiences. Arch Ital Chir (1967) 93(1):673–96.
    1. Audonnet M, Signolet I, Colas-Ribas C, Ammi M, Abraham P, Henni S. Exercise Transcutaneous Oximetry of the Buttocks – External Validation With Computed Tomography Angiography. Circ J (2017) 81(8):1123–8. doi: 10.1253/circj.CJ-16-1316
    1. Abraham P, Picquet J, Bouyé P, L’Hoste P, Enon B, Vielle B, et al. . Transcutaneous Oxygen Pressure Measurements (Tcpo2) at Ankle During Exercise in Arterial Claudication. Int Angiol (2005) 24(1):80–8.
    1. Kovacs D, Csiszar B, Biro K, Koltai K, Endrei D, Juricskay I, et al. . Toe-Brachial Index and Exercise Test can Improve the Exploration of Peripheral Artery Disease. Atherosclerosis (2018) 269:151–8. doi: 10.1016/j.atherosclerosis.2018.01.023
    1. Héroux ME, Stubbs PW, Herbert RD. Behavior of Human Gastrocnemius Muscle Fascicles During Ramped Submaximal Isometric Contractions. Physiol Rep (2016) 4(17):e12947. doi: 10.14814/phy2.12947
    1. Leenstra B, Wijnand J, Verhoeven B, Koning O, Teraa M, Verhaar MC, et al. . Applicability of Transcutaneous Oxygen Tension Measurement in the Assessment of Chronic Limb-Threatening Ischemia. Angiology (2019) 6:3319719866958. doi: 10.1177/0003319719866958

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