The 30-minute op that can save di­a­betes pa­tients from los­ing a leg

Irish Daily Mail - - Good Health - By MATTHEW BAR­BOUR

LAST year, Gra­ham Baker was fac­ing the prospect of los­ing his left leg be­low the knee, a com­pli­ca­tion of his type 2 di­a­betes.

Poorly con­trolled blood sugar lev­els had en­cour­aged the ar­ter­ies in his left calf to fur up, and this was ob­struct­ing the blood flow so much the tis­sues and bones in his lower leg were be­ing starved of blood and oxy­gen.

‘I had a scan to mon­i­tor the blood flow in my left leg and was told that without sur­gi­cal in­ter­ven­tion, I would likely lose the lower part of my leg — my years of poor di­a­betes man­age­ment had ba­si­cally blocked up the main artery,’ says 52-yearold carer, Gra­ham.

But spe­cial­ists said they could save the leg — and it could be done un­der lo­cal anaes­thetic in less than an hour. It in­volved a newly re­fined pro­ce­dure that clears the artery of block­ages.

Gra­ham — who is mar­ried to Beryl, 53 — had the pro­ce­dure, called en­dovas­cu­lar revas­cu­lar­i­sa­tion last Septem­ber and his leg was saved.

There are many peo­ple in the same po­si­tion who could also ben­e­fit from the pro­ce­dure, but don’t know about it.

Block­ages in the blood ves­sels in the legs (known as pe­riph­eral ar­te­rial dis­ease) are com­mon, but peo­ple with di­a­betes are par­tic­u­larly prone.

This is be­cause ni­tric ox­ide, a gas we all pro­duce that helps keep blood ves­sels healthy, be­comes less ef­fec­tive in the pres­ence of re­peat­edly high blood sugar — as can oc­cur in di­a­betes.

As a re­sult, the blood ves­sels are at risk from in­flam­ma­tion; this in turn en­cour­ages the build-up of fatty de­posits called plaques, which ul­ti­mately im­pede blood flow.

While this af­fects all the body’s blood ves­sels, the ef­fect is pro­nounced in the legs be­cause the veins and ar­ter­ies are longer.

As the block­ages can ham­per the blood sup­ply, which would nor­mally help with heal­ing, a mi­nor in­jury to the foot or lower leg can de­velop into an ul­cer and in­fec­tion, which can spread to the bone. Once there, the in­fec­tion can­not be treated with an­tibi­otics, mean­ing am­pu­ta­tion is the only op­tion.

THE num­ber of di­a­betes­re­lated am­pu­ta­tions is on the rise in Ire­land, with 451 peo­ple un­der­go­ing the op­er­a­tion in 2015, the last year for which HSE fig­ures are avail­able; the num­ber in 2014 was 443.

Pro­gres­sive dam­age to the blood ves­sels and nerves of the legs and feet can cause se­vere prob­lems. ‘Without ad­e­quate blood sup­ply in di­a­bet­ics oth­er­wise mi­nor ail­ments, such as ul­cers, can lead to the loss of the foot,’ says Dr Ra­man Uberoi, a con­sul­tant in­ter­ven­tional ra­di­ol­o­gist.

‘In­creas­ing the blood flow even tem­po­rar­ily can help.’

En­dovas­cu­lar revas­cu­lar­i­sa­tion is a sim­ple way to do that. It in­volves mak­ing a small in­ci­sion in the groin, then feed­ing a wire (guided by X-ray) into the af­fected artery.

A bal­loon and a stent — a tiny mesh tube sim­i­lar to the spring in a pen — is in­serted over the wire to squash the block­age and hold open the artery.

The stents are of­ten coated with the drug pa­cli­taxel, which helps to pre­vent the build-up of scar tis­sue that can lead to re-nar­row­ing of the artery.

The same technique is used for treat­ing blocked ar­ter­ies in the heart.

‘In a straight­for­ward case, which most are, the process takes only 30 min­utes,’ says Dr Philip Haslam, a con­sul­tant in­ter­ven­tional ra­di­ol­o­gist.

Data shows the pro­ce­dure is suc­cess­ful in 85-90 per cent of pa­tients 12 months later.

The technique, re­cently re­fined so even small ves­sels can be cleared, has bet­ter out­comes than tra­di­tional by­pass tech­niques that in­volve open­ing up the leg to re­move a vein that is used to by­pass the block­age, says Dr Haslam, and stud­ies show that pa­tients who have en­dovas­cu­lar revas­cu­lar­i­sa­tion spend a third less time in hospi­tal and are 12 per cent less likely to need an am­pu­ta­tion than those who have a by­pass.

The pro­ce­dure is avail­able at most, but not all, ma­jor city hos­pi­tals in the UK and Ire­land and the re­sults are prov­ing to be very pos­i­tive.

Com­pli­ca­tions from the pro­ce­dure are rare, Dr Uberoi ex­plains.

‘Oc­ca­sion­ally the artery can’t be un­blocked be­cause of the de­gree of plaque build-up. Some­times the nar­row­ing in the artery can em­bolise — or break into pieces — as a re­sult of the pro­ce­dure, and flow off to smaller blood ves­sels where it can cause fur­ther block­ages,’ says Dr Uberoi.

‘If the blood ves­sel is too blocked, open surgery is needed, but that re­quires longer hospi­tal stays, and car­ries a greater risk of in­fec­tion.

NIKKI Joule, pol­icy man­ager with a ma­jor di­a­betes char­ity, be­lieves peo­ple with di­a­betes need more ac­cess to such pro­ce­dures. ‘Di­a­bet­ics should have the best pos­si­ble care and sup­port from a mul­ti­dis­ci­plinary foot­care team who can de­liver the best re­sults, in­clud­ing ac­cess to spe­cial­ists who can re­pair dam­aged ar­ter­ies in legs and feet.’

Gra­ham, who’s had type 2 di­a­betes since the age of 36, had al­ready had a toe am­pu­tated in 2013.

He’d also pre­vi­ously suf­fered an in­fec­tion in his sec­ond toe and the metatarsals — the long bones — in his left foot, and had them sur­gi­cally re­moved.

He was sur­prised at how straight­for­ward the new pro­ce­dure was.

‘I couldn’t feel it at all, and I was awake through­out.

‘When the sur­geon got to the block­age, he in­flated a bal­loon to widen the artery, and the pain in my shin — where the block­age was lo­cated — was ex­cru­ci­at­ing for three to four sec­onds,’ he says.

Gra­ham was out of the­atre within 45 min­utes. ‘The con­sul­tant told me it had been a com­plete suc­cess,’ he says. He was able to walk that af­ter­noon and was dis­charged from hospi­tal the next day, and adds: ‘My left leg was saved, and for that I’m eter­nally grate­ful.’

Pic­ture: GETTY

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