The 30-minute op that can save diabetes patients from losing a leg
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 that 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 Graham, a carer from High Wycombe, Bucks.
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, at the John radcliffe Hospital in Oxford 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.
In fact, new figures reveal that one person a day needlessly loses their foot or leg because this simple procedure isn’t more widely available.
Blockages in the blood vessels in the legs (known as peripheral arterial disease) is 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.
Every
year there are around 12,000 lower limb amputations in the UK, the majority of which are for people with diabetes.
‘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 at the John radcliffe.
‘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, m, a consultant interventional nterventional radiologist at Newcastle Hospitals Foundation Trust.
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.
So why aren’t more patients being offered this?
The problem, says Dr Haslam, is there simply aren’t enough interventional radiologists — specially trained X-ray doctors — who can perform this type of image-guided surgery.
‘We need to double the trained Ir workforce from 433 to nearly 1,000, in order to meet the current demand, never mind the future demand,’ he adds.
‘We need more funding dedicated towards training doctors in this area,’ he explains. ‘Since it’s a quick, cheap, effective and largely painless procedure, this needs to be addressed.’
The procedure is available at most, but not all, major city hospitals. And Dr Uberoi, who is president of the British Society of Interventional radiology ( BSIr), warns that as the number of diabetics in this country — currently four million — continues to rise, ‘the demand for interventional radiology procedures to clear arteries will be even more acute’.
He adds: ‘ Crucially, you’re avoiding a whole heap of extremely serious complications further down the line with a quick and painless procedure, with obvious benefits to the patient as well as to the NHS.’
Complications from the procedure are rare, he 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.
‘Compared with endovascular revascularisation, it’s a far from optimal option.’
NIKKI
JOUle, policy manager at Diabetes UK, agrees that 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 when in August last year he developed redness and pain in his left foot. Scans revealed that this was due to poor blood flow in the artery supplying it.
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.’