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Diabetic angiopathy

Angiopathy is the generic term for a disease of the blood vessels (arteries, veins, and capillaries). The best known and most prevalent angiopathy is the diabetic angiopathy, a complication that may occur in chronic diabetes. more...

Dandy-Walker syndrome
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Diabetes insipidus
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Diabetic angiopathy
Diabetic nephropathy
Diabetic neuropathy
Diamond Blackfan disease
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There are two types of angiopathy: macroangiopathy and microangiopathy. In macroangiopathy, fat and blood clots build up in the large blood vessels, stick to the vessel walls, and block the flow of blood. In microangiopathy, the walls of the smaller blood vessels become so thick and weak that they bleed, leak protein, and slow the flow of blood through the body. The decrease of blood flow through stenosis or clot formation impair the flow of oxygen to cells and biological tissues (called ischemia) and lead to their death (necrosis and gangrene, which in turn may require amputation). Thus, tissues which are very sensitive to oxygen levels, such as the retina, develop microangiopathy and may cause blindness (so-called proliferative diabetic retinopathy). Damage to nerve cells may cause peripheral neuropathy, and to kidney cells, diabetic nephropathy (Kimmelstiel-Wilson syndrome).

Macroangiopathy, on the other hand, may cause other complications, such as ischemic heart disease, stroke and peripheral vascular disease which contributes to the diabetic foot ulcers and the risk of amputation.

Diabetes mellitus is the most common cause of adult kidney failure worldwide. It also the most common cause of amputation in the US, usually toes and feet, often as a result of gangrene, and almost always as a result of peripheral vascular disease. Retinal damage (from microangiopathy) makes it the most common cause of blindness among non-elderly adults in the US.

"Diabetic dermopathy" is a manifestation of diabetic angiopathy. It is often found on the shin.


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Electrotherapy reoxygenates inframalleolar ischemic wounds on diabetic patients: A case series
From Advances in Skin & Wound Care, 5/1/02 by Goldman, Robert J



OBJECTIVE: To retrospectively evaluate the ability of high voltage pulsed current (HVPC) to increase microcirculation in critically ischemic wounds (transcutaneous oxygen[TcPO^sub 2^] less than 10 mm Hg) and, as a result, to improve wound healing. DESIGN AND METHODS: Clinical case series with successive adult diabetic subjects (3 men and 3 women) with nonsurgical ischemic malleolar or inframalleolar skin lesions, each subject serving as his or her own control.Wound area and TcPO^sub 2^ were measured periodically. Presence of distal arteriosclerosis was assessed on 5 patients by 2-dimensional, time-of-flight magnetic resonance angiography. End point was either complete wound closure or leg amputation.

RESULTS: Maximum mean TcPO^sub 2^ was 2 +/- 2 mm Hg at the wound edge before the start of electrotherapy. After electrotherapy began, maximum TcPO^sub 2^ was 33 +/- 18 mm Hg (N=6; P

CONCLUSION: The results of this clinical case series suggest that electrotherapy can improve periwound microcirculation of ischemic inframalleolar skin lesions.

Lower extremity amputation is an expensive complication of diabetes mellitus.1 Risk factors such as peripheral neuropathy and angiopathy can lead to distal lower extremity ischemic skin lesions and can possibly result in amputation. If feasible, ischemic ulcers are treated by surgical revascularization. A patient is not an operative candidate, however, if he or she has critical occlusive disease but no suitable outflow vessel for the bypass conduit or if the patient has a profound comorbidity that makes anesthesia a high risk. Unfortunately, numerous patients with peripheral vascular disease and diabetes have these impediments to surgery. Too often, the end result is a lower extremity amputation.

High voltage pulsed current (HVPC; also known as electrical stimulation) has been employed by health care practitioners to augment the healing rate of chronic wounds with few adverse events, according to prospective, randomized, blinded clinical trials2-5 and a recent meta-analysis.6 The salutary effect reported for HVPC has been attributed, at least in part, to increased blood flow to wounds. Increased blood flow to tissue from electrotherapy is reported by many clinical and in vitro studies.7-12

Cutaneous microcirculation consists of nutritional capillaries of the papillary dermis and nonnutritional arteriovenous plexuses of the subpapillary dermis and subdermis.13 Skin blood flow is quantified by laser blood flow, skin temperature, and transcutaneous oxygen (TcPO^sub 2^). TcPO^sub 2^ is an absolute measure of oxygen in units of partial pressure in the dermis.14 In prospective trials, TcPO^sub 2^ is an independent predictor of future lower extremity amputation. A TcPO^sub 2^ measurement less than 50 mm Hg carries a 3-fold increased risk for amputation.15 In addition, TcPO^sub 2^ predicts the healing success of residuum incisions for amputation at a transtibial level. A below-knee TcPO^sub 2^ measurement greater than 40 mm Hg carries a good prognosis; a TcPO^sub 2^ measurement less than 20 has a poor prognosis.14,16,17

For intact limbs, TcPO^sub 2^ predicts healing of infrapopliteal wounds in diabetic subjects better than segmental volume plethysmographyis or toe segment pressures.19 In addition, TcPO^sub 2^ may have sensitivity and specificity approaching 80% in the ability to infer flow of underlying macrovessels of the leg and foot.21 Normal perilesion TcPO^sub 2^ measurement is greater than 50 mm Hg; less than 20 mm Hg is ischemic, and less than 10 mm Hg is critically ischemic. Critically ischemic wounds have a guarded prognosis for complete closure. For the present study, critical ischemia was defined as a periwound TcPO^sub 2^ measurement less than 10 mm Hg.


HVPC improves microperfusion in the vicinity of inframalleolar ischemic skin lesions and tends to promote healing if microperfusion improves sufficiently to reach near-normal physiologic levels. A controlled clinical trial is needed to confirm these speculative positive clinical findings.


1.Grunfeld C. Diabetic foot ulcers: etiology, treatment, and prevention. Adv Intern Med 1991;37:103-32.

2.Baker LL, Chambers R, DeMuth SK Villar F. Effects of electrical stimulation on wound healing in patients with diabetic ulcers.

Diabetes Care 1997;20:405-12.

3. Feedar J, Kloth L, Gentzkow G. Chronic dermal ulcer healing enhanced with monophasic pulsed electrical stimulation. Phys Ther 1991:71:639-49.

4. Griffin J,Tooms R, Mendius R, Clifft J, Zwaag R, ElZeky F. Efficacy of high voltage pulsed current for heating of pressure ulcers in patients with spinal cord injury. Phys Ther 1991;71:433-44.

5. Kloth L, Feedar J. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther 1988;68:503-8.

6.Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen 1999;7:495-503.

7. Peters EJ, Armstrong DG,Wunderlich RP, Bosma J, Stacpoole-Shea S, Lavery LA. The benefit of electrical stimulation to enhance perfusion in persons with diabetes mellitus. J Foot Ankle Surg 1998;37:396-400; discussion 447-8.

8.Mawson AR, Siddiqui FH, Connolly BJ, et al. Effect of high voltage pulsed galvanic stimulation on sacral transcutaneous oxygen tension levels in the spinal cord injured. Paraplegia 1993;31:311-9.

9. Lundeberg T, Kjartansson J,Samuelsson U. Effect of electrical nerve stimulation on healing of ischaemic skin flaps. Lancet 1988;2:712-4.

10.Claeys L, Horsch, S. Transcutaneous oxygen pressure as predictive parameter for ulcer healing in endstage vascular patients treated with spinal cord stimulation. International Angiology 1996; 15:344-9.

11. Likar B, Poredos R Effects of electric current on partial oxygen tension in skin surrounding wounds. Wounds 1993;5:32-46.

12. Khalil Z, Ralevic V, Basirat M, Dusting G, Helme R. Effects of aging on sensory nerve function in rat skin. Brain Res 1994;641:265-72.

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15. Adler Al, Boyko EJ, Ahroni JH, Smith DG. Lowerextremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22:1029-35.

16.Bacharach JM, Rooke T, Osmundson PJ, Gloviczki P. Predictive value of transcutaneous oxygen pressure and amputation success by use of supine and elevation measurements. J Vasc Surg 1992;16:558-62.

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tors for amputation in patients with diabetes mellitus, a case control study. Ann Intern Med 1992;117:97-105.

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19.Kalani M, Brismar K, Fagrell B, Ostergren J, Jorneskog G. Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care 1999;22(1):147-51.

20.Goldman R, Stolpen A. Infrapopliteal TcPO 2 predicts local arterial flow. Arch Phys Med Rehabil 1998;79:1146.

21.Electrotherapeutic Terminology in Physical Therapy. Updated by the Section on Clinical Electrophysiology of the American Physical Therapy Association, publication order number P-72, December 2000.

22. Food and Drug Administration Modernization Act of 1997, 105 USC 105-115 (1997).

23.21 Federal Register Code 21CFR10.3 (2001) (codified at 21 895.5850).

24.Salcido R,Goldman R. Prevention and management of pressure ulcers and other chronic wounds. In: Braddom R, editor. Textbook of Rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000: p 645-65.

25.Winter G,editor. Epidermal regeneration in the domestic pig. Chicago: Year Book Medical Publishers; 1970.

26. Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers, Diabetic Ulcer Study Group. J Vasc Surg 1995;21:71-81.

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28. Runyan JW.The Memphis chronic disease program. JAMA 1975;231:264-7.

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31. McDermott VG, Meakem JP, Carpenter JP, et al. Magnetic resonance angiography of the distal lower extremity. Clin Radiol 1995;50:741-6.

32. Carpenter JP, Baum RA, Holland GA, Barker CF. Peripheral vascular surgery with magnetic resonance angiography as the sole preoperative imaging modality. J Vasc Surg 1994;20:861-71.

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determinant for major amputation in diabetic subjects with foot ulcers. Diabetes Care 1998;21:625-30.

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35. Goldman R, Pollack S. Electric fields and proliferation in a chronic wound model. Bioelectromagnetics 1996;17:450-7.

36.Bourguignon GJ. Electric stimulation of protein and DNA synthesis in human fibroblasts. FASEB J. 1987; 1:398-402.

37. Goldman R, McCauley RL, Richie D, Abrams S, Robson MC, Herndon D. Electrically induced modulation of collagen synthesis in cultured human fibroblasts. Surgical Forum 1990;XLI:616-8.

38.Bettany J, Fish D, Mendel F. High-voltage pulsed direct current: effect on edema formation after hyperflexion injury. Arch Phys Med Rehabil 1990;71:677-81.

39.Katusic Z. Superoxide anion and endothelial regulation of arterial tone. Free Radical Biology Med 1996;20:443-8.

40. Bucala R, Tracey K, Cerami A. Advanced glycosylation products quench nitric oxide and mediate defective endothelium-dependent vasodilatation in experimental diabetes. J Clin Invest 1991;87:432-8.

41.Wu F. Relative cost of amputation and total contact casting [Undergraduate Thesis]. Philadelphia, PA: University of Pennsylvania; 1996.

Robert J. Goldman, MD; Barbara I. Brewley, RN; and Michael A. Golden, MD

Robert J. Goldman, MD, is an assistant professor and Barbara I. Brewley, RN, is a rehabilitation nurse in the Department of Rehabilitation Medicine; and Michael A. Golden, MD, is an associate professor in the Department of Surgery, Division of Vascular Surgery, University of Pennsylvania, Philadelphia, PA. Submitted October 11, 2000; accepted in revised form June 11, 2001.


Alan H. Stolpin, MD, PhD; Mark Rosen, MD, PhD; and David A. Roberts, MD, PhD, of the Department of Radiology, University of Pennsylvania, for interpretation of magnetic resonance angiograms. Andrew J. Cucchiara, PhD, of the General Clinical Research Center, University of Pennsylvania, for statistical analysis. Joseph Cavorsi, MD, and Pam Unger, PT, of the Institute for Advanced Wound Healing, St Joseph's Hospital Medical Center, Reading, PA, for expertise on wound healing and electrotherapy. Funding and equipment for this research was provided by the University of Pennsylvania Research Foundation; University of Pennsylvania Pilot Grant for Patient-Oriented Research; National Heart, Lung, and Blood Institute, Lung and Blood 1R41HL61983-01; Chattanooga Group, Hixson, TN; and Universal Technology Systems, Jacksonville, FL.

Copyright Springhouse Corporation May/Jun 2002
Provided by ProQuest Information and Learning Company. All rights Reserved

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