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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 559-563

Role of ankle peak systolic velocity in predicting healing of diabetic foot lesions


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission14-Mar-2015
Date of Acceptance13-Apr-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Tawfik A Eldeen Tawfik
98 Elmotamayez District, Sherouk City, Cairo Ismailia Road, Cairo, 45511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198709

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  Abstract 

Objective
The aim of the present study was to determine whether ankle peak systolic velocity (APSV) can predict healing of diabetic foot lesions.
Background
Problems associated with the diabetic foot are prevalent worldwide. Diabetic foot lesions contribute significantly toward the morbidity and mortality of patients with diabetes mellitus. This study was carried out to evaluate the APSV as a predictor of healing in diabetic foot lesions.
Patients and methods
Diabetic patients referred to the General Surgery Department of Menoufia University were included in the study. Patients were included if they had foot lesions, such as ulcers, gangrene, or tissue necrosis, and had no palpable pedal pulses. End points were healed, healing, and nonhealing or amputation. In total, 50 diabetic foot patients were included in the study. All of them were subjected to the following: an assessment of full history; physical examination, including foot examination through peripheral pulses including Doppler examination, measurement of APSV, and ankle-brachial index; and routine investigations.
Results
Twenty-four patients reached the end point of adequate healing or complete healing. On the other hand, 26 patients had nonhealing lesions. The APSV was significantly higher in patients with healed or healing lesions compared with the patients with nonhealed lesions: 57.8 ± 12.72 versus 24.9 ± 9.55 cm/s (P < 0.001). At a cut-off point of 40 cm/s, the APSV showed a sensitivity of 90.91%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 92.3%, with a diagnostic accuracy of 97.4% in predicting the healing of diabetic foot lesions. There was a significant difference between the APSV before and after revascularization: 23.4 ± 6.5 versus 58.8 ± 12.3 cm/s (P < 0.001).
Conclusion
APSV could predict the healing of diabetic foot lesions with a high degree of accuracy in this group of patients.

Keywords: ankle peak systolic velocity, diabetes mellitus, diabetic foot ulcer, peripheral vascular disease


How to cite this article:
Hosny AM, Ahmed Zeed NA, Eldeen Tawfik TA. Role of ankle peak systolic velocity in predicting healing of diabetic foot lesions. Menoufia Med J 2016;29:559-63

How to cite this URL:
Hosny AM, Ahmed Zeed NA, Eldeen Tawfik TA. Role of ankle peak systolic velocity in predicting healing of diabetic foot lesions. Menoufia Med J [serial online] 2016 [cited 2020 Apr 4];29:559-63. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/559/198709


  Introduction Top


Foot ulcer is a disabling complication and not uncommon among patients with diabetes mellitus. The predictive factors for the development of diabetic foot ulcer are peripheral neuropathy, duration of diabetes, poor glycemic control, and peripheral vascular disease, which has been reported as a major significant risk factor [1] . The ankle-brachial index (ABI) is widely used for the assessment of the degree of peripheral ischemia [2],[3] . However, this parameter is not accurate in the presence of arterial wall calcification as it gives false high results [4] . The toe-brachial index (TBI) has been used as an alternative because digital arteries are not highly affected by calcification [5],[6] . However, the incidence of digital artery calcification among diabetics is still significant [7] . In addition, it is impossible to measure toe pressures in a substantial number of patients presenting with diabetic foot lesions because the toes are affected by ulcers or gangrene or are amputated, which makes the TBI invalid or impossible to use [8] .

In the present study, we describe a new alternative parameter for the assessment of the degree of peripheral ischemia - ankle peak systolic velocity (APSV). APSV is the mean of the peak systolic velocities measured across the distal tibial arteries at the ankle level.

We showed that APSV strongly correlates with the ABI and with the TBI whenever those can be reliably measured. APSV is not affected by vessel calcification and can be measured in the presence of toe gangrene or amputation; therefore, APSV is advantageous in those situations; moreover, it can be measured during arterial duplex scanning of the lower extremities, which is routinely performed in most centers for the assessment of peripheral ischemia, where it takes no extra time and adds no extra cost to that of the routine arterial duplex scan. The objective of the current study was to determine whether APSV could be used to predict the healing of diabetic foot lesions.


  Patients and methods Top


This study included 50 diabetic foot patients who presented to the General Surgery Department of Menoufia University Hospitals, Sheebin El-Koom, Egypt, during the period from April 2013 to October 2014. The patient population consisted of 28 men and 22 women with a mean age of 62.2 ± 7.2 years. To carry out this research, the oral approval of the patients and that of the ethics committee in the hospital were obtained.

Inclusion criteria

Only diabetic patients with absent pedal pulses and complaining of foot lesions (tissue necrosis, ulcer, or gangrene) were included in the study.

Exclusion criteria

Patients with venous ulcers, malignant ulcers, and autoimmune ulcers and those with ischemic limbs but without foot lesions (i.e. rest pain) were excluded from the study.

Clinical examination

At the initial clinical presentation, full history was taken from every patient and the clinical data (age, sex, risk factors, comorbidities, ABI, and full details of duplex scanning including APSV) were prospectively collected. Lesions were treated by daily dressings and followed up monthly. Postmanagement wound dressing protocol was standardized where the patients were followed up until they reached one of the end points of the study, which were a healed wound, a healing wound, a nonhealing wound, and major amputation. A wound was considered completely healed if it was fully covered with intact skin. In addition, it was considered adequately healing if it was completely covered with healthy granulation tissue, with the absence of tissue necrosis or infection. On the other hand, a wound was considered nonhealed if it did not show signs of healthy granulation tissue during follow-up. Treating physicians were blinded to the results of APSV. During the follow-up, data were collected as regards wound status, the details of the management plan, details of duplex scanning including APSV, and ABI values. Duplex scanning was carried out by an experienced operator using a duplex scanner with a color-coding facility (esaote MyLab50, Esaote, Napoli, Italy) using a 5-12 MHz linear transducer. APSV is the mean of the peak systolic velocities of the anterior and posterior tibial arteries measured at the ankle level as shown in [Figure 1]. The assessment of APSV was carried out as part of the arterial duplex scan where all patients were rested 1 h before scanning and were examined in the supine position; the recordings were made with the room temperature adjusted to 22°C to measure the peak systolic velocities of the distal posterior tibial artery at the malleolar level and the distal anterior tibial artery at the ankle-joint level. Peak systolic velocities were averaged over three cardiac cycles; if a focal stenotic lesion was detected in one of the distal tibial arteries, velocity measurements were taken distal to the stenosis. No alterations were made to the patient's medications before scanning.
Figure 1: Triphasic wave signals and peak systolic velocities of anterior tibial (ATA) and posterior tibial arteries (PTA) measured at the ankle level, showing peak systolic velocity of ATA = 50 cm/s and PTA = 40 cm/s as marked by (+) mark on the velocity scale, so the APSV in this patient's limb = 50 + 40/2 = 45.

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Statistical methodology

The data collected were tabulated and analyzed using the statistical package for social sciences (SPSS Inc., Chicago, Illinois, USA). A probability value (P-value) less than 0.05 was considered statistically significant.

Descriptive statistics

Number, percentage, mean ± SD were determined.

A P value of greater than 0.05 was considered statistically nonsignificant and a P value of less than 0.05 was considered statistically significant.


  Results Top


The study included 50 limbs, belonging to 50 patients; their mean age was 62.2 ± 7.2 years. All patients were diabetic. The demographic characteristics and risk factor distribution are shown in [Table 1].
Table 1 Baseline clinical characteristics of patients


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Twenty-four limbs with diabetic foot lesions reached the end point of adequate healing or complete healing: 23 patients underwent angioplasty revascularization and one was a candidate for conservative treatment. Twenty-two (44%) limbs did not heal: three (6%) limbs ended with nonhealing lesions (all had endovascular intervention), six (12%) limbs had below-knee amputations following failed revascularization (five endovascular interventions and one bypass surgery), and 13 (26%) limbs had above-knee amputation following failed revascularization (two endarterectomy and 11 bypass surgery). Four (8%) patients died ([Figure 2]).
Figure 2: End points of the current study, showing 48% healing, 6% nonhealing, 12% below-knee amputation, 20% above-knee amputation, and 8% death.

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The average mean APSV of the 24 limbs with healed or adequately healing lesion was significantly higher than that of the 26 limbs with nonhealing lesions: 57.86 ± 12.72 versus 24.90 ± 9.55 cm/s (P < 0.001) ([Table 2] and [Figure 3]).
Figure 3: Correlation between APSV and healing; at a value of 57.86 ± 12.72 cm/s, the patients healed, whereas at a value of 24.91 ± 9.55 cm/s, the patients neither healed nor showed any progression of healing. APSV, ankle peak systolic velocity.

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Table 2 Comparison between patients as regard ankle peak systolic velocity


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The receiver operating characteristic curve was used to determine the cutoff APSV value with the maximum sensitivity and specificity. A cut-off value of 40 meant a sensitivity of 90.91%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 92.3%, with a diagnostic accuracy of 97.4% in predicting the healing of diabetic foot lesions ([Figure 4]). [Table 3] shows that smoking, renal failure, and a history of previous amputation have a significant effect especially on the nonhealed patients.
Figure 4: The receiver operating characteristic curve determined the cutoff APSV value with the maximum sensitivity and specificity. A cut-off value of 40 has a sensitivity of 90.91%, a specificity of 100%, with a diagnostic accuracy of 97.4% in predicting healing of diabetic foot lesions. APSV, ankle peak systolic velocity.

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Table 3 Logistic regression of factors affecting the patients


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  Discussion Top


Many noninvasive methods have been described to predict wound healing of foot lesions in diabetic patients. These include ankle-brachial pressure [9] , toe-brachial pressure [9],[10] , transcutaneous oxygen [10] , skin perfusion pressure [11],[12],[13] , radioisotope clearance [14] , photoplethysmography [15] , and laser Doppler ultrasonography [12] .

The utility of the ankle-brachial pressure measurement is limited by the fact that a significant proportion of diabetic patients suffer some degree of arterial wall calcification, which may render ankle pressure impossible to measure or falsely elevated [16],[17] . The utility of toe-branchial pressure measurement is also limited by the possibility of calcification of the digital arteries in the diabetic patients and by the ulceration or tissue necrosis of the toes of many patients, which may render toe pressure measurements inaccurate or impossible [8] .

APSV is not affected by such limitations [18] . Skin perfusion pressure at a cut-off value of 40 mmHg has a sensitivity of 72% and a specificity of 88% in predicting wound healing [11] . Transcutaneous oxygen measurements at a cut-off value of 34 mmHg have a sensitivity of 78.6% and a specificity of 83% in predicting wound healing [19] . The sensitivity and specificity of APSV in our study compared favorably with the previously reported results of APSV, skin perfusion pressure, and transcutaneous oxygen. In the present study, APSV was used to predict healing of diabetic foot lesions. If foot perfusion was significantly impaired, as indicated by a low APSV, healing was unlikely. However, if foot perfusion was adequate, as indicated by a high APSV, wound healing was highly expected. Using the receiver operating characteristic curve it was found that the cut-off value of 40 cm/s gives the highest specificity and sensitivity to predict healing in this cohort of patients: a sensitivity of 90.91%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 92.3%, with a diagnostic accuracy of 97.4% in predicting healing of diabetic foot lesions. In their study, Bishara et al. [18] stated that APSV at a cut-off value of 35 cm/s showed a sensitivity of 92.9%, a specificity of 90.6%, a positive predictive value of 92.9%, and a negative predictive value of 90.6%. In their study, Taheri et al. [20] stated that APSV at a cut-off value of 40 cm/s has a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81, 78, 40, 95, and 78, respectively.


  Conclusion Top


APSV is an attractive arterial flow measure. This fast and simple functional measurement can be a valuable addition to the duplex examination to objectively quantify the vascular status and to monitor the progression of diabetic foot ulcer over time, especially in patients in whom the ABI cannot be reliably determined. This study demonstrates that the APSV is a reproducible measure that can be acquired in almost every diabetic foot patient to identify the degree of ischemia and predict the healing of foot lesions.

Larger studies in future are required to further support this conclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Young MJ, Adams JE, Anderson GF, Boulton AJ, Cavanagh PR. Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects. Diabetologia 1993; 36 :615-621.  Back to cited text no. 7
    
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Apelqvist J, Castenfors J, Larsson J, Stenström A, Agardh CD. Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care 1989; 12 :373-378.  Back to cited text no. 9
    
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Goss DE, de Trafford J, Roberts VC, Flynn MD, Edmonds ME, Watkins PJ. Raised ankle/brachial pressure index in insulin-treated diabetic patients. Diabet Med 1989; 6 :576-578.  Back to cited text no. 17
    
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Bishara RA, Taha W, Alfarouk MO, Abdel Aal K, Wasfy S. Duplex detected ankle peak systolic velocity: a new parameter for the assessment of degree of peripheral ischemia. Int Angiol 2004; 23:368-372.  Back to cited text no. 18
    
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20.
Taheri H, Amendola M, Pfeifer J, F Albuquerque, M Levy. Does peak ankle velocity (PAV) accurately reflect lower extremity arterial perfusion as assessed by ABI? J Vasc Surg 2013; 58 :1154-1155.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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