Morphological and diagnostic parallels in the pathology of the lower extremity veins in patients with purulent-necrotic complications of diabetic foot syndrome
Authors: Smirnov G. A. , Petrova V. V. , Akimov V. P. 
Published: May 2019

Objective: to study the peculiarities of the state of the lower extremities venous system in patients with complicated diabetic foot syndrome (DFS).

Materials and methods. The study group – 106 patients with type 2 diabetes mellitus (DM) and purulent-necrotic complications of DFS treated in the surgical department of the St. Petersburg State Medical Academy in 2009-2014. 30 preparations of the lower extremities obtained as a result of amputations in patients with purulent-necrotic complications of DFS and from corpses after autopsy. Conducted a macroscopic study of the lower extremities veins with a visual assessment of the changes and microscopic examination with the staining of histological preparations with hematoxylin and eosin, according to Van Gieson and Masson; ultrasound duplex examination (ultrasound) of the lower extremities veins in patients with DFS according to the standard protocol.

Results. Macroscopic evaluation in 90.0 % of cases revealed an excess of extracellular fluid (edema) of the extremities tissues. An analysis of the ultrasound findings of the lower extremity veins demonstrates the presence of lymphostasis in patients with diabetes in 83.0 %. In the overwhelming majority of preparations of vessels of the extremities with DFS (97.0%), a segmental expansion of the venous lumen was detected. Such a change can be the cause of cases detected during ultrasound in 60.0% and 73.0%, respectively, of dilatation of the veins and valvular insufficiency. In both morphological and ultrasound studies in no more than 15.0% of cases, the expansion sites were in the superficial veins, and fragments of an increase in the diameter of the lumen of the deep veins were found in 60.0% of patients, which demonstrates the likely difference in the nature of changes in the veins in diabetes and with varicose veins. In macroscopic and then histological studies, pronounced intramural and parabasal fibrosis of venous vessels was found in 37.0 0% and in 67.0 0% of cases, respectively. A rather specific feature to characterize the lesion of the venous system in diabetes is an increase in sonographic density of paravasal tissues, especially around the veins of the deep system (about 35.0% of observations). The findings of the ultrasound study describe the incompressibility of a vein or a decrease in its elasticity in the absence of data on the presence of a local thrombus, signs of current or resolved phlebothrombosis in 29.0% of cases in patients with DFS, which exceeds the general population frequency of this pathology even by the highest estimates of researchers. A morphological study of blood clots in venous vessels was found in 57.0% of observations, which may be due to the clinical insignificance or difficulty of visualizing small parietal thrombi and blood clots of small diameter venous vessels, but it confirms both complex disorders of the hemostatic system in diabetes and changes in venous walls predisposing to intravascular thrombosis.

Conclusion. Patients with purulent-necrotic complications of DFS in most cases have signs of damage to the lower extremities venous vessels, it is specific. Standard duplex ultrasound can detect these changes.