Condition of the blood flow of lower limb in patients with diabetes foot syndrome with signs of sepsis, in dependence on the level of Monckeberg's sclerosis
Authors: Shapoval S. D. , Savon I. L. , Trybushnyj O. V. , Maksymova O. O. , Smyrnova D. O. , Sedun D. J. 
Published: June 2019

Peripheral arterial occlusion and microvascular disorders are important factors that contribute to the onset of lower limb disease in patients with diabetes. Monckeberg's sclerosis (arteriosclerosis) arteriosclerosis is diagnosed as a random finding when performing radiography of the upper or lower extremities, but may be a complicating factor in systemic response syndrome and sepsis in patients with diabetic foot syndrome.

Purpose of the study. Analyze the condition of the blood flow of lower limb in patients with diabetes foot syndrome with signs of sepsis, in dependence on the level of Monckeberg's sclerosis.

Materials and methods. 75 patients with diabetes were examined, due to diabetic foot syndrome. 11 (14,7%) patients had type I diabetes, the average duration of which was 16,41 ± 3,85 years, 64 (85,3%) patients had type II diabetes, with of 12,25 ± 2,54 years duration. The age of patients with type I diabetes was 35 ± 5,72 years, with type II diabetes was – 63,51 ± 10,22 years. Men with type I diabetes were 63%, with type II diabetes – 53%. According to the latest recommendations Sepsis-3 (2016) and classification criteria, patients had signs of sepsis, which required a certain combination therapy.

Patients with sepsis were divided into two groups: group I consisted of 38 patients with an infected ulcer, abscess and phlegmon; to group II of 37 patients with gangrene of the toes, forefoot, gangrene of the entire foot or lower limb.

The first group of 38 patients included 5 with type I diabetes and 33 with type II diabetes. By age, sex, concomitant pathology of the group was representative.

Main vessels were investigated using ultrasound duplex scanning. Determined arterial systolic pressure at the level of the ankle, with the subsequent calculation of the ankle-humeral index, Arterial systolic pressure was also determined at the level of I toe. We had conducted radiography of the foot in two projections. We had Used X-ray classification of Monckeberg's sclerosis (V. A. Gorelysheva et al., 1989) in stages.

Research results. Patients in both groups were examined identically. The treatment was carried out in accordance with the standards of patient management with the development of sepsis; surgical intervention was justified on the basis of information obtained from the survey and clinical data. Patients of group I were performed: dissection of an abscess, phlegmon, sequestrectomy and arthrotomy. In group II – one or several fingers amputation, transmetatarsal amputation of the foot, amputation at the level of the calf or thigh.

33 (86,8 %) patients of group I and 30 (81,0%) patients of group IIhad signs Monckeberg's sclerosis varying stages. In 19 (58%) patients, group I, the X-ray picture of the distal arteries matched to grade 3 according to the presented classification Monckeberg's sclerosis, 9 (27%) patients had signs of grade IV, 3 (9%) – grade V. 6 (20%) patients, II groups had an X-ray picture of grade III, 13 (43%) patients had signs of grade IV, 11 (36%) had signs of grade V. All 9 patients with type I diabetes had signs of arteriosclerosis.

Using X-ray data, it is possible to classify Monckeberg's sclerosis by stages. However, with the duration of the disease for more than 10 years, the calcifications of the walls of the arteries of the foot in the form of a convoluted dense rope or column with simultaneous defeat of the smaller branches, which is characteristic of the final stages of the disease.

Despite the fact that as a result of calcifications, the vascular wall becomes rigid and loses the ability to reduce and dilate, the blood flow in it is preserved, and the level of SAT varies from > 200 to 80 mmHg. The presence of Monckeberg's sclerosis by radiography of the lower extremities was detected in 33 (86.8%) patients in group I and 30 (81,0%) in group ІІ. With an increased level of vascular involvement, Monckeberg's sclerosis increases the likelihood of developing critical ischemia and gangrene (х2 = 5,41; р = 0,02).

In patients of group I with systolic blood pressure of more than 120 mmHg the disease outlook was more favorable than in patients without a pulse wave or systolic blood pressure of the finger less than 80 mmHg (х2 = 11,76; р = 0,0006).

With a decrease in systolic blood pressure of less than 30 mmHg to save the distal part of the foot or the limb did not succeed. Calcification of the vascular wall does not affect the arterial patency directly, but after the formation of thrombosis, the blood flow stops.

Conclusions. In patients with sepsis, with signs of diabetic foot syndrome, which are characterized by a neuropathic form (ulcer, abscess, phlegmon), the presence of Monckeberg's sclerosis, even the last stages, with preserved systolic blood pressure of 200–120 mmHg does not lead to the development of critical deterioration blood circulation.

Deterioration of the rheological conditions of the lower extremity, with a systolic arterial pressure 80–50 mmHg below in combination with stage III–IV Monckeberg's sclerosis increases the risk of gangrene of the foot and limb. In the presence of Monckeberg's sclerosis of 3–5 stages in the small arteries of the foot, it is possible to maintain the integrity of the foot by maintaining a generally sufficient volume of blood flow, due to the fight against atherosclerosis of main vessels, to maintain systolic blood pressure not lower than 80–60 mmHg.