# Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome--A Narrative Review
## 4 Diabetic Foot Syndrome
[104] analyzed the impact of the association of DFS with cardiovascular risk and demonstrated that patients with diabetic foot are associated with more cardiovascular risk factors and have a higher prevalence of cardiovascular pathologies with a negative prognostic role or subclinical impairment. In the same study, follow-up over a 5-year period showed an increased risk of an acute vascular event, the main factors associated with cardiovascular morbidity being duration of diabetes, age, glycosylated hemoglobin value and association of DFS. Diabetic foot may also be considered a marker of cerebrovascular risk through the clinical picture marked by numerous associated cardiovascular risk factors [105]. Imaging assessment of patients with DFS provides details with therapeutic value for the diabetologist and surgeon alike by identifying associated osteitis or neuroarthropathy or by providing for assessment of the arteries prior to angioplasty [106]. The methods used are varied, from bone X-rays to computed tomography (CT) or nuclear magnetic resonance (MRI) evaluation, vascular ultrasonography (US), radionuclide imaging examination or positron emission tomography (PET) [107]. One of the main challenges is to differentiate infectious radiological changes from those associated with neuroarthropathy [108]. MRI is the gold-standard imaging method for the detection of osteomyelitisitis [109]. A meta-analysis by [PERSON] et al. [110] revealed that of all the previously mentioned imaging methods, MRI is the only one with a sensitivity and specificity of over 90%. Bone X-rays can be used in the initial screening of DM patients, but the sensitivity is low. In the early stages, radiographic evaluation does not identify osteomyelitisitis [111]. Its most common applications are in the identification of Charcot osteoarthropathy or the detection of calcification of the posterior dorsal artery in Monckeberg's sclerosis [112; 113; 114]. DFS-associated infections are easily diagnosed with CT and MRI by highlighting small intraosseous abscesses or sinus tracts [115]. Radionuclide imaging is often associated with imaging techniques that identify morphological aspects, thus providing superior accuracy. Single-Photon Emission Computed Tomography can be used both as a screening test and to assess labeled leukocyte imaging location and activity [116; 117]. US has multiple implications in the assessment of patients with DFS, being used both in risk stratification of patients with DM and for arterial mapping, assessment of arterial vascular lesions or identification of calcifications [118; 119]. US is also involved in the diagnosis and management of patients with DF ulcers. The results of three prospective randomized clinical trials have been reported in the literature demonstrating additional reduction in ulcer area and faster complete healing compared to sham treatment [120; 121; 122]. The management of patients with DFS is complex, involving both glycemic control, control of cardiovascular risk factors, administration of analgesic medication, revascularization and surgical treatment [123]. The surgical treatment of these patients is complex and includes various types of interventions such as debridement, Achilles tendon lengthening (reduces the risk of recurrence of ulcers [124; 125]) and vascular surgery. [PERSON] et al. [126] recently highlighted that this minimally invasive technique is associated with a faster re  
Figure 1: Risk factors for DFS (adapted from [103]). covery compared to the classical conservative management represented by immobilization, while improvements in radiological aspects are also targeted. Superficial ulcers can be treated conservatively, but bone or tendon involvement requires surgical reconstruction sometimes associated with revascularization methods to prevent osteomyelitisitis [127]. Data from the literature emphasize two basic principles in the surgical management of patients with DFS: revascularization of lesions (endovascular or bypass techniques) and management of associated infections [128].