Cutaneous microcirculation in the neuropathic diabetic foot improves significantly but not completely after successful lower extremity revascularization
Cutaneous microcirculation in the neuropathic diabetic foot improves significantly but not completely after successful lower extremity revascularization
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DOI：
10.1067/mva.2002.121126
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发表时间：
2002-03-01
影响因子：
4.3
通讯作者：
Veves, A
中科院分区：
文献类型：
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作者：
Arora, S;Pomposelli, F;Veves, A
目的：探讨大血管重建术对神经缺血型糖尿病足微循环的影响。研究设计与方法：对13例糖尿病周围动脉病变伴神经病变患者(DI组)行大血管重建术前及术后4~6周足部皮肤微血管反应性测定。我们还将他们与年龄匹配和性别匹配的15名糖尿病和神经病变患者、7名没有神经病变的患者和12名健康患者作为对照进行比较。我们使用单点和激光多普勒扫描成像来测量足部皮肤在加热到44℃以及离子导入1%乙酰胆碱(内皮依赖性反应)和1%硝普钠(内皮非依赖性反应)时的血管扩张反应。DI组对热的反应从术前的289%+/-90%(比基线增加的百分比，以伏特计)增加到术后的427%+/-61%(P<；0.05)，但仍与糖尿病和神经病变患者的反应(318%+/-51%)相当，低于无神经病变的患者(766%+/-220%)和健康对照组(891%+/-121%；P<；.0001)。DI组的乙酰胆碱反应也从术前的6%+/-4%提高到术后的26%+/-8%(P<；0.05)，与糖尿病合并神经病变患者(18%+/-3%)和无神经病变患者(38%+/-8%)相似，但仍低于对照组(48%+/-9%；P<；.001)。DI组硝普钠反应由10%+/-4%改善至29%+/-9%(P<；0.05)，与神经病理性(25%+/-9%)、非神经性(32%+/-6%)和对照组(40%+/-5%)相似。依赖于C纤维伤害性感受器的健康功能，DI组的神经血管反应在基线(5%+/-9%)和手术后(14%+/-110%)和神经病变组(33%+/-21%)相似，但与非神经病变组(110%+/-40%)和对照组(198%+/-54%)相比显著降低(P<；.001)。结论：糖尿病神经病变下肢血管扩张受损导致功能性缺血，这种情况明显改善，但不能通过成功的搭桥手术完全纠正。因此，尽管大血管血流得到充分纠正，糖尿病合并神经病变的患者仍有发生足部溃疡或现有溃疡未能愈合的高风险。
Objective: The purpose of this study was the examination of the effect of successful large vessel revascularization on the microcirculation of the neuroischemic diabetic foot.Research design and methods: We measured the cutaneous microvascular reactivity in the foot in 13 patients with diabetes with peripheral arterial disease and neuropathy (group DI) before and 4 to 6 weeks after successful lower extremity arterial revascularization. We also compared them with age-matched and sex-matched groups of 15 patients with diabetes and neuropathy, seven patients without neuropathy, and 12 healthy patients for control. We used single-point and laser Doppler scan imaging for the measurement of the foot skin vasodilatation in response to heating to 44degreesC and to iontophoresis of 1% acetylcholine (endothelial-dependent response) and 1% sodium nitroprusside (endothelial-independent response).Results. The group DI response to heat increased from 289% +/- 90% before surgery (percent increase over baseline measured in volts) to 427% +/- 61% (P < .05) after surgery but was still comparable with the response of the patients with diabetes and neuropathy (318% +/- 51%) and lower than the responses of the patients without neuropathy (766% +/- 220%) and the healthy patients for control (891% +/- 121%; P < .0001). The group DI acetylcholine response also improved from 6% +/- 4% before surgery to 26% +/- 8% after surgery (P < .05) and was similar to the responses of patients with diabetes and neuropathy (18% +/- 3%) and patients without neuropathy (38% +/- 8%) but still lower when compared with the response of the patients for control (48% +/- 9%; P < .001). The sodium nitroprusside response for group DI improved from 10% +/- 4% to 29% +/- 9% (P < .05) and was similar to the responses of the neuropathic (25% +/- 9%), nonneuropathic (32% +/- 6%), and control (40% +/- 5%) groups. The group DI neurovascular response, which depends on the healthy function of the C-fiber nociceptors, was similar at baseline (5% +/- 9%) and after surgery (14% +/- %10) and in the neuropathic group (33% +/- 21%), but it was dramatically reduced when compared with the nonneuropathic (110% +/- 40%) and control (198% +/- 54%) groups (P < .001).Conclusion: Impaired vasodilation in the diabetic neuropathic lower extremity leads to functional ischemia, which improves considerably but is not completely corrected with successful bypass grafting surgery. Therefore, patients with diabetes and neuropathy may still be at high risk for the development of foot ulceration or the failure to have an existing ulcer heal despite adequate correction of large vessel blood flow.