Cath Lab Digest

Literature Review

Nonhealing foot ulcers, characterized by a lack of self-repair over time, are prevalent among individuals with diabetes mellitus.¹ Although surveillance reports of diabetic foot ulcers are fraught with limitations, primarily due to the number of ulcers managed in the outpatient setting, the prevalence ranges from 5.3 to 10.5 per 100 people, depending on the type of diabetes and age of the patient.² The diabetic population represents 4% of the total US population; however, nearly 50% of all lower-limb amputations are performed in these individuals, underscoring the high risk for foot ulcers associated with diabetes.³ Diabetes is strongly and independently associated with peripheral arterial disease (PAD) and its most frequent symptom, intermittent claudication. In one population-based study (N = 6,450), patients with PAD were twice as likely to have diabetes as healthy controls (odds ratio 2.0, 95% confidence interval, 1.6 to 2.5).⁴ Peripheral arterial disease is an independent risk factor for foot ulcers.⁵ Impaired blood flow of both the macrovascular and microvascular circulations secondary to vascular occlusion and ischemia promote the development and exacerbation of foot ulceration and impair the healing process by impeding delivery of oxygen and nutrients to the wound.

Foot ulcers are resistant to many forms of therapy. Even when the basic tenets of chronic wound care such as offloading, debridement, and maintenance of a moist wound base are employed, healing these wounds remains difficult at best. Indeed, the lack of a uniformly effective regimen utilized in the general medical population to treat foot wounds is reflected in the high amputation rate among patients with diabetes. Recently, anecdotal reports suggest that cilostazol, which was approved in Japan in 1988 for the treatment of PAD-associated ulcerations, pain, and coldness and is FDA-approved for the treatment of intermittent claudication in the US, appears to increase the rate of wound healing in patients with diabetes. This report describes the clinical experience of one such patient who presented with a nonhealing wound of the left great toe and a second ulceration at the medial plantar aspect of the left foot.

Case Study

A 54-year-old woman with type 2 diabetes and PAD presented at the wound-care clinic for evaluation of an open foot wound that had not healed over approximately 6 months. The woman's diabetes was non-insulin dependent for 24 years, but glycemic control was managed by insulin for 1 year before presentation. The patient had several cardiovascular risk factors: her father had a history of coronary artery disease and myocardial infarction; she smoked cigarettes for 20 years but had quit 17 years before presentation; and she had a history of hypercholesterolemia.

For the 5 months immediately following the wound's development, the patient received chloramine-T whirlpools (Chlorazene® Whirlpool Antiseptic, Lake Erie Medical, Hinckley, Oh.) and collagenase (Santyl®; Smith and Nephew, Largo, Fla.) treatment at the direction of her primary care physician. One month before she came to the wound clinic, she underwent femoral-popliteal bypass surgery, at which time the wounds were debrided. Following surgery, the patient developed a systemic infection, extending her hospital stay and mandating the use of intravenous antibiotics. Subsequent treatment consisted of the chloramine-T whirlpools with some additional debridement around the wound. Local treatment to the wound consisted of collagenase applied twice daily. She was fully weight-bearing with ambulation. The patient had been advised that below-knee amputation was imminent if the wounds failed to heal.