Keywords
diabetes-related peripheral arterial disease - endovascular revascularization - interventional
radiology - Saudi Arabia
Introduction
Diabetic foot disease (DFD) is a common and serious complication of diabetes that
represents a major health concern with high associated mortality and morbidity rates.
DFD is classified under the umbrella of “critical limb ischemia” (CLI), which varies
in symptoms from rest pain to ulcers and tissue loss.[1] DFD is attributed to many causative factors, the most common of which are peripheral
sensory neuropathy and peripheral arterial disease (PAD).[2] In Saudi Arabia, the prevalence of peripheral sensory neuropathy among patients
with diabetes is 29.1%.[3] PAD has a prevalence rate of approximately 23.1% in the Saudi diabetic population.[4] Foot ulcers are associated with an increased risk of lower limb amputation in patients
with diabetes.[2]
A study conducted in Saudi Arabia showed that the findings of two previous studies
as well as three methodological publications led to the prediction that approximately
325 amputations are likely to occur annually in Jeddah, compared with 741 in Riyadh
and 3,970 in Saudi Arabia.[5] Thus, the main goal of peripheral ischemic foot ulcer treatment is limb preservation.[2] A multidisciplinary team, including interventional radiologists, vascular surgeons,
foot surgeons, podiatrists, endocrinologists, family physicians, and physiotherapists,
is essential for the effective treatment of PAD. Successful revascularization and
improved perfusion have had fundamental roles in reducing the rate of amputation among
diabetic foot patients over the last decade.
Treatment options have been developed for non-healing ischemic DFD, including surgical
bypass for the occluded vessels (performed through vascular surgery) or endovascular
revascularization (i.e., percutaneous transluminal angioplasty or stenting), which
is mostly performed through interventional radiology. Nonsurgical treatment has many
advantages. Specifically, effective nonsurgical treatment presents an achievable,
safe, minimally invasive, low-risk, and cost-effective set of procedures for limb
salvage in a high percentage of diabetic patients.[6] However, because of the rapid development of new technology, public awareness of
the effectiveness of endovascular options in the treatment of diabetic PAD has not
been thoroughly investigated, especially in Saudi Arabia. Raising public awareness
plays a key role in early treatment and prevention of amputation. This study aimed
to assess the level of awareness and knowledge among the Saudi population regarding
interventional radiology as an option for the treatment of DFD.
Materials and Methods
In this cross-sectional study, the self-administered online survey for the year 2021
was distributed at random through social media platforms. A simple random sample of
1,776 participants was calculated using a Raosoft sample size calculator.[7] The minimum sample size needed to conduct this study with a confidence interval
of 99% was 664.[7] Data were collected using Google forms (Google Sheets) and were coded and processed
using Microsoft Excel and the Software Statistical Package for the Social Science
(SPSS) version 23 (SPSS, Inc., Chicago, Illinois, United States).
The survey questionnaire started with an informed consent document, and all participants
provided their written informed consent for participating in the study.
The survey questionnaire contained 20 multiple choice questions divided into three
main sections ([Supplementary Material S1], available online only). The first section consisted of demographic data, including
nationality, region, gender, age, education level, employment in the medical field
(students or working professionals), and family history of diabetes ([Table 1]).
Table 1
Demographic data
|
%
|
|
Gender
|
Male
|
24.6
|
|
Female
|
75.4
|
|
Nationality
|
Saudi
|
97.4
|
|
Non-Saudi
|
2.6
|
|
Age
|
Less than 20
|
9.5
|
|
20–30
|
25.8
|
|
31–40
|
22.3
|
|
41–50
|
26.4
|
|
More than 50
|
16
|
|
Education level
|
Illiterate
|
0.5
|
|
Primary, Middle, or Secondary school
|
20.1
|
|
University
|
71.8
|
|
Master or PhD
|
7.5
|
The second section covered questions about knowledge and perceptions regarding DFD,
including definition of DF, current positive family history, associated symptoms,
causative factors, DFD treatment options (including conservative treatment with wound
care and antibiotics, revascularization, and amputation), and individual opinions
regarding DFD as a common complication of diabetes in Saudi Arabia. The third section
focused on endovascular revascularization as a treatment option for DFD-related PAD.
Questions included familiarity with this procedure, if the procedure was considered
minimally invasive, the type of anesthesia used in this intervention, participants'
opinions on whether the procedure could contribute to reducing the amputation rate,
and the source of their information. The accuracy and validity of the questionnaire
were confirmed by two consultants: an interventional radiologist and a family physician.
Descriptive statistics, including frequencies and percentages, were used to describe
items and study variables. As these variables represent nominal data, Chi-square tests
were conducted to assess differences in variable distribution as well as associations
between variables based on the study objectives. Statistical significance was set
at a p-value ≤0.05.
The study was approved by the Ethical Research Committee of the College of Medicine
at the University of Hail, Saudi Arabia. This study was conducted in accordance with
the principles of the Declaration of Helsinki.
Result
A total 1,743 people participated in this study (75.4% female; 24.6% male), the majority
of them were Saudi (97.4%). Their age was classified into five groups with the majority
of participants in the 41 to 50 and 20 to 30 years age groups (26.4 and 25.8%, respectively).
In addition to that, around two-thirds (71.8%) were university students or had Bachelor's
degree ([Table 1]).
The survey tool was distributed through social media platforms within the Kingdom
of Saudi Arabia and the percentages from each region were as follows: Middle 33.6%,
North 27.5%, West 13.2%, East 13.0%, and South region 12.7%.
A history of diabetes mellitus was found in 67.5% of the participants' families. Moreover,
12.1% of all respondents had a family history of DFD. By using Chi-square test was
conducted to evaluate the relationship between the family history of DFD with some
demographic parameters. DFD awareness was significantly associated with 34.1% of the
participants (p = 0.001) of age group of 41 to 50 years. Similarly, with a central region of SA by
33.6% (p = 0.000).
The reported symptoms of patients with DFD are mentioned in [Table 2]. The Table shows that a majority of the patients have poor glycemic control. Regarding
the knowledge of DFD, around half of the participants (56.8%) did not know what DFD
is, and even those who knew about it (43.2%), 8.2% of the participants had a wrong
impression of it ([Table 3]).We sought to establish relationships associated with the correct definition of
DFD and found that the level of education and occupational health were statistically
significant. The relation between correct definition of DFD and level of education
was characteristically associated with university students by 74.8% (p = 0.000). Likewise, medical students and workers showed an advantage over non-medical
students by 86.9% (p = 0.000). Contrarily, the age in relation to knowledge of DFD was statistically insignificant
(p = 0.42).
Table 2
Diabetic foot disease symptoms
|
%
|
|
Poor glycemic control
|
30.3
|
|
A feeling of coldness, pain, burning sensation or tingling in the foot
|
24.9
|
|
Foot redness or hotness
|
15.7
|
|
Loss of sensory or motor function of the foot
|
15.1
|
|
Foot deformity
|
11.3
|
Table 3
Public awareness of diabetic foot definition
|
Do you know what diabetic foot disease is?
|
%
|
|
Yes
|
43.2
|
|
No
|
56.8
|
|
Yes
|
43.2%
|
|
An open wound that is difficult to heal and loss of tissue which is commonly located
on the bottom of the foot
|
91.8
|
|
Tightening or tearing of the ankle joint ligaments
|
2.9
|
|
Bony protrusion on the underside of the heel
|
2.9
|
|
Chronic skin disease or recurrent itching
|
2.4
|
The highest percentage of people were unaware of the common causes of DFD (54.1%),
given the fact that neuropathy and foot ischemia are the responsible causes, which
42.6% agree and 3.3% disagree.
A total of 61.3% felt that DFD is one of the most common complications of diabetes
in Saudi Arabia, 33.9% had no idea about that and 4.9% believed that DFD is not considered
a common complication.
Awareness of treatment of DFD varied among respondents ([Fig. 1]) with the highest two relative percentages between 35.7% reported that by conservative
treatment with wound care and antibiotics and 30.1% reported that by revascularization.
We focused on asking those who had a family history of DFD regarding the treatment
options. It appeared that the highest percentage (16.9%) chose amputation as a definitive
treatment. Around 14.2% of diabetic patients reported the conservative treatment with
wound care and antibiotics as the preferred treatment, 12.8% selected the revascularization
option, and 7.7% denied any information about the options at all.
Fig. 1 Public awareness of treatment options of diabetic foot.
As for the awareness about endovascular revascularization for the treatment of DFD,
the majority of patients (90.2%) had never heard about the interventional radiological
approach, while only 9.8% were familiar with it.
Notably, the knowledge and awareness of endovascular revascularization have been influenced
by many factors such as age, occupation, and family history. The median age group
20 to 30 years is well aware of the procedure by 30.4%. Almost equal percentage between
41 to 50 years (22.6%) and 31 to 40 years (20.0%). It was also a statistically significant
outcome in relation to employment/training in the medical field (90.5%) and in family
history of DFD (87.9%).
Concerns about the interventional radiology approach, to be considered as safe and
minimally invasive, were investigated among the familiar group. It showed that 62.5%
had no concerns, 8.3% had some worries, and 29.2% were unsure whether it is a risky
procedure or not.
A total of 56.3% of the participants were aware about local anesthesia, which is the
type of anesthesia used to perform this procedure, while 30.5% did not know about
it, and 13.2% reported it as a general anesthesia. The fact that the endovascular
revascularization can contribute to the reduction of the amputation rate of the diabetic
foot was approved by 73.8% of the participants, 19% had no idea about it, and 7.1%
did not agree with it.
We found that the largest source of the participants' information were social media
28.7% and internet 26.2% followed by friends or relatives 16.0%, family physician
10.2%, medical books 10.2%, and the patient's surgeon 8.6%.
Discussion
Endovascular intervention allows for a minimally invasive low-risk procedure and it
can be performed under local anesthesia, and thus public health efforts are necessary
to promote knowledge of this treatment modality within the Saudi population.[8]
In two studies conducted in Saudi Arabia, patients had no knowledge of interventional
radiology procedures as treatment choices for their medical conditions. According
to a study conducted in 2020, 74.2% of participants had never heard of radiofrequency
ablation as a thyroid nodule treatment option.[9] Another study of Saudi women's awareness of uterine artery embolization found that
76.1% had never heard of this procedure.[10] This current study is the first to evaluate the Saudi population's awareness of
interventional radiology procedures for the treatment of DFD. Majority of respondents
in this online survey had no knowledge of interventional radiology treatment options
for DFD. Involvement in the medical field, whether by employment or study, had a major
impact on awareness of interventional radiology treatment options for DFD. These deficiencies
arise from a lack of awareness about treatment options, whereas public health education
and specialist consultation prevent amputation.
Conclusion
The findings of this study highlight the need for further efforts to raise public
awareness of the importance of the role of endovascular intervention in the treatment
of DFD with poor perfusion, as important medical decisions require patients to be
well-informed and active in the decision-making process.
