Diabetes mellitus und periphere arterielle Verschlusskrankheit (PAVK)

Bundesweit steigt die Zahl stationär behandelter Patienten mit peripherer arterieller Verschlusskrankheit (PAVK). Dabei beträgt der Anteil der Diabetiker mit kritischer Extremitätenischämie mittlerweile fast 50 %. Demzufolge werden auch von den jährlich durchgeführten rund 16 000 hohen Amputationen infolge von Durchblutungsstörungen über 70 % bei Menschen mit Diabetes mellitus durchgeführt. Als nichtinvasive hämodynamische Funktionsuntersuchungen werden Knöchel- und Zehendruckmessungen, die Doppler-Pulskurvenanalyse, die Duplexsonografie und die transkutane Sauerstoffdruckmessung empfohlen und ermöglichen zusammen mit der bildgebenden Diagnostik die richtige Diagnose. Multimorbide diabetische Patienten mit kritischer Extremitätenischämie sollen, sofern möglich und bei geeigneter Expertise, zunächst endovaskulär revaskularisiert werden. Trotz einer etwas schlechteren Offenheitsrate ist die Beinerhaltungsrate dem Ergebnis nach einer Bypassanlage vergleichbar.

Throughout Germany the number of people being treated for peripheral arterial occlusive disease (PAOD) as inpatients in hospital is increasing. The proportion of these who are diabetics with severe limb ischaemia is now almost 50%. Of the 16,000 amputations performed annually as a result of circulatory disorders, therefore, over 70% are on people with diabetes mellitus. As non-invasive haemodynamic function examinations, ankle and toe pressure measurements, the Doppler pulse curve analysis, duplex sonography and transcutane oxygen pressure measurements are recommended and, together with imaging diagnostics, enable the correct diagnosis. Multi-morbid diabetic patients with severe limb ischaemia should, where possible and with appropriate expertise, initially undergo endovascular revascularisation. Despite a somewhat poorer patency rate, the rate of leg retention is comparable to the results following bypass procedure.

Key words

peripheral arterial occlusive disease (PAOD) - severe limb ischaemia - amputation - non-invasive haemodynamic function examinations - endovascular revascularisation - patency rate

• Literatur

• 1 Fowkes GFR, Rudan D, Rudan I et al Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382: 1329-1340
• 2 Diehm C, Schuster A, Allenberg H et al High prevalence of peripheral arterial disease and comorbidity in 6.880 primary care patients: cross sectional study. Atherosclerosis 2004; 172: 95-105
• 3 Lawall H, Lüdemann C. Diagnostik und Therapie der peripheren arteriellen Verschlusskrankheit bei Diabetespatienten. Diabetologie 2015; 11: 12-21
• 4 Morbach S, Müller E, Reike H et al Diabetisches Fuß-Syndrom. Praxisleitlinie DDG. Diabetologie 2013; 8: 180-188
• 5 Maylar N, Fürstenberg T, Wellmann J et al Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. Eur Haert J 2013; 34: 2706-2714
• 6 Pscherer S, Dippel FW, Lauterbach S et al Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Prim Care Ciabetes 2012; 6: 241-246
• 7 Schaper NC, Andros G, Apelquist J et al Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 2012; 28: 218-224
• 8 Game FL, Hinchcliffe RJ, Apelquist J et al A systematic review of interventions to enhance the healing of chronic foot ulcers of the foot in diabetes. Diabetes Res Rev 2012; 28: 119-141
• 9 Huyn S, Forbang I, Allison MA et al Ankle-brachial index, toe-brachial index, and cardiovascular mortality in patients with and without diabetes mellitus. J Vasc Surg 2014; 8: 1-6
• 10 Lawall H, Huppert P, Rümenapf G. S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der PAVK. AWMF-LL. 065/003. 2015
• 11 Reinecke H, Unrath M, Freisinger E et al Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence. Eur Heart J 2015; 36: 932-938
• 12 Pearce BJ, Toursarkissian B. The current role of endovascular intervention in the management of diabetic peripheral arterial disease. Diab Foot Ankle 2012; 3 DOI: 10.3402.
• 13 Reekers JA, Lammers J. Diabetic foot and PAD: the endovascular approach. Diabetes Metab Res Rev 2012; 28: 36-39
• 14 Hinchliffe RJ, Andros G, Apelquist J et al A systematic review of the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev 2012; 28: 179-217
• 15 TASC Steering Committee. Jaff MR, White CJ, Hiatt WR et al An update on methods for revascularization and expansion of the TASC Lesion Classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the management of peripheral arterial disease (TASC II). J Endovascular Ther 2015; 22: 663-677
• 16 Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev 2012; 28: 40-45
• 17 Venermo M, Biancari F, Arvela E et al The role of kidney disease as a predictor of outcome after revascularisation of ulcerated diabetic foot. Diabetologia 2011; 54: 2971-2977