For the diagnosis of ischemia, the observed clinical symptoms must be verified by performing tests. Although the ankle brachial pressure index (ABI) offers the simplest and fastest technique, the additional use of loading is useful for detecting mild peripheral arterial disease (PAD). Because the ankle arteries readily become calcified, blood pressure can be evaluated in the toe arteries, which are not easily calcified. Intermittent claudication should be assessed by gait representation techniques; further, resting pain, ulceration, and necrosis must be assessed by evaluating skin microcirculation. These physiologic tests are useful for assessing severity, differentiating from other causes, and indicating the timing of treatment.

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The first choice treatment for critical limb ischemia, the most severe manifestation of peripheral arterial disease (PAD), is revascularization therapy. In contrast, walking exercise with anti-platelet therapy is the best for PAD without critical limb ischemia to improve the ability to walk without claudication for an extended period of time and to prevent from cardiovascular events. Supervised exercise is recommended, although if it is not feasible, home exercise should be started as soon as possible. Mechanisms for improvement of intermittent claudication may be increase in collateral flow and anriogenesis, nitric oxide-dependent vasodilation, increase in mitochondrial energetic and decrease in markers of systemic inflammation. Even after revascularization therapy, exercise should be continued to prevent from cardiovascular events.

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By increased in patients with diabetes and chronic kidney disease and aging, in addition to the peripheral artery disease (PDA) due to atherosclerosis, such as diabetic neuropathy and peripheral arterial disease, having further complication of malnutrition and infection, patients with wound of limb, including diabetic foot are increasing. Nutritional therapy for wound healing is a basic treatment. The nutritional management for atherosclerotic cardiovascular disease, it is necessary to make the management of the risk factors (diabetes, chronic kidney disease, dyslipidemia and metabolic syndrome) and the nutritional status of them. Nutritional assessment is constructed from clinical diagnosis, somatometry, weight change, dietary intake and blood date. Nutritional screening must be made using the subjective global assessment (SGA). Because of most of patients with wound of limb have malnutrition. The comprehensive nutritional assessment is important.

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Surgery, trauma or sepsis not only affects local response but also generalized metabolic changes which is independent on the various stresses. Critical illness is typically associated with a catabolic stress state in which patients commonly demonstrate a systemic inflammatory response. Nutritional therapy must focus to attenuate the metabolic response to stress by inflammatory cytokines, and not to feeding nutrients alone. Overfeeding should be avoided to reduce complications. It is vital that the right amount of energy, protein and micronutrients are given at the right stage of critical illness. In most cases, enteral feeding is the preferred method, although the critically ill patient’s gut may not always function correctly. Thus, special technique for feeding, tubes or drugs may be required in addition to knowledge of pathophysiology.

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Evidence-based guidelines for nutritional intervention for ischemic foot lesion has been lacking. Therefore, we treat ischemic wound based on the concept of wound healing. For limb salvage of ischemic intractable wound, arginine supply may be one of the important points. Even in the case of limb amputation, continuous arginine supply may be beneficial for healing of the wound of amputation site.

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The basic methods of medical nutritional therapy are; first, selecting optimal route of delivery; second, assessing and feeding the desirable amount of energy, protein, water, vitamins and electrolytes considering the size of wound and complications; followed by monitoring patients. It is necessary to take into account that complications, the amount and the infusion rate of total parenteral nutrition (TPN) and enteral nutrition (EN) are different because of the different route of absorption. It is not recommended to use TPN for a long term due to the risk of bacterial translocation. TPN should be used only when the intestinal route is unavailable or a circulatory system is unstable. When advancing EN, optimal formulas, and infusion rate should be determined, and careful monitoring should be done. Careful monitoring should be provided especially when advancing from TPN to EN.

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Foot care team is composed of Certified Foot care Educator nurse who perform mainly foot care and doctors who treat foot lesions belonging to department of nephrology, diabetes mellitus, cardiology, plastic surgery, and vascular surgery in our hospital. Nephrology doctors establish an outpatient clinic for foot diseases and work as gatekeeper to help the patients to introduce to the appropriate specialist. We also hold a foot care conference every 2 weeks and make a presentation about several patients and discussed each other. This conference enables us to understand the patients deeply each other and to treat in a cross-sectional and multidisciplinary way. In order to treat patients with foot lesions, it is indispensable to keep in close contact with the doctors and nurses whose technique come up to the standard. Our foot care team establishes the completed system in which all the necessary and possible medical care for the foot lesions can be performed in the hospital.

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In the medical treatment of critical limb ischemia (CLI), revascularization is in essential procedure. The methods of revascularization are divided roughly into surgical bypass surgery (BS) and endovascular treatment (EVT). Selection of BS or EVT is dependent on the idiosyncrasies of the medical facilities. In our hospital, revascularization is performed by a cardiologist, a cardio vascular surgeon or both mutually supporting each other. We are calling this endeavor “complementary revascularization strategy.” In the six years, since implementing this strategy, we performed revascularization on 181 lower limbs affected CLI. Six patients were lost during hospitalization; the mortality rate was 3.6%. Six patients discontinued medical treatment, so there isn’t data on their prognosis. Five patients received revascularization for major amputation, not for limb salvage. In the end, limb salvage succeeded in 144 out of 164 cases (Limb salvage rate was 87.8%).

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In critical limb ischemia, the angiosome in three branches of the lower legoften changes location in the foot, supplying nutrition to the periphery througharterial-arterial connection.We compared foot wounds macroscopically and by angiography, examined their correlation to the angiosome and concurrently investigated the correlation between the regions of endovascular treatment (EVT) and the ulcer healing rate. A high rate of agreement (82.1%) was observed between the sites of ulceration and those of vascular occlusion in the foot. Moreover, the site of vascular patency after EVT and the ulcer-healing rate were analyzed. No significant difference was observed in the lower leg (91.7% in the direct group vs. 81.5% in the indirect group), whereas a significantly higher rate of cure was detected in the foot (96.6% in the direct group vs. 72.7% in the indirect group). These results suggest that an ulcer can be cured and major amputation avoided, as long as the patency of the feeding artery of the angiosome is maintained in a foot wound after EVT.

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We have performed modified transmetatarsal amputation (modified TMA) which preserves perforators around metatarsal bones to prevent soft tissues necrosis. In some cases, declines in blood flow to soft tissues and necrosis couldn’t avoid, nevertheless modified TMA was performed. In order to examine the causes of declines of blood flow to peripheral tissues, we researched 11 patients’ changes of skin perfusion pressure (SPP) before and after modified TMA. All patients were operated revascularization procedure before TMA. 3 patients’ both dorsal and plantar SPP rose. 3 patients’ both dorsal and plantar SPP decreased and their wound healings were protracted. 4 patients’ either side SPP decreased on the other side SPP rose and 2 of their wound healings were protracted. Revascularized arteries were obstructed on 3 patients whose both side SPP decreased. Perforator occlusion will be responsible for either side SPP decreasing. Modified TMA has high rate of wound healing. But it has a possibility that leads to soft tissue necrosis because of perforator occlusion. How to prevent perforator occlusion is our future consideration.

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Objective: Among diabetic patients, end-stage renal disease, in particular hemodialysis, relates to the occurrence of diabetic foot. We investigated the foot complications among diabetic nephropathies before hemodialysis. Methods: There were 106 patients [80 male, average age 62.0 (33–80) years, diabetic duration 17.7±8.8 years, HbA1c (NGSP) 7.7±1.5%, serum creatine 1.9±0.9 mg/dl, eGFR (estimated glomerular filtration rate) 33.0±14.5 ml/min/1.73m²]. We evaluated the occurrence of the foot complications and analyzed the risk factors by the Cox proportional hazards model. Results: The mean observation period was 32.4±22.2 months, and 10 patients underwent therapy for diabetic foot. By multivariate analysis, smoking, diastolic blood pressure and serum creatinine level were significantly associated with the event of diabetic foot [hazard ratio (HR): 13.0, 95% confidence interval (CI): 1.16–435.8, HR: 1.18, 95% CI: 1.03–1.37, HR: 9.03, 95% CI: 1.05–123.6]. Conclusions: It was suggested for the optimal prevention of diabetic foot complications, a multilateral approach was necessary, especially life-support instruction for smoking cessation and therapeutic intervention for hypertension and renal dysfunction.

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I, as a physical therapist, joined in a foot health care course held by the health promotion division of Tsuchiura City to provide educational activities to prevent foot lesions. The purpose of the course is to make frail elderly people realize the necessity of foot care and to make them familiar with how to check their own health condition of foot and how to perform appropriate care for foot. The course included basic knowledge on foot, foot trouble, how to exercise, and how to choose and wear shoes properly, as well as skill practice based on the above instructions. Although many participants responded to the post-course questionnaire that they understood the importance of foot care, their actual level of understanding was not figured out; thus it would be necessary to change the questions and to continue the follow-up. Considering that the number of diabetic patients has been increasing and the associated risk for foot lesion may be a concern, educational activities for preventive foot care on a regional basis are believed to be essential.

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For the treatment of critical limbs, ischemia,collaboration with wound reconstructive surgeons and cardiologists performing revascularization is important. The foot care unit affiliated with related departments opened at our hospital in July 2010 for limb salvage, mainly under the leadership of the departments of cardiovascular internal medicine and plastic surgery. We have treated 105 patients up until October 2011. The primary diseases included 48 cases (51 limbs) of foot ulcer and gangrene, with complications of peripheral arterial diseases (PADs) in all cases. Intravascular treatment was conducted for 41 limbs with PAD complications, and the initial success rate was 85.3%, of which surgical debridement or minor amputation was performed on 19 limbs. Regarding open wounds following operation and chronic ulcer, platelet-rich plasma therapy was conducted in 20 limbs, and negative pressure wound therapy in 6 limbs. Among all of the patients treated, 30 limbs healed, 10 cases died, and the others are currently receiving ongoing treatment. Cardiovascular internal medicine specialists and plastic surgeons examine patients together at the outpatient clinic, and prepare and implement a multidisciplinary treatment plan including vascular reconstructions and operation. We cooperate with physicians in each related department and efforts in team medicine have been made for the purpose of prompt management, shortening of treatment period, and limb salvage.

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We use meropenem plus vancomycin (MV) as an empiric therapy for patients with infectious critical limb ischemia (CLI) in our hospital. The objective of this study is to investigate the efficacy of MV for infectious CLI patients. In 40 patients with infectious CLI receiving either MV group (n=17) or antibiotics other than M or V (control group, n=23), we evaluated 1-year limb salvage rate (avoiding rate of major amputation of lower limb). The Limb salvage rate was significantly different between MV group and control group (88% vs 57%, p=0.03).In a comparison of Rutherford-5 and 6 patients for the 1-year limb salvage rate, there was significant difference in only rutherford-5 patients (p=0.049). However, there was no significant difference in the 1-year survival rate (p=0.69). In conclusion, we provided evidence that the empiric therapy with meropenem plus vancomycin is effective for patients with infectious CLI.

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Objective: To assess prognostic factors associated with major adverse event (MAE) after endovascular therapy (EVT) for hemodialysis patients with critical limb ischemia (CLI). Method: Between September 2009 and October 2010, 72 hemodialysis patients with CLI (Rutherford 5 and 6: 79%) were studied. Definition of MAE was included major amputation or death, and the independent predictors of MAE were analyzed. Results: Overall MAE was observed in 24% (17/72). In the patients with MAE group patients with spending longer time before they consulted cardiovascular specialist (with MAE: 243±245 days vs without MAE: 114±112 days, P=0.014), lower BMI (with MAE group: 20±2 vs without MAE: 22±3, P=0.01) and higher CRP level (MAE: 4.4±5.1 mg/dl vs without MAE: 1.5±2.8 mg/dl, P=0.003) were more frequently observed. Conclusion: Time to visit vascular specialist, BMI and CRP level were predictors of MAE. Sustained limb salvage and clinical success can be achieved with an active surveillance program, multidiscipline team care, and prompt assisted EVT during long-term follow-up.

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We reported a 64-year-old case with intermittent claudication and ischemic ulceration of right 1^st-toe. His right distal superficial femoral artery was totally re-occluded and we decided the vascular re-canalization therapy was impossible. PGE₁ was administrated about 2 weeks, and the combination therapy with exercise and Waon therapy were continuous performed about 10 months. After 10 months, right ABI was significantly increased from 0.44 to 0.80, and walking distance was increased from 250 m to more than 1000 m. SPP (dorsal/plantar)was improved to 29/24 from 9/14 and ulceration of toe was completely healed. The combination therapy with exercise and Waon therapy was useful to improve the ischemic ulceration of lower extremity.

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The number of diabetes patients is increasing worldwide, and these patients often develop foot problem. The need for diabetic foot care awareness was recognized at our institution. And precautionary management fee for diabetic complications was induced in April 2008. From December 2009, we started administering foot care to hospitalized diabetes patients and have been promoting education and motivation for foot care, along the provision of coordinated nursing care in ward and ambulatory settings. In a period of 1 year, 23 patients were cared for under this initiative, and some patients with diabetic foot ulcer were treated and cured. However, we found that the following areas under coordinated activities needed to be addressed: (1) improvement in the ability of the medical staff to evaluate patient condition and provide appropriate care, (2) nursing occupational adjustment for the promotion of foot care, (3) reinforcement of recognition of the need for foot care among doctors, (4) implementation of a protocol for activities between the ward and ambulatory care setting, and (5) better coordination between medical and prosthetic specialties.

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