When Mr Victor Susainathan developed a wound almost 2.5cm long on his right toe last March, he didn’t think much of it at first.
The 56-year-old IT project manager, who was diagnosed with diabetes four years ago, went about his daily activities as usual but got increasingly worried when the wound did not seem to heal and began to turn black in colour.
“I went to the polyclinic to get the wound dressed. For about three weeks, it looked like it was getting better, but then it would open up and bleed again, so I decided to look into it further,” he recalls.
Deciding to get specialist help, Mr Victor was introduced by friends to Dr Tang Tjun Yip, a senior vascular and endovascular surgeon and medical director at The Vascular & Endovascular Clinic at Gleneagles Hospital and a visiting specialist at the International Specialists Clinic. It was then that he found out he had a diabetic foot ulcer – an open sore commonly located on the bottom of the foot and a blocked artery in his leg preventing oxygen from reaching his foot to heal the ulcer.
Why are people with diabetes more prone to foot problems?
One in three Singaporeans are at risk of developing diabetes in their lifetime, and it comes with the risk of other health complications, such as damaged nerves and narrowed or blocked arteries in the legs and feet termed peripheral artery disease.
Such nerve damage, or neuropathy, occurs throughout the body, but most often in the legs and feet, and arterial insufficiency causes poor blood circulation to these parts, notes Dr Tang.
This results in tingling or numbness, swelling, and slow healing of wounds and sores. Other symptoms to look out for include blackened tissue, changes to skin or toenail colour, and discharge of fluid or pus.
“Common foot problems amongst those with diabetes include ulcers, deformities and gangrene – irreversible damage to body tissue due to lack of blood supply,” explains Dr Tang. “They often result from poor blood circulation or lack of sensation due to nerve damage caused by elevated systemic blood glucose levels.”
These conditions can greatly affect quality of life whilst also increasing the risk of major lower limb amputation and in some cases, death, warns Dr Tang.
“Very often, this is because patients with diabetic foot conditions present late, when the disease has advanced and there is major tissue loss,” he adds. “This is usually due to lack of awareness of their condition, not knowing its seriousness, or being in denial.”
Minimally invasive keyhole procedure as an effective treatment
In Mr Victor’s case, the blood flow in his right leg was severely restricted. Dr Tang immediately recommended lower limb revascularisation using balloon angioplasty, which would restore blood flow to the blocked or narrowed arteries in the leg and improve the blood supply to the foot to help heal the ulcer.
“Angioplasty is a minimally invasive keyhole procedure that inserts tiny balloon catheters via a tiny 0.2cm hole in the artery of the groin, to widen narrow arteries and improve blood circulation in the legs and feet, thus helping the foot ulcer to heal,” explains Dr Tang.
The procedure is also repeatable if the vessels get blocked again and can be performed under light sedation and local anaesthetic. “It is another added advantage to minimise complications in these patients who usually have other co-morbidities like heart problems and kidney issues,” adds Dr Tang.
It also offers a quicker post-operative recovery compared to traditional open bypass surgery.
“The operation took a few hours. I was kept under observation for one night and the next morning, I could resume walking. There was no inconvenience at all,” recalls Mr Victor.
Typically, diabetic foot ulcers can take up to six months to recover completely even when blood flow to the foot has been optimised.
Nonetheless, the challenge with lower limb revascularisation lies in keeping blood vessels open and ensuring that the blood circulation is restored to allow optimal tissue healing, notes Dr Tang.
At The Vascular & Endovascular Clinic, newer technologies see the balloons used in angioplasty coated with stimulants to prevent blood vessels from re-narrowing in the future.
The newer balloons use sirolimus, an anti-restenotic agent to minimise re-narrowing of the blood vessels and allow optimal blood flow to the foot.
The use of these balloons comes off the back of Dr Tang’s 2021 seminal research. Also known as the PRESTIGE study1, these specialised balloons were used in diabetic patients with blocked vessels and found that over 80 per cent of the arteries in the leg treated remained open and free from requiring reintervention at six months. Furthermore, approximately a third more of these blood vessels were able to be kept open longer compared to conventional balloons that did not use the sirolimus drug.
“In some cases, stenting (putting a small metal tube inside the arteries to hold them open) or atherectomy (coring out the blockages in arteries) is performed in addition to angioplasty,” adds Dr Tang.
For severe cases, open bypass surgery may still be required, where a vein or artificial graft is used to reroute blood flow around a blocked artery.
Adopting a holistic postoperative recovery care
Mr Victor says he feels his blood circulation has improved and there is now more sensation in his toes, but he knows that it is also up to him to manage his condition successfully for the medium and long term.
Following the operation, he used a wheelchair and walker for three weeks so as not to apply too much pressure on his wound. In addition to antibiotics, he now takes blood-thinning and cholesterol -lowering medications to prevent future complications and re-narrowing of his leg and foot arteries.
“After Dr Tang introduced a dietician to me, I focused on eating well-balanced meals with less unhealthy food and sugar and paid more attention to my physical activity to control my diabetes,” says Mr Victor. “During my recent appointment, Dr Tang also carried out a simple skin-grafting procedure as a follow-up to help cover the wound on my foot and reduce the need for continued wound dressings.
“It’s important to find a specialist doctor that doesn’t focus only on solving your current issues, but also helps to plan for your future well-being and preventing further complications of your chronic disease,” Mr Victor added.
For more information or to book an appointment, visit The Vascular and Endovascular Clinic.
1World’s first experience treating TASCII C & D tibial occlusive disease using the SELUTION SLR™ sirolimus eluting balloon - 6 months results from the PRESTIGE study” has been accepted for publication in the Journal of Endovascular Therapy Tang TY, Yap CJQ, Soon SXY, Chan SL, Lee QWS, Yap HY, Tay HTL, Chong TT J Endovasc Ther. 2021; 28(4) doi: 10.1177/15266028211007457.
