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 If you smoke and are diabetic, you have a higher risk of losing a leg or part of a foot due to lower limb arterial disease, in which blood vessels in the legs are hardened or blocked.
EVERY day, two people in Singapore lose a foot or part of their lower leg, not because of accident or trauma but as the result of a blood vessel disease affecting the lower leg.
These individuals either smoke or have diabetes. And if they are diabetic smokers, their risk of amputations goes up.
According to Dr Mathew Sebastian (right photo), a vascular surgeon who is Senior Consultant at the Department of General Surgery at Singapore General Hospital, every year about 800 people go through amputations due to a condition known as lower limb arterial disease.
 Blood flow in legs affected
The human body has blood vessels performing different functions. Veins carry blood to the heart while arteries take blood away from the heart. Dr Sebastian says, “Lower limb arterial disease is an extremely dangerous condition as blood vessels in the legs are hardened or blocked. Blood flow will be affected, leading to decreased sensation and poor circulation. When this condition affects the arteries in the calf, it’s much more difficult to treat than blockages in the upper part of the leg.” Symptoms include pain or cramps in the buttocks, thighs or calves after walking a distance. These sensations subside after rest but often return with further exertion.
Injured toe turns ‘black’
Dr Sebastian, a specialist in blood vessel diseases, says for people with the disease, a small wound or ulcer in the foot can have serious consequences. An accidental stub of the toe or a kick against a hard surface can lead to irreversible damage.
“The person may not realise there is an injury because there is decreased sensation in the affected foot. The wound can become infected and deteriorate very rapidly due to a combination of poor blood flow and immune suppression. In days or weeks, that toe can turn necrotic as the tissues begin to die. What he then sees is a black toe. This means the tissues are dead and that toe is gone. The priority will be to save the foot,” he explains.
Smokers who do not have diabetes fare better than diabetic smokers but only if they give up cigarettes after treatment. “For those who smoke, there is less rapid progression of the disease. Once the blockages are cleared, there is a very good chance of saving the legs. But the patient will have to stop smoking,” Dr Sebastian says.
 Diabetics face second amputation
For people who do not smoke but have diabetes, the outcome of an amputation can affect their lives drastically. This is especially if the person is elderly with other medical problems such as hypertension and high cholesterol, warns Dr Sebastian.
“About half these patients would be wheelchair bound. Fifteen per cent would be confined to their homes. Once there is a major amputation in one leg, 10 to 15 per cent of them will lose the other leg within a year. But even with a second amputation, they may die within that year because they can’t move around. Many of these patients also suffer from serious heart diseases which contribute to the high mortality rate.”
Leg bypass surgery and angioplasty
There are treatment options for blocked blood vessels in the legs, similar to those for clogged arteries in the heart. Depending on their condition, patients who have lower limb arterial disease undergo a leg bypass surgery or a balloon angioplasty.
In a leg bypass surgery, the substitute blood vessel is usually taken from the same leg or the other leg. This blood vessel taken is the superficial vein which is then used to reconstruct the diseased artery. The size of the leg bypass wound depends on the operated area.
A less invasive procedure is the balloon angioplasty which involves inflating a blocked artery using a balloon catheter. The patient’s foot is left with a 2mm puncture wound where the catheter is inserted.
Dr Sebastian says a detailed assessment of the patient’s condition will help doctors decide which method will give him the best outcome. In the past three years, surgeons and radiologists in the SGH vascular and interventional team have treated some 700 patients using balloon angioplasty. Bypass surgeries are for patients whose angioplasties are not successful. “We managed to save about 80 per cent of their legs.”
More cases expected
Unfortunately, many people with lower limb arterial disease do not see a doctor until it is too late.
“The number of people who come to us with gangrene in their lower limbs is rising at a frightening rate. If these patients came to us at an earlier stage, the outcome would be better. In the next 10 years, due to the ageing population with baby boomers hitting their 60s, and with the rise in the number of diabetics, we will have an explosion in the number of such patients,” Dr Sebastian observes.
Dr Sebastian cites possible reasons for the delay in seeking treatment. “Maybe it’s a person’s mindset or he is not aware of the consequences. Or it could be a cultural thing. Older people may think their leg pain is due to ageing. Some diabetics could also be in denial about the risk of amputation.”
 Early screening as prevention
Dr Sebastian is pleased that at the primary healthcare level, there is now increasing awareness of lower limb arterial disease. “Many people are being screened for loss of sensation, poor pulse in the foot, leg ulcers and other symptoms that may lead to toe and foot damage.”
He urges those at risk to do their bit by detecting potential problems early, and if they have any injuries, to take good care of their wounds.
“If the affected individual comes in early for treatment, the outcome will be better,” he adds. |