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How are ulcers due to varicose veins in diabetics managed?

Q: My Mother is about 61 years old and is a diabetic. Exactly a year back she underwent a by-pass surgery on her left leg due to varicose veins (ulcer in the left leg) and the angiogram report said that there was less blood supply to both her legs. Now she is doing fine. She is being prescribed Ecosprin-150 & Acitrom 2 mg daily. Now, my question is: the doctor told us (an year back) that there is only 28% blood flowing to her right leg & should not get any ulcers; then there will be no problem. I want to know that if a person gets only 28% blood supply, is it ok or some problem may occur in the future? What precautions need to be taken to avoid any risk? We are checking her sugar levels every month, which are consistent i.e. fasting blood sugar 80-100 and post prandial 100-120, from the past 6-7 months. She is taking 20 units of insulin every morning. My mother gets backache if she stands for about an hour or two. She also walks for about 45 minutes to an hour every morning. I think I have given a clear picture of the patient, so please help.

A:I am not sure if the ulcer in the leg is venous or arterial. In the report you write that the bypass operation was for varicose veins and yet that the angiogram is showing blood supply reduced to 28%. In diabetes with varicose veins, the ulcers could be either arterial or venous. Anyway, I shall try to give advice on the basis of the information given. To start with the reduction of blood flow up to 28% does not seem likely as there is no way of checking blood flow with any precision except measuring the Ankle/Brachial Index, this also is not totally reliable in the diabetics due to vascular calcification. In this case it seems unlikely that the blood flow is that low as you have written that your mother walks for 45 minutes to an hour everyday, which means that there is a reasonable blood flow. This is sufficient proof that unless she gets a diabetic foot there is no imminent danger to her legs. The treatment strategy that she should follow is as under: - She should keep a sound glycaemic control on the Diabetes, which can be done by regular use of Insulin and diet control. This means that she should decide on a diet, which is suitable for her age and constitution and stick to the same. This will not allow her to go hypoglycaemic or hyperglycaemic. - You should stay in regular touch with your physician or an endocrinologist. - She should continue with Aspirin as advised. For the present she should continue with Acitrom and keep good control on INR. She should continue the Aspirin even when the Acitrom is stopped. - She needs to evaluate the Lipid profile and keep the same at normal level. This might mean that she has to take Statins. Her doctor should be able to give advice, which particular tablets and in what doses. - She must maintain regular exercise, walking would be ideal for both arterial & venous disease. - She needs to continue with the advice of the vascular surgeon regularly and urgently when there is a problem with the feet like infection or ulceration and gangrene. - Lastly, she should not walk bare foot and take good care of her feet to keep these dry, clean and protected from injury.

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