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Table of Contents
GUIDELINE
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 55-62

Guidelines on the diagnosis and treatment of diabetic foot


Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Date of Submission02-Feb-2019
Date of Acceptance28-Apr-2019
Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Yongquan Gu
Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Bering 100053
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_15_19

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  Abstract 


Diabetic foot is one of the serious chronic complications caused by diabetes mellitus. The guidelines introduce the fundamental concepts of diabetic foot, distinction between diabetic lower-extremity ischemia and lower-extremity arteriosclerosis with concurrent diabetes mellitus, pathological features of diabetic foot lesions, and the prognosis. This article focuses on the diagnosis and treatment of diabetic foot, including endovascular arterial revascularization of lower extremity, arterial bypass reconstruction, and stem cell transplantation. The selection of therapeutic schemes for the larger, middle, and small artery lesions and the perioperative management are also discussed in detail.

Keywords: Diabetic foot, diagnosis, treatment


How to cite this article:
Yongquan Gu. Guidelines on the diagnosis and treatment of diabetic foot. Vasc Invest Ther 2019;2:55-62

How to cite this URL:
Yongquan Gu. Guidelines on the diagnosis and treatment of diabetic foot. Vasc Invest Ther [serial online] 2019 [cited 2019 Dec 14];2:55-62. Available from: http://www.vitonline.org/text.asp?2019/2/3/55/271905

China International Exchange and Promotive Association for Medical and Health Care Diabetic Foot Branch





  Fundamental Concepts Top


The distinction between diabetic lower-extremity ischemia and lower-extremity arteriosclerosis concurrent diabetes mellitus

There is no essential difference between the two medical disorders. They are two phenomena, occurring at different timing of the disease progression. Atherosclerosis is one of the phases of lipid metabolism disorders. While complicated with diabetes mellitus, there is an imbalance of carbohydrate metabolism at the same time. The disorders of carbohydrate metabolism exacerbate pathological changes in the wall of the arteries, resulting in atherosclerosis.

Diabetic foot and diabetic lower-extremity ischemia

The concept of diabetic foot was first described by Oakley in 1956. In 1972, Catterall defined it as a loss of sensation due to the neuropathy and loss of tissue due to ischemia and combined with infection in the affected foot. The definition of diabetic foot by the World Health Organization is, “The foot of a diabetic patient that has the potential risk of pathologic consequences, including infection, ulceration, and/or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease, and/or metabolic complications of diabetes in the lower limb.”

Diabetic foot includes a group of diseases, with essential components as follow: the first is hyperglycemia, the second is tissue loss due to nutrition disorder (ulcer or gangrene), and the third is accompanied with nervous and/or vascular disorders. There are three types of diabetic foot: neuro type, ischemia type, and neuro-ischemia type (also known as combined type). In the Chinese population, the main type is the combined neuro-ischemic type, followed by the ischemia type, while the simple neuro type is rare.

Diabetic lower-extremity ischemia is that reduced lower limb perfusion due to arterial arteriosclerosis in the patient with diabetes mellitus, regardless of which occurred earlier, as long as both issues are existed at the same time. The clinical manifestations of diabetic lower-extremity ischemia are similar with the simple arteriosclerotic ischemia, but the former is more difficult to manage. The common clinical presentations are ischemic symptoms in early, skin coolness, muscle tiredness, and pain with walking, which are called intermittent claudication. The critical ischemia is defined as rest pain, or tissue loss, including foot ulcers or gangrene with or without infection.

Definition of amputation

According to the international clinical guidelines for diabetic foot, amputation is defined as distal resection of a limb. Repeated amputation is the previous amputation stump that was not healed, and the amputation revision is needed from the distal end. New amputation: the previous amputation was cured but amputated for newly developed lesions from the distal end. Minor amputation: amputation below the ankle. Major amputation at and above the ankle level amputation (entire foot is removed).


  Epidemiology of Diabetic Foot Top


Epidemiology

  1. Of all nontraumatic low amputations, diabetes accounts for 40%–60%
  2. Of the low distal amputations associated with diabetes, 85% occurred after foot ulcers
  3. In diabetic patients, four of five ulcers are caused or worsened by trauma
  4. Diabetes feet ulcer prevalence rates were 4%–10%.


Domestic epidemiology

  1. Multicenter data showed that in the patients over 50 years old, diabetes lower-extremity arterial disease accounted for 19.47% in China [1]
  2. In a single-center study, the proportion of lower-extremity arterial disease was 35.36% in diabetic patients over 60 years old [2]
  3. A multicenter study in Beijing showed that the incidence of lower-extremity vascular disease in type 2 diabetes mellitus was 90.8%. Among them, severe cases accounted for 43.3%[3]
  4. Diabetic patients with both legs lesions showed symmetrical development.[4]



  Diabetes Mellitus and Peripheral Vascular Disease Top


Relationship between vascular disease and diabetes mellitus

  1. Peripheral vascular disease is the most important factor affecting the prognosis of diabetic foot ulcers
  2. Peripheral vascular ischemia can be easily detected by simple clinical examinations: skin color and temperature, dorsalis pedis pulse, and ankle-brachial blood pressure index
  3. Noninvasive vascular examination is used to assess the probability of diabetic foot ulcers. The ankle blood pressure, and occasionally, toe blood pressure measurements may not be accurate due to artery calcification
  4. Rest pain secondary to ischemia may disappear in diabetic patients because of peripheral neuropathy
  5. Microvascular diseases are not the main cause of foot ulcers
  6. Conservative treatment measures include walking exercise program (if there is no foot ulcers or gangrene), appropriate footwear, smoking cessation, and active treatment of hypertension, hyperlipidemia, and hyperglycemia
  7. After revascularization, the patency rate and limb salvage rate were not different between diabetics and nondiabetic patients. Therefore, diabetes cannot be a contraindication for vascular revascularization.


Atherosclerosis in diabetic patients mainly involves atherosclerosis and atherosclerosis inside the arterial wall. The former is caused by ischemia due to arterial stenosis and obstruction; the latter is the artery calcification causes blood vessels to form a hard pipeline. It can cause lumen stenosis and distal ischemia, and the hardening of the arteries seriously interferes with indirect measurements of arterial blood pressure. Microvascular lesions are not the main cause of skin lesions.

According to the international clinical guidelines of the diabetic foot, the arterioscleroses in the patients with diabetes, compared with nondiabetes, are (1) more common, (2) occurred in younger patients, (3) no gender differences, (4) multiple segment lesions, and (5) lesions locate in more distal segment (aortoiliac arteries were less likely involved).

Similar features have also been found in our researches in China.

Characteristics of diabetic angiopathy

The classification of diabetic foot needs to be graded according to the degree of lesion. At present, the widely accepted grading methods are Wagner classification and Texas classification, but because of the complexity of diabetic foot, there are great differences in vascular disease, neuropathy, infection degree, soft tissue and bone destruction, so any classification method can not be perfect.[1] Wagner classification: this classification method was first proposed by Meggitt in 1976 and later popularized by Wagner [5]. It is the most widely used classification method in clinical and scientific research at present [Table 1].[2] Texas classification method: Texas classification method was proposed by Lavery et al.[6] of Texas San Antonio University in the United States [Table 2]. This classification method evaluates diabetic foot ulcer and gangrene from two aspects of lesion degree and etiology, which better reflects wound infection and ischemia. Compared with Wagner grade, it is better to evaluate the severity of wound and predict limb prognosis.
Table 1: Wagner Classification

Click here to view
Table 2: Texas Classification

Click here to view



  Prognosis of Diabetic Foot Top


A prospective multicenter study in Italy followed up 1107 patients with diabetic lower limb ischemia for 8 years; the outcomes included ulcer, amputation, and death.

Determinants of the prognosis of diabetic foot ulcer are complex, and early effective treatment is greatly associated with the better prognosis.


  Treatment Top


Diabetic foot is generally classified as neurological, ischemic, and mixed types.[7] In the past, majority of people with diabetic foot were considered as neurological type, but some recent studies found that majority of the diabetic foot problems were mixed type, followed by ischemic types, while neurological types were relatively rare.[8] For neurological types, there is a lack of effective treatment. Ischemic lesions can be treated with arterial revascularization of the lower limb, and most patients can achieve certain curative outcomes.[7] Even if the mixed type lesions (neurological combined with ischemia), successful reconstruction of the blood flow can partially relieve the neurological damage symptoms.

In the treatment of diabetic foot, we should pay attention to the comprehensive treatment as well. The ideas that diabetic foot should be treated with conservative medical treatment or be treated surgically are not comprehensive. The “improvement of circulation, control blood glucose, anti-infection, local debridement, dressing change, nerve nutrition, and support treatment” as the “six core components” described by the Air Force General Hospital of PLA is a very good concept. Based on this, we advocated the following two factors that should be added: (1) control the cause of disease, such as blood pressure control, lipid lowering, and smoking cessation. If the causes are not removed, the lesion continues to develop, and the ideal outcomes will not be able to achieve. (2) Amputation (including minor and major amputation): when gangrene occurs, amputation is still a treatment choice. In any case, the reconstruction of the arterial blood flow in the lower extremity is the most important and critical step in the treatment of diabetic lower limb ischemia.


  Medical Treatment of Diabetic Foot Top


1. Metabolic management: for diabetic foot patients, we should pay more attention on control blood glucose, insulin should be the first choice to control blood glucose [9], at the same time, we should fully control blood glucose [glycosylated hemoglobin (HbA1c) < 7%],[10],[11],[12] and reduce the incidence of hypoglycemia as much as possible to reduce the incidence of foot ulcer and infection, and then reduce the risk of amputation [13]. However, because diabetic foot patients are always older and have many complications, it can not only emphasize that the HbA1c should be controlled below 7%. Individualized control objectives recommended by the Chinese Medical Association Endocrinology Branch about HbA1c control objectives for adult type 2 diabetes mellitus [14]. For patients with diabetic foot complicated with hypertension, blood pressure should be controlled below 140/85 mmHg, statins should be given to patients with diabetic foot complicated with lipid metabolism, and the level of low density lipoprotein cholesterol should be controlled below 2.1 mmol/L, if the patient combined with lower extremity arterial disease, the level of low density lipoprotein cholesterol should be controlled below 1.7 mmol/L. If there is no clinical contraindication, low dose aspirin (75-150 mg/d) should be given [15].

2. Lower extremity exercise rehabilitation: Exercise improves walking distance and walking time in patients with intermittent claudication in ischemic or neuroischemic patients with intact foot skin [16]. Compared with placebo or routine care, supervised exercise rehabilitation significantly increased the maximum walking distance in patients with lower extremity arterial lesions [weighted mean difference (WMD)=218.01 m, 95% CI: 161.54-274.48 m, P<0.00001], painless walking distance (WMD =174.19 m, 95% CI: 130.25-218.13 m, P<0.00001), 6min walking distance (WMD =42.91 m, 95% CI: 25.41 m, P<0.00001)[17]. At the same time, it can also significantly improve the motor function indexes of patients with lower extremity arterial lesions, such as walking impaired questionnaire (WIQ) distance score, WIQ speed score, WIQ climbing ladder score. It is suggested that intensive walking exercise can improve the exercise tolerance of patients with intact ischemic or neuroischemic type of foot skin, improve motor function, and do not increase the occurrence of adverse events, so it is a safe and effective treatment [17].

3. Medicine treatment

(1) Vasodilator therapy: The current clinical use of vasodilators include alprostadil injection of lipid microspheres, sodium beprostatin, cilostazol, sogrelate hydrochloride, naphthalene furosemide, clindil and pentoxifylline. Cilostazol, a potent phosphodiesterase iii inhibitor, was recommended in 2007 by the pan-atlantic collaborative organization (tasc) ii guidelines as a first-line drug for the treatment of intermittent claudication.[18] In the treatment of diabetic foot, cilostazol can both inhibit platelet aggregation and prevent thrombosis; on the other hand, it can also increase the blood flow of the narrow artery and improve the blood extraction state of the affected limb by dilating the blood vessels.[19] The application of cilostazol can significantly delay the occurrence of amputation in diabetic patients [17] and improve the condition of arterial ischemia in the lower extremities of diabetic foot patients.[20] In general,24 weeks of cilostazol (100 mg, bid) treatment can effectively prevent ulcers in diabetic foot patients;[21] after 8 weeks of cilostazol (100mg, bid) treatment, patients with type 2 diabetes with lower extremity ischemia have significantly improved percutaneous oxygen partial pressure, intermittent claudication, limb chills, and pain and are better than aspirin.[22] (WMD = 31.41 m, 95% CI: 22.38-40.45 m, P<0.00001; WMD = 19.89 m, 95% CI: 9.95%), (WMD = 19.89 m, 95% CI: 9.44-30.34 m, P = 0.0002), (WMD = 43.12 m, 95% CI: 18.28-67.96 m, P = 0.0007; WMD = 32.00 m, 95% CI: 14.17-49.83 m, P = 0.0004). In addition, patients with LEAD treated by endovascular therapy (balloon angioplasty and stent implantation) had less reocclusion events than thiaclopidine (OR = 0.32, 95% CI: 0.13-0.76, P =0.01), and cilotazol treatment was an independent predictor of prevention of restenosis.[23] Adverse effects of cilostazol were mainly headache, diarrhea, stool abnormalities, dizziness, and palpitations, but the symptoms were mild and tolerable. Severe adverse events including cardiovascular events and mortality did not increase compared to placebo, but the long-term efficacy was not clear [24]. The recommended dose of cilostazol is 50–100 mg/time, Bid.

The sagrel hydrochloride is a multi-target circulation improving agent, and has specific antagonistic action on the 5-hydroxytryptamine (5-HT)2 receptor of the platelets and the vascular smooth muscle, thereby inhibiting the platelet aggregation caused by 5-HT2, inhibiting the vasoconstriction and the proliferation of smooth muscle cells, and improving the deformability of the red blood cells, improve collateral circulation and microcirculation disturbance. A meta-analysis included 9 RCTs studies showed that the treatment of lower limb ischemic lesions with salgreate hydrochloride can reduced the ulcer area, increased ABI, distal blood flow and the pain-free walking distance [25]. One RCT study indicated that the treatment of diabetic lower extremity ischemic lesions by the administration of saggrel hydrochloride can effectively increase the maximum walking distance and the pain-free walking distance, and can partially improve the flow velocity of the dorsal artery and the posterior tibial arteries and the ABI index [26]. Therefore, it is recommended to treat ischemic symptoms such as ulceration and cold sensation caused by chronic arterial occlusion, especially for rest pain. The recommended dose of salgreate hydrochloride is 100 mg/time, Bid. In the prostaglandins, the efficacy and tolerability of the lipid microsphere alprostadil injection are the best. The meta-analysis shows that the prostaglandin E1 (PGE1) can significantly increase the walking distance compared to the placebo, and the walking ability keep increasing [27] even after the treatment is finished. The dose of alprostadil injection is recommended as 10 ug/ time, Qd or Bid, intravenous drip for 14-21 days. The treatment of beprostol can improve the subjective symptoms of lower limbs of diabetic peripheral arteries disease, such as burning-like sensation, cold sensation, labor pain, needle-like pain and sensory abnormality [28]. Beprostol can effectively improve the symptoms of patients with intermittent claudication [29]. The dosage of the beta-prostaglandin sodium is recommended to be 20-40 ug/time, Bid or Tid according to the degree of ischemia.

At present, there are many other vasodilators for clinical application, such as pentoxifylline, traditional Chinese medicine, etc.

(2) Antiplatelet therapy: for patients with diabetic foot, the clopidogrel is a medicine obtained indications of diabetic foot treatment. Compared with aspirin, clopidogrel can significantly lower the whole-cause mortality (RR = 0.73, 95% CI: 0.58-0.93) and the cardiovascular events (RR = 0.81, 95% CI: 0.67-0.98). However, the risk of severe bleeding is slightly increased [30]. In addition, the dual antiplatelet therapy of the combination of clopidogrel and aspirin significantly reduced the major amputations after the lower limb revascularization [RR = 0.68, 95% CI: 0.46-0.99, the number of patients to be treated (NNT) = 94[31] compared to the aspirin alone. Therefore, it is recommended that clopidogrel is another treatment option for patients who are not resistant to aspirin or allergic to aspirin.

In addition, the combination of aspirin or aspirin with dipyridamole (ASA/DIP) can significantly improve the patency of the transplanted artificial blood vessels in patients with diabetic foot. This effect was not found at autograft vessel, but this benefit was found at multiple time points in the artificial vascular graft, including 12 months post transplantation (OR = 0.19, 95% CI: 0.10-0.36, P<0.00001)[24]. Combination of aspirin with clopidogrel did not increase the risk of major or fatal bleeding, but increased the overall bleeding risk (OR = 2.65, 95% CI: 1.69-4.15), Includes mild bleeding (OR = 2.34, 95% CI: 1.37-4.00) and moderate bleeding (OR = 4.13, 95% CI: 1.37-12.45)[32].

(3) Anticoagulant drugs (heparin, low molecular weight heparin and oral anticoagulant): There is no clear evidence to support the application of anticoagulant therapy in the intermittent claudication stage of the patients with diabetic foot [33]. It has been demonstrated that the use of new oral anticoagulants in patients with peripheral arterial disease can effectively reduce the occurrence of limb ischemia events [34]. Comparison with aspirin alone, patients with peripheral arterial disease, in combination with rivaroxaban 2.5 mg bid, could significantly reduce the incidence of limb major adverse events (severe limb ischemia requiring intervention amputation due to ischemia) up to 46% (OR = 0.54, 95% CI: 0.35-0.82, P = 0.0037). At the same time, the combined treatment regimen could reduce 70% of the major amputations (OR = 0.30, 95% CI: 0.11-0.80, P = 0.011). In addition, in comparison with aspirin, the treatment with rivaroxaban 5 mg bid alone could significantly reduce the incidence of major adverse events in the limb by 33% (OR = 0.67, 95% CI: 0.45-1.00, P = 0.046)[2]. At the same time, with aspirin alone, patients with peripheral arterial disease combined with rivaroxaban 2.5 mg bid plus aspirin could significantly reduce the incidence of major cardiovascular events (myocardial infarction, stroke or cardiovascular death) by 28% (OR = 0.72, 95% CI: 0.57-0.90, P = 0.0047)[35]. In patients with peripheral arterial disease that have experienced major adverse limb events compared to aspirin alone, the risk of re-amputation can be significantly reduced with aspirin alone (OR = 0.52, 95% CI: 0.30-0.91, P = 0.02) compared with aspirin alone; The risk of reintervention was also significantly reduced (OR = 0.76, 95% CI: 0.60-0.91, P = 0.03)[36]. In patients with severe limb ischemia [37], low molecular weight heparin combined with aspirin significantly reduced the vascular occlusion/ restenosis (up to 85%) (OR = 0.15, 95% CI: 0.06-0.42, P = 0.0003) in patients with severe limb ischemia compared with aspirin alone [37]; The combination of Batroxobin and aspirin significantly reduced the re-stenosis of diabetic patients (OR = 0.28, 95% CI: 0.13-0.60), with no significant increase in bleeding and other adverse events in the digestive tract. In the early treatment of acute limb ischemia, the initial operation or the thrombolytic therapy occurred for 30 days,6 months or 1 year. However, the incidence of stroke in the initial thrombolytic therapy group (1.3%) was significantly increased (OR = 6.41, 95% CI: 1.57- 26.22) than in the initial operative treatment group (OR = 6.41, 95% CI: 1.57-26.22); the incidence of major bleeding at 30 days was 8.8% and 3.3% (OR = 2.80, 95% CI: 1.70-4.60)[38]; the rate of embolization at the distal end of the lesion was 12.4% and 0% (OR = 8.35, 95% CI: 4.47-15.58); therefore, in patients with acute limb ischemia, The initial operation treatment or the thrombolytic therapy has no significant difference to the limb or death, but the initiation of the thrombolytic therapy increases the risk of limb ischemia and bleeding complications.

Reconstruction of the blood flow of the lower limb

All kinds of methods for the treatment of lower limb ischemia in China and internationally are summarized.

Endovascular treatment for lower-extremity artery

Methods include percutaneous artery angioplasty (mainly refers to simple balloon dilatation), balloon dilatation followed by stenting, and primary artery stenting. As a minimally invasive approach, endovascular interventional treatment can be considered as the first choice in the patients with high surgical risks.[39],[40]

  • Lower-extremity artery endovascular interventional treatment indications: a good inflow and outflow of artery tract, high risk for open surgery, and proximal inflow vascular disease (stenosis or occlusion); endovascular interventional treatment can also be considered
  • Efficacy evaluation: if the interventional treatment is successful, symptoms can be relieved or improved. The current evaluation includes subjective and objective studies. The subjective symptoms include a decrease in pain, or limb cold sensation improved. The objective studies include the ankle brachial index, wound healing, and limb salvage.


Lower-extremity artery bypass grafting

Open surgery bypass can be used for the treatment of diabetic lower limb ischemia. There are two commonly used procedures. One is, at present, the most widely used femoral artery to popliteal artery (above or below knee) bypass. The other is the distal bypass to a tibial artery or dorsalis pedis artery, which is technically more difficult.

  • Indications of open arterial bypass: (1) there are good arterial inflow and outflow and (2) patient is in good health condition and can tolerate open surgery
  • Efficacy evaluation is similar to that following endovascular intervention of the lower limb. It should be emphasized that precaution should be given to patients with severe cardiopulmonay and cerebrovascular diseases or other diseases.


Autologous stem cell transplantation

Autologous stem cell transplantation is a new technique developed in recent years. In China, it has not been widely accepted; only some medical centers are able to evaluate and decide whether to choose stem cell treatment according to a patient's particular situation. Bone marrow, peripheral blood, cord blood, and embryonic stem cells are commonly used in stem cell transplantation. Currently, bone marrow and peripheral blood stem cell transplantation are relatively commonly utilized. We mainly use autologous stem cells to treat lower limb ischemia. There are at least two advantages of autologous stem cells: (1) there is no immunological rejection and (2) there are no ethical concerns of using embryonic stem cells.

How to choose treatment

Clinically, choosing the modalities of treatment and efficacy evaluation are still challenging. The general principle is to choose approaches based on the patient's special condition, rather than in the way that the individual surgeon is in charge. The following principles are used for choosing the treatment of diabetic lower limb ischemia.

  • Great artery (abdominal aorta and iliac artery) lesions. Endovascular intervention or artery bypass graft or hybrid procedures are recommended based on the patient's overall condition and economic status. For younger and low-risk patients, artery bypass grafting or interventional therapy or hybrid surgery can be employed. For the patients with high surgical risks, interventional therapy is recommended
  • Medium diameter artery (femoral–popliteal artery) lesions can be treated with endovascular intervention, open bypass grafting, hybrid operation, or autologous stem cell transplantation
  • Small artery (infrapopliteal artery) lesions. Endovascular intervention, open bypass, hybrid operation, or autologous stem cell transplantation are the options. Different from femoropopliteal artery, small artery lesion can be treated using autologous stem transplantation as a priority since it has better outcomes.


Perioperative management

Regardless what type of treatment is employed, perioperative management is always a key. It is highly a ent, the main perioperative measures are as follows:

  • Anticoagulant treatment. Blood hypercoagulability exists in many patients with diabetic lower limb ischemia. If it is diagnosed, anticoagulant should be given to prevent thrombosis
  • Antiplatelet therapy. Antiplatelet therapy prevents platelet aggregation and thrombosis
  • Vasodilator. Vasodilators are recommended to reduce peripheral vascular spasm, prolong the patency of graft and percutaneous transluminal angioplasty or (and) stent, and benefit the differentiation of stem cells
  • Defibrinogen therapy. Fibrinogen is often higher than normal in patients with diabetic foot. In those patients, defibrinogen therapy is particularly important.


Member of the panel involved in the discussion of the guide:

  • Yongquan Gu (Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University)
  • Xingwu Yan (Department of Endocrinology, West China Hospital, Sichuan University)
  • Caizhe Yang (Department of Endocrinology, Air Force General Hospital)
  • Daifeng Hao (Department of Burn and Plastic Surgery, The First Affiliated Hospital of General Hospital of PLA)
  • Peng Liu (Department of Vascular Surgery, China-Japan Friendship Hospital)
  • Xiaoqiang Li (Department of Vascular Surgery, Gulou Hospital Affiliated to Medical College of Nanjing University.)
  • Yufeng Jiang (Department of Endocrinology, The 306th Hospital of PLA)
  • Penghua Wang (Department of Metabolism, Tianjin Medical University Metabolic Disease Hospital) and Guo Lianrui (Department of Vascular Surgery, Xuanwu Hospital Capital Medical University)
  • Yong Yang (Department of Vascular Surgery, Second People's Hospital of Yunnan Province)
  • Xing Ji (Department of Vascular Surgery, Shandong Provincial Hospital)
  • Jianping Gu (Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University)
  • Maoquan Li (Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine)
  • Shuliang Lu (Shanghai Burns Institute, Ruijin Hospital, Shanghai Jiaotong University School of Medicine)
  • Huimin Zhou (Department of Endocrinology, The First Affiliated Hospital of Hebei Medical University)
  • She Zhao (Endocrinology, Wuhan Central Hospital)
  • Huimin Han (Department of Endocrinology, Da Qing Fourth Hospital
  • Hua Xiang (Department of Vascular Surgery, Hunan Provincial People's Hospital)
  • Junmin Bao (Department of Vascular Surgery, Changhai Hospital, Second Military Medical University
  • Zhen Li (Department of Vascular Surgery, the First Affiliated Hospital of Zhengzhou University)
  • Yiqing Li (Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology)
  • Chiyu Jia (Department of Burns and Plastic Surgery, The 309th Hospital of PLA)
  • Jinyu Liu (Key Laboratory of Pathobiology, Ministry of Education, Norman Bethune College of Medicine, Jilin University)
  • Qiuhong Zhou (Department of Endocrinology, Xiangya Hospital of Central South University)
  • Aihong Wang (Department of Endocrinology, The 306th Hospital of PLA)
  • Binghui Li (Wuhan Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology)
  • Jichun Zhao (Department of Vascular Surgery, West China Hospital of Sichuan University)
  • Pingping Huang (Chinese Academy of Medical Sciences, Peking Union Medical College, Institute of Hematology, Hospital of Hematology)
  • Yanzheng He (Department of Vascular Surgery, The Affiliated Hospital of Southwest Medical University).


Acknowledgments

This work was supported by grants from Beijing Hospitals Authority Training Programme (PX2018035), Beijing Hospitals Authority Youth Programme (QML20180804), Beijing Hospital Administration “Dengfeng” talent training program (DFL20150801), Capital health development scientific research project (2016/1/2012) and National key research and development plan project (2017YFC1104100).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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