Undiagnosed Neuropathy Among Patients Presenting For Evaluation and Treatment of Peripheral Artery Disease.
Ian Braustauskas1, Ashlee E Stutsrim1, Matthew S Edwards1, Ross P Davis1, Tim Craven1, Maureen K Sheehan1, Matthew A Corriere2, Matthew P Goldman1
1Wake Forest University, Winston Salem, NC;2University of Michigan, Ann Arbor, MI
OBJECTIVES:Peripheral neuropathy is associated with amputation risk among patients with peripheral artery disease (PAD), but neuropathy screening is not a routine part of clinic visits to vascular specialists. To explore the prevalence of undiagnosed neuropathy and utility of screening by vascular surgeons, we evaluated patients referred for confirmed or suspected PAD using a standardized instrument.
METHODS:Patients referred to vascular surgery clinics for diagnosed or suspected PAD were recruited from two centers. Exclusion criteria were history of neuropathy or amputation. Screening utilized the Michigan Neuropathy Screening Instrument (MNSI). Scores >2 were considered abnormal, and scores >4 were considered positive for peripheral neuropathy. Mean scores between PAD and diabetes groups were evaluated using two-way ANOVA.
RESULTS:158 patients were recruited and screened. Mean age was 67±12 years, 34% were women, and mean ankle brachial index (ABI) was 0.79±0.31. PAD symptoms were claudication in 79, chronic limb threatening ischemia (CLTI) in 52, while 27 were asymptomatic. Diabetes was prevalent in 40% of the patients (mean duration 14 years). Although no patients had an established diagnosis of neuropathy, 23% had an abnormal MNSI score and 22% of patients had a MNSI score consistent with neuropathy. Diabetic patients with CLTI had significantly higher MNSI scores than their non-diabetic counterparts with CLTI (4.88 vs. 2.78; p=0.0003) as well as diabetic patients without PAD (4.88 vs. 2.67; p=0.02). MNSI scores in the non-diabetic patients with CLTI were also higher than non- diabetic patients without PAD (2.78 vs. 1.64; p=0.06), although not significant. In non-diabetic patients, mean MNSI scores were not significantly different between patients with claudication vs CLTI. Box-and-whisker plots depicting distributions of the MNSI scores by DM and PAD status are shown in the figure.
CONCLUSIONS:A significant proportion of both diabetic and non-diabetic patients presenting to vascular specialists for PAD have abnormal MNSI scores and undiagnosed peripheral neuropathy. In diabetic patients CLTI is significantly associated with higher MNSI scores than all other groups; however, abnormal MNSI scores are prevalent in non-diabetic PAD patients as well. Expanding screening for neuropathy to vascular surgery clinics is feasible and has potential to improve PAD care through better risk stratification and targeted educational interventions to lower amputation risk. More research is needed to evaluate prospective associations between underlying neuropathy and risk for PAD progression and amputation risk in the diabetic and non-diabetic population. Systematic surveillance of this cohort for incident amputation is currently ongoing. 
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