Uncovering the hidden side of diabetes

Diabetes is among the top ten causes of death worldwide (WHO), accounting for 3.4 million deaths last year (The Diabetes Atlas). While awareness of blood glucose control, nutrition, and lifestyle is improving in some regions, diabetes prevalence continues to rise everywhere. Over the next two decades, cases in low- and middle-income countries are projected to increase by 45-145% (The Diabetes Atlas).

Beneath the surface lies another side of the disease, one that’s hidden, invisible to the naked eye, but crucial to understanding diabetes and its complications. The world of microcirculation: the vast network of tiny blood vessels that provide healing oxygen and nutrients to every cell and tissue, and just about every organ of the body.

In this post, I discuss why microcirculation matters in the context of diabetes, how early changes can serve as warning signs, and share the story of one woman whose microcirculation measurements changed the fate of her foot.

//Liuting Xu

Why microcirculation matters

In a healthy person, the microcirculation continuously adapts to local demands, providing oxygen and nutrients as needed. Diabetes gradually disrupts this finely tuned system, causing endothelial dysfunction, reduced perfusion, slower wound healing, and greater susceptibility to infection.

Microvascular dysfunction underlies many of the most serious complications of diabetes — foot ulcers, retinopathy, and neuropathy — yet it often remains undetected until significant damage has occurred.

By the time more familiar signs of diabetes appear, such as blurry vision, extreme fatigue, or changes in skin color, microvascular damage may already be advanced. Without the right diagnostic tools, these early changes remain invisible.

Why microcirculation isn’t enough

Standard diagnostic tools focus on macrocirculation and include ultrasound, ankle-brachial index (ABI), and/or toe-brachial index (TBI). While valuable, these measurements don’t detect small-vessel pathology that may be present — even before macrovascular issues arise.

A patient with diabetes may have a normal ABI yet impaired microvascular perfusion in the foot — a mismatch that may not become apparent until an ulcer develops.

People with diabetes often have incompressible arteries due to medial arterial calcification — calcium buildup in the middle layer of arterial walls — which stiffens the arteries and produces falsely elevated ABI values.

All patient data presented here is anonymized and used in compliance with applicable privacy regulations. No information that can identify the patient or clinical site has been disclosed.

A limb preserved

Behind every data point is a person — someone whose quality of life can take a dramatic turn with the proper assessment and treatment.

One such case, observed during a clinical demonstration of PeriFlux 6000, involved a middle-aged woman with diabetes and comorbid conditions, including a right foot ulcer.

Step 1 — macrovascular assessment
Her ABI and TBI values were within reference ranges. 

Step 2 — microvascular evaluation with TcpO2
Given the location of the foot ulcer and marked skin discoloration, TcpO2 was measured at two sites on the dorsal surface of her right foot.

The baseline for site #1 is just below the impaired-healing threshold of 40 mmHg. On oxygen challenge, her levels improved by 10mmHg and 15 mmHg. The hospital’s guidelines, based on Dr. Caroline Fife’s findings [1], state that if the increase during an oxygen challenge is below 10 mmHg, amputation healing failure is likely without an intervention.

Step 3 — additional microcirculation insight with SPP
Skin perfusion pressure (SPP) was then measured at three levels on each foot — lateral, medial, and toe.

With all SPP values above 40 mmHg, in combination with her TcpO2, ABI, and TBI results, the clinician decided not to proceed with amputation.

Seeing what’s hidden

This case highlights how microcirculation assessment can inform clinical decisions and change patient outcomes.

On World Diabetes Day, we are reminded that diabetes is more than a metabolic disease characterized by chronic hyperglycemia. It is a significant risk factor for circulatory disorders, and uncovering the hidden microcirculatory component provides clinicians with crucial insight.

If you’d like to know more about PeriFlux 6000 or PeriCam PSI, and how these advanced vascular diagnostic tools can support clinicians in the treatment of patients with diabetes, you can contact your local distributor or sales representative for a demo Contact

As Perimed’s global distributor manager, I work with partners around the world to bring advanced vascular diagnostic solutions to local healthcare providers. With a deep understanding of global medical markets, I am dedicated to helping clinicians make a difference.

I hold a master’s degree in bioentrepreneurship from Karolinska Institute in Stockholm, Sweden.