Below-the-Knee Intervention for Ischemic Diabetic Foot in Kurdistan, Iraq: A Case-Control Study

Abstract

Management of the ischemic diabetic foot (DF) due to infrapopliteal arterial disease is challenging and controversial. Observation, bypass surgery, and endovascular intervention are the 3 available options. Outcome of percutaneous transluminal angioplasty (PTA) versus conservative therapy is evaluated in this prospective study from Sulaymaniyah, Iraq. Over 2years starting at January 2018, 40 patients with ischemic DF underwent PTA and compared with a control group (n=78) of ischemic DF managed conservatively. Besides clinical assessment, all patients underwent Doppler ultrasonography and computed tomography angiography while conventional angiography was reserved for PTA group. Patients who fulfilled the standard angiographic findings underwent standard PTA, and their outcome was compared with the control group. Mean age was 64 years; 70% (n=28) were men with a male: female ratio of 2.3: 1. Renal function was impaired in (n=11, 27.5%), and 7 (17.5%) patients were smokers. The commonest clinical presentation was nonhealing ulcers (n=39, 97.5%), and most patients (n=39, 97.5%) had Fontaine IV and Rutherford V-VI grades. Most lesions were anatomically complex; Trans-Atlantic Inter-Society Consensus C and D types, Graziani class ≥4 (75%), long segment (n=28, 70%), and chronic total occlusion (n=26, 65%). Success rate was (n=38, 95%), and no patient died. Ulcer healing was higher (67.5% vs. 34.6%), and ulcer recurrence was lower (20% vs. 47.4%) in PTA group but amputation rate was not significantly different (12.5% vs. 12.8%) (P<0.05). Although amputation and death rates were not significantly different, endovascular intervention achieved better ulcer healing in ischemic DF compared with the conservative approach.