The Endorevolution – Going Further in Endovascular Techniques Dedicated to Neuroischemic Diabetic Foot

Abstract

Introduction: The prevalence of Diabetes Mellitus (DM) is increasing. Diabetic patients have a 15-25% lifetime risk of developing a foot ulcer and its annual incidence can reach 25-30% if arterial disease is present. Diabetic angiopathy is a unique vascular disease that has predilection for below-the-knee arteries. Endovascular techniques have been revolutionizing the revascularization of neuroischemic diabetic foot (NIDF) patients, showing consistently high limb salvage rates.In addition, the survival of NIDF patients reaches 50% at 5 years after revascularization and limb salvage, but decreases to 50% at 2 years after a major amputation. Methods: Retrospective institutional review of consecutive patients requiring endodistal revascularization (January 2010 - December 2018). The aim of the present study is to report our experience concerning NIDF patients who underwent tibial arteries revascularization. The primary outcomes were to evaluate the technical success, the limb salvage, the rate of major and minor amputation and the global survival of this population. Results: This study included 373 patients, which corresponded to 540 limbs. The mean age was 70,8 years-old; 66,2% were men, with a mean time of diagnosed diabetes of 15 years. The comorbidities presented were hypertension (81%), hypercholesterolemia (44%), chronic renal disease (31,9%; of those 42,8% in hemodialysis) and smoking (20,1%).Isolated rest pain was present in 4,6% of the patients and foot ulcer in 95,4%. The iliac sector was concomitantly treated in 0,9% of the procedures and the femoro-popliteal sector in 62,6%. Femoral antegrade approach, was obtained in 90,5% of the procedures. The retrograde distal approach was made when the anterograde revascularization failed to cross the occlusion (7,6% of procedures). Direct revascularization according to the respective angiosome was obtained in 59,1% of the cases. In the femoro-popliteal sector, PTA was performed in 49,7% of the procedures (2,4% with DEB) and recanalization and stenting in 47,9%. Tibial arteries stenting was performed in 2% of procedures, as a bail-out technique. The technical success (defined as crossing the occlusion and recanalization to a pedal vessel) was achieved in 85,5% of the procedures. The median follow-up (FU) time was 8 months (mo).During FU, 13,6% of patients was submitted to major amputation and 35,1% to minor amputation. The major amputation free-survival rate was 81,7% at 12 mo and the rate of complete healing at 12 mo was 66,9%. The 12 mo global survival was 81%. Direct angiossomic revascularization (p=0,03) and the number of tibial arteries recanalized (p=0,01) were associated with higher rates of limb salvage and healing. In the opposite side, there was association between the increasing of renal dysfunction and the absence of healing (p=0,04). The endovascular reintervention rate was 21,3% and the median time was 225 days after the first procedure. Conclusion: With the introduction of devices specifically designed for the treatment of below-the-knee vascular disease, recanalization of the tibial and pedal arteries has become technically feasible. The results of this study on endodistal revascularization, highlights the need to prioritize investigation and revascularization in NIDF to improve the outcome of foot ulcer, giving the possibility of salvaging a greater number of limbs. Disclosure: Nothing to disclose