Limb Salvage In Diabetic Patients Research Articles

Effectiveness of autologous mononuclear cells as adjuvant therapy in patients with ischaemic diabetic foot ulcers receiving indirect lower limb revascularization.

The current study aimed to evaluate the effectiveness of peripheral blood mononuclear cells (PB-MNCs) therapy for patients with ischaemic diabetic foot ulcers (DFUs) treated through indirect revascularization. The study is a prospective non-controlled observational study including patients with neuro-ischaemic DFUs who received indirect peripheral revascularization and showed a persistence of wound ischaemia defined by the absence of angiographic collateral vessels and TcPO2 values < 30mmHg in the wound angiosome area. All patients received 3 cycles of PB-MNCs therapy administered along the wound related artery based on the angiosome theory. The primary outcomes measures were healing, major amputation, and survival after 1year of follow-up. The secondary outcomes measures were the evaluation of tissue perfusion by TcPO2 and foot pain defined by the Numerical Rating Scale (NRS). Overall 52 (9.7%) patients were included. Most patients were aged (> 70years), all of them were affected by Type 2 Diabetes with a long diabetes duration (> 20years). Almost 80% were assessed as grade 2D- 3D of Texas University Classification. Forty-four patients (84.6%) patients healed and survived, 2 (3.85%) healed and deceased, 2 (3.85%) not healed and deceased, 4 (7.7%) not healed and survived. No major amputations were recorded. A significant increase of TcPO2 after PB-MNCs therapy were recorded in comparison to the baseline (43 ± 9 vs 18 ± 8mmHg, p < 0.0001), such asa concomitant reduction of foot pain (1.8 ± 1.2 vs 6.2 ± 2.1, p < 0.0001). PB-MNCs resulted effective to promote wound healing and limb salvage in diabetic patients with ischaemic DFUs who received indirect revascularization.

Prognostic Ability of the Wound, Ischemia, Foot Infection (WIfI) Classification System in Diabetic Patients with Non-Healing Ulcer

Abstract Objectives Several classifications have been published to predict limb salvage in diabetic patients with non-healing ulcer to aid in the management plan. The Society for Vascular Surgery (SVS) Lower Extremity Guidelines Committee has composed a new classification system that reflects the three major factors that impact amputation risk and clinical management Our goal was to evaluate the predictive ability of this wound, ischemia and foot infection(WIfI) classification as a predictor of limb salvage in diabetic patients with non-healing ulcer Methods a prospective single arm observational cohort study conducted on 50 patients within 2022 at single center, Ain Shams University Hospitals, Patients are diabetics who had non healing ulcers some of the cases underwent angioplasty or debridement, then follow up of the wounds was done. Limbs were stratified into clinical stages 1 to 4 based on the SVS WIfI classification for amputation risk. Results Our study included 38 males (76%) and 12 females (24%). The age range between 35 years and 73 years with mean age of 59±8.81. All of the patients are diabetic. The percentage of patients with hypertensive ( 76 %), 54% of them were smoker &amp; 7 were suffering from ESRD. limb salvage was achieved on 75 % of cases. All cases have been classified according to WIFI classification into clinical stages I-IV and their percentage were 6%,12%,40% and 42% respectively. WIfI classification was significant in predicting the major or minor amputation as well as ulcer healing. As Major amputation among each WIfI classification group low, moderate and high risk was 0%, 10%, 47% respectively. Risk of minor amputation was 22%, 40% and 76% respectively. While ulcer healing was 100%, 85% and 52% respectively. Conclusion The likelihood of an amputation after one year in patients with non healing ulcer increases with higher WIfI stages, so The WIfI classification is applicable in prediction of limb salvage in diabetic patients with non-healing ulcer. Smoking and aging also decreases the chance of limb salvageability

Limb Salvage in Diabetic Patients With Combination of Radical Excision, Antibiotic Impregnated Bone Cement, and External Fixator Application

In patients with diabetes, foot ulceration is a major cause of morbidity and hospitalization. The combination of deep ulcers and underlying osteomyelitis in patients with diabetes frequently leads to chronic nonhealing foot ulcers. These patients have often ended up with amputation. From 2003 to 2017, 17 of 175 diabetic patients (11 males and 6 females, 37 to 82 y old) were treated for diabetic foot and presented with complaints of ulceration, osteomyelitis, and foot gangrene. Magnetic resonance imaging–guided necrotic tissue debridement was performed, after the placement of antibiotic-impregnated bone cement, and soft tissue defect reduction was performed with an external fixator. Approximately 4 weeks later, polymethylmethacrylate was removed, and then the external fixator was removed after the soft tissue defect was closed. No patients had recurrent ulceration or osteomyelitis seen on radiographs up to their latest follow-up. There was pin tract infection in 2 patients who were treated with oral antibiotics and wound dressings. All patients have a fibrous union in the metatarsophalangeal joint. Compared with other radical techniques such as amputation, amputation, and long-term wound dressings, salvage of limbs with an external fixation can be used in selected patients who have osteomyelitis and soft tissue defects after debridement. Level of Evidence: Diagnostic level III—nonrandomized controlled cohort study.

Influence of pedal arch quality on 5-year survival and limb salvage in patients with diabetic foot ulcers undergoing peripheral angiography.

The aim of this study was to evaluate the influence of pedal arch quality on 5-year survival and limb salvage in diabetic patients with foot wounds undergoing peripheral angiography. Between January 2014 and December 2014, 153 diabetic patients with foot wounds underwent peripheral angiography. Final foot angiograms were used to allocate patients according to pedal arch: complete pedal arch (CPA), incomplete pedal arch (IPA), and absent pedal arch (APA). Five-year survival and limb salvage rates were analyzed with Kaplan-Meier curves and compared by means of Gehan-Breslow-Wilcoxon test. Associations of patient and procedure variables with overall survival and limb salvage outcomes were sought with univariate and multivariate analyses. A below-the-knee (BTK) artery was the target vessel in 80 cases (52.3%). Five-year Kaplan-Meier rates of survival were similar in all groups (p = 0.1): CPA 30%, IPA 27.5%, and APA 26.4%. Five-year limb salvage rates were significantly better in patients with CPA/IPA (p < 0.001): CPA 95.1%, IPA 94.3%, and APA 67.3%. In the whole population study, multivariate analysis showed significant association of smoking (p = 0.01), chronic renal failure (p = 0.02), and severity of foot wounds (p < 0.001) with survival. Coronary artery disease (p = 0.03), severity of foot wounds (p = 0.001), and pedal arch status (p = 0.05) showed strong association with limb salvage. Pedal arch quality significantly affected limb salvage but not survival at 5 years in patients with diabetic foot ulcers. Smoking, chronic renal failure, and severity of foot wounds affected overall survival, whilst coronary artery disease, and severity of foot wounds limb salvage.

Percutaneous transluminal angioplasty for isolated infrapopliteal arterial occlusive disease in diabetic patients with critical limb ischemia

Background Critical limb ischemia (CLI) is considered the most severe stage of peripheral artery disease. Patients with CLI typically have the disease affecting multiple levels (i.e. aortoiliac, femoropopliteal, and infrapopliteal). CLI due to isolated infrapopliteal arterial disease is commonly seen in patients with long-standing diabetes mellitus, chronic kidney disease, or the elderly. Endovascular treatment of infrapopliteal arteries has been considered a primary approach for revascularization in CLI. Objective The aim of this study was to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) for isolated infrapopliteal arterial occlusive disease in diabetic patients with CLI. Patients and methods This prospective study included 20 diabetic patients with CLI in 28 limbs due to isolated infrapopliteal arterial occlusive disease who underwent infrapopliteal PTA between January 2017 and January 2019 in Mataria Teaching Hospital, Cairo, Egypt. Results The study was conducted on 20 diabetic patients, 12 (60%) men and eight (40%) women. Their age ranged between 54 and 76 years with a mean age of 65 years. Successful recanalization was achieved in 23 (82.1%) limbs. Reintervention was needed in five (17.9%) limbs and it was successful in four limbs. The follow-up period ranged from 6 to 18 months with the mean overall follow-up being 12.5 months. The primary patency rate and secondary patency rate were, respectively, 78.3 and 80% at 1 year. The limb salvage rates after 1 year were 75%. Mortality rate after 1 year was 10%. Conclusion PTA is effective and the preferred procedure for revascularization and limb salvage in diabetic patients with CLI due to isolated infrapopliteal arterial occlusive disease.

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers.

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Limb Salvage in Diabetic Patients with No-Option Critical Limb Ischemia: Outcomes of a Single Center Experience

Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with diagnosis of DF and CLI. All patients were followed-up for at least one year and/or total recovery. The primary endpoint was one-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At one year, AFS, limb salvage, and survival rates were 34%, 34% and 83%, respectively. Lesions located proximal to Lisfranc joint were associated with major amputation (HR 2.1 [1.2-3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log rank p=0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02-59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival. Funding Statement: The authors declare: None. Declaration of Interests: The authors report no relationships that could be construed as a conflict of interest. Ethics Approval Statement: Clinical and procedural data from all patients admitted to Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) are recorded in a dedicated clinical database and accurately verified for completeness and accuracy against the patients’ clinical charts. Patients are prospectively followed up for at least 12 months. The analysis was based on current clinical practice, therefore the regulatory authorities required an ordinary written informed consent to procedures and data collection, which was obtained from all patients. The protocol of the study was in accordance with the Declaration of Helsinki.

Limb salvage in diabetic patients with no-option critical limb ischemia: outcomes of a specialized center experience.

ABSTRACTObjective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot lesions (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center.Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with a diagnosis of DF and CLI. All patients were followed-up for at least 1 year and/or total recovery. The primary endpoint was 1-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival.Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At 1 year, AFS, limb salvage, and survival rates were 34%, 34%, and 83%, respectively. Lesions located proximal to the Lisfranc joint were associated with major amputation (HR 2.1 [1.2–3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log-rank p = 0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02–59.89]).Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had a greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival.

Commentary on ‘Strategies for Free Flap Transfer and Revascularisation with 10 Year Outcome in the Treatment of Large Diabetic Foot Lesions’

acceptable results in the other two groups. 1 The study provides a large single centre series about this topic, and the authors are to be congratulated for their efforts in the surgery, treatment, and follow up of these patients, most of whom would have experienced major limb amputation sooner or later. The data are presented clearly and give hope that this may be an additional method for limb salvage in diabetic patients with non-healing wounds or ulcers. Nevertheless, there are some points that should be discussed and mentioned before recommending such an extensive therapy given the time and costs. As can be seen in this study, the authors have done about five free flap transfers per year for diabetic foot lesions. Thus, it should be clear that this procedure is a rare and selected one for these patients, and that the indications for this therapeutic modality are negatively selected and fail

Diabetic Foot Salvage by Limited Access Dressing (LAD)

Moist wound healing and Negative pressure wound therapy (NPWT) are newer concepts in wound management. NPWT has been shown to be a safe and effective treatment for complex diabetic foot wounds. Limited Access Dressing (LAD) combines the principles of moist wound healing and NPWT along with a provision of two additional ports (1216Frtube) for instilling antimicrobial solution of choice and alters the wound environment without any need to change the dressing. LAD utilizes definite intermittent negative pressure schedule (30 minutes of negative suction and 3½ hours of rest period; minimum 30mmHg of negative pressure). Intermittent negative pressure regimen of LAD reduces the total duration of negative pressure and need for specially designed suction devices. The LAD design has notable advantages, while avoiding some major disadvantages such as an inaccessible offensive smelling wound environment and relatively high treatment cost. Neuropathy, angiopathy, skin changes (cracks), callosities, and foot deformities leads to nonhealing ulcers followed by infection. Non healing ulcers and infection are major reasons for progressive tissue destruction in diabetic patients. Repeated radical debridement leads to loss of certain amount of viable tissue exposing vital structures, bone, ligaments and subsequent desiccation of exposed tissues and infection starts avicious cycle of debridement and further tissue destruction leading to amputation. LAD has been proved to control wound infection, and help in separation of dead tissue from living tissue by autolytic and mechanical debridement while preserving viable tissue as compared to that by surgical debridement. By virtue of better control of infection and systemic inflammatory response syndrome (SIRS), early physiotherapy (minimizing stiffness and deformity), advantages over other modern methods of dressings and ultra conservative debridement (minimal damage to viable tissue by safer intra LAD natural separation of necrotic tissue), LAD acts as a reliable and effective method of limb salvage in diabetic patients.

Limb Salvage in Diabetic Patients: The Italian Experience

Diabetes is rapidly increasing worldwide and diabetic foot is the main cause of non-traumatic lower limbs amputation. However epidemiological data report a reduction of amputee’s rate in different European countries and in USA. Also in Italy there were excellent results related to the improvement of treatment strategies. The aim of this commentary is to describe the Italian model analyzing the reasons that have contributed to this success.

Treatment of peripheral arterial disease in diabetes: A consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers

In many series of diabetic foot ulcer care, heel ulcers greater than 4 cm across have been identified as an independent predictor of limb loss. Therefore, we set out to pursue the most aggressive limb salvage algorithm in patients with heel ulcers greater than 4 cm in diameter. Over 5 years, we identified 21 patients, 39-84 years of age, all with diabetes mellitus, with heel ulcers greater than 4 cm in diameter and had magnetic resonance imaging or bone scan evidence of osteomyelitis. Seven of the 21 patients had end-stage renal disease defined as being haemodialysis dependent. All patients had ankle brachial indices <0·4 or monophasic pulse volume recordings. All patients underwent distal bypass surgery with vein. After adequate perfusion was obtained, all patients underwent partial calcanectomy and intra-operative negative pressure wound therapy (NPWT) placement. This was followed by treatment with recombinant platelet-derived growth factor (PDGF). One patient underwent amputation during the healing process secondary to ongoing sepsis. Twenty of 21 patients healed acutely (within 6 months). Three of 20 patients went on to subsequent below knee amputation within 12 months of healing primarily. At 2 years, 12 of 21 (57%) were ambulating independently, 1 of 21 was dead, 4 of 21 had undergone amputation, 4 (19%) had limbs that were intact but were not ambulating. A total limb salvage rate of 76% at 2 years mirrored the secondary patency rates, with 100% follow up. Heel ulcers require multimodality therapy if they are going to have any chance to heal. We believe the algorithm presented allows for the required revascularisation and a modulation of the heel ulcer microenvironment by augmenting the microcirculation through NPWT, and improving the proliferative capacity with PDGF.

Below the knee angioplasty for limb salvage in diabetic patients with critical lower limb ischemia

Introduction: It is well known that atherosclerotic involvement in diabetic patients with critical limb ischemia (CLI) mainly affects below-the-knee (BTK) arteries. But the therapeutic efficacy of percutaneous transluminal angioplasty (PTA) in such patients has not been clearly defined. Aim: This study aims to assess the clinical success and the limb-salvage rates for infragenicular angioplasty as the initial treatment of critically ischemic lower limbs in diabetic patients. Materials and methods: From December 2006 to October 2008, a consecutive series of 64 limbs in 54 diabetic patients with critical limb ischemia (Rutherford categories 4,5,6) were treated by primary infragenicular angioplasty. Our primary end points were immediate technical success, sustained clinical improvement, haemodynamic outcome, and limb salvage rate. Secondary end points were periprocedural complications and 30-day all cause mortality. Results: The mean age of our 54 patients was 62 years (48-70 years). The initial technical success was achieved in 94% of procedures, with limb salvage rate of 100%, 95%, 89%, and 84% at 1, 3, 6, and 12 months respectively, haemodynamic improvement of 96%, 89%, 79%, and 60% at 1, 3, 6, and 12 months respectively, and sustained clinical improvement of 100%,95%, 89%, and 84% at 1, 3, 6, and 12 months respectively,. The periprocedural adverse events occurred in 5 (7.8%) procedures, and the 30-day all cause mortality was 1/54 (1.85%). Conclusion: Primary infragenicular angioplasty for limb salvage in the diabetic patient population represents an efficacious method to improve wound healing in critically ischemic limbs, taking into consideration the fragile nature and co-morbidities in such selected patient population.

Subintimal Angioplasty for Below-the-Ankle Arterial Occlusions in Diabetic Patients With Chronic Critical Limb Ischemia

To assess the feasibility and efficacy of subintimal angioplasty (SA) in the treatment of below-the-ankle arterial occlusion in diabetic patients with chronic critical limb ischemia (CLI). SA was applied in 37 diabetic patients (24 men; mean age 70.9+/-8.5 years, range 52-88) with chronic CLI and occlusive disease of the dorsalis pedis artery (DPA) and/or plantar artery (PA) but were poor candidates for intraluminal angioplasty or bypass surgery. Tissue loss was present in 31 (54.4%) of 57 afflicted limbs, and rest pain was reported in 51 (89.5%) limbs. SA was performed to create continuous arterial flow to the foot for limb salvage. The clinical symptoms, DPA or PA pulse volume scores, and ankle-brachial index (ABI) were compared before and after SA. Wound healing, amputation, and restenosis of target vessels were also evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and freedom from amputation. Below-the-ankle SA was performed successfully in 55 (83.3%) of 66 arteries in 57 limbs. Median pulse volume scores and ABIs were 0.33+/-0.55 and 0.31+/-0.19 before SA and 2.04+/-1.05 and 0.80+/-0.14 after SA, respectively (p<0.0001 for both). The 30-day mortality was 2.7%. Median follow-up was 9.1+/-6.1 months (range 1-18). Major complications occurred in 1 (2.7%) patient and minor complications in 3 (8.1%). Twelve months after SA, Kaplan-Meier analysis showed that the limb salvage rate was 94.6%, the freedom from amputation was 89.2%, and the survival rate was 97.3%. SA of the dorsalis pedis artery and/or plantar artery is a useful technique for lower limb salvage in diabetic patients with chronic CLI who are not candidates for bypass surgery.

Infrapopliteal angioplasties for limb salvage in diabetic patients: Does the clinical outcome justify its use?

Purpose:To analyze the results of infrapopliteal percutaneous transluminal angioplasty (PTA) as a primary treatment modality in diabetic patients with non- healing ulcers or gangrene.Materials and Methods:We retrospectively studied 35 angioplasties, performed as the first line of treatment to salvage diabetic feet. The patients were followed up for 12 months.Results:Grade 1 and 2 ulcers were seen in only 20% of patients (5.71 and 14.28%, respectively); 37.14% of patients had grade 3 ulcer, and 42.8% were in the gangrene stage (grade 4 - 34.2% and grade 5 - 8.5%). A total of 77 lesions in 46 arteries (including six popliteal and suprapopliteal lesions) were dilated in 35 limbs. Of the 71 infrapopliteal lesions, 86% of lesions were classified as group C or D (group A - 9.3%, group B - 4.65%, group C - 37.2%, and group D - 48.83%). Overall technical success rate was 84.7%. The vascular complication rate was 26% (12 arteries out of 46). Clinical success was achieved in 29.1% of cases at the end of 6 months and 58.6% at the end of one year. Limb salvage rates were 79.4% at the end of 6 months and 75.8% at the end of one year.Conclusions:A high technical success rate can be achieved even in situations traditionally considered unfavorable for angioplasty. Infrapopliteal angioplasty can produce limb salvage rates comparable to bypass surgery in diabetic patients with extensive disease.

Guidelines for the treatment of arterial insufficiency ulcers

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994–1999 in Area 7, Madrid, with a population of 569 307 and an estimated diabetic population of 37 932 (15 505 men and 22 427 women). The level of arterial reconstruction and associated risk factors were ascertained. Results: A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients ( n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100 000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score ( P<0.05) and were less frequently smokers ( P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study ( P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people ( P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass ( P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients ( P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05). Conclusion: Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Percutaneous transluminal angioplasty of tibial arteries for limb salvage in the high-risk diabetic patient.

Recent advances in balloon catheter technology allow percutaneous transluminal angioplasty (PTA) of small arteries such as the tibial arteries. PTA can thus be used to treat lower limb ischemia in diabetic patients whose arterial occlusive disease is often localized to the tibial arteries. This series included 14 consecutive diabetic patients who underwent tibial PTA for treatment of limb-threatening ischemia from 1986 to 1992. PTA was selected over conventional bypass procedures because of a lack of autogenous conduit or because of an unacceptably high surgical risk. Limb loss was imminent without prompt improvement in foot perfusion in all patients. Mean follow-up of 17 months demonstrated long-term limb salvage in 10/13 (77%) and "late" cardiac-related death in 3/13 (23%). This series demonstrates that although conventional arterial bypass should routinely supersede angioplasty procedures, tibial PTA offers the opportunity for limb salvage in diabetic patients with inadequate autogenous conduit for distal tibial bypass and may serve as an option for those who are considered too high risk for conventional bypass. Morbidity and mortality rates of tibial PTA parallel those of major amputation in this population with the obvious benefit of achieving limb salvage in carefully selected diabetic patients.

Limb Salvage of Infected Diabetic Foot Ulcers with Microsurgical Free-Muscle Transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.