The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome

Distal bypasses in patients with diabetes and infrapopliteal disease: technical considerations to achieve success

The combination of diabetes and peripheral arterial disease (PAD) is challenging in many ways. The characteristic and complex distal distribution of PAD often encountered in patients with diabetes means that bypass surgery in this context is technically challenging. In addition, many of these patients have a burden of serious comorbidities that must be optimized and managed concurrently. While the authors acknowledge that "achieving success" in distal bypass relies on much more than technical expertise, there are some technical aspects that should be considered when planning surgery on these patients. This article outlines some important issues in the treatment pathway of a patient with diabetes and PAD requiring distal bypass surgery--from selection and optimization of the patient (in the context of a multidisciplinary team) and preoperative workup, to the operative strategy planning, technical tips, and nonoperative adjuncts. These considerations, as well as sound knowledge of the underlying disease process, confounding medical factors and awareness of the difficulty in predicting treatment outcomes, should help maximize the chances of success.

Ulcer healing after peripheral intervention-can we predict it before revascularization?

Complete ulcer healing is one of the most important goals of treatment for critical limb ischemia; however, it is still difficult to inform patients of the time to ulcer healing before performing revascularization. The time to ulcer healing has a great impact on the cost of treatment and patient's quality of life. To predict it, the factors that influence delayed ulcer healing should be explored. According to a review of the literature investigating ulcer healing after revascularization, the influential factors can be classified into 5 categories: (1) systemic factors; (2) clinical state of tissue defect; (3) infection; (4) wound management strategy; and (5) revascularization strategy (endovascular or open repair, the angiosome concept). It is also important to ensure sufficient blood supply to predict ulcer healing probability in the individual patient. Several new methodologies, such as measuring tissue circulation around the tissue defect and intraoperative imaging techniques, have been reported. Because the status of ischemic tissue loss and wound healing ability can affect the decision-making process in selecting the revascularization strategy, understanding the many factors that influence ulcer healing after revascularization is indispensable for physicians performing revascularization. Accumulating ulcer healing data via well-designed clinical research can help to establish a new paradigm for the revascularization strategy from the viewpoint of ulcer healing.

Wound morphology and topography in the diabetic foot: hurdles in implementing angiosome-guided revascularization

Purpose. Angiosome-guided revascularization is an approach that improves wound healing but requires a surgeon to determine which angiosomes are ischemic. This process can be more difficult than anticipated because diabetic foot (DF) wounds vary greatly in quantity, morphology, and topography. This paper explores to what extent the heterogeneous presentation of DF wounds impedes development of a proper revascularization strategy. Methods. Data was retrieved from a registry of patients scheduled for below-the-knee (BTK) revascularization. Photographs of the foot and historic benchmark diagrams were used to assign wounds to their respective angiosomes. Results. In 185 limbs we detected 345 wounds. Toe wounds (53.9%) could not be designated to a specific angiosome due to dual blood supply. Ambiguity in wound stratification into angiosomes was highest at the heel, achilles tendon, and lateral/medial side of the foot and lowest for malleolar wounds. In 18.4% of the DF, at least some wounds could not confidently be categorized. Proximal wounds (coinciding with toe wounds) further steered revascularization strategy in 63.6%. Multiple wounds required multiple BTK revascularization in 8.6%. Conclusion. The heterogeneous presentation in diabetic foot wounds hampers unambiguous identification of ischemic angiosomes, and as such diminishes the capacity of the angiosome model to optimize revascularization strategy.