Surgical revascularization techniques for diabetic foot

Optimizing Lower Extremity Local Flap Reconstruction in Peripheral Vascular Disease

BACKGROUND

Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle.

METHODS

A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables.

RESULTS

Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042).

CONCLUSIONS

Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals.

Evolving Trends in the Management of Diabetic Foot Ulcers: A Narrative Review

The prevalence of diabetic foot ulcers (DFUs) is projected to increase worldwide, which necessitates a review of the current management principles and the development of new approaches to care. The principles of management involve proper glycemic control, infection control, pressure redistribution, wound care debridement, and revascularization. Other modalities of management, such as hyperbaric oxygen therapy and negative wound pressure therapy, are also being explored. While some aspects of DFU care lack high-quality evidence, a multidisciplinary approach incorporating these evolving trends has the potential to improve outcomes and prevent lower extremity amputations in this challenging condition. This review highlights the need for further research to establish definitive treatment protocols for optimal DFU management.

Amputation in diabetic foot ulcer: A treatment dilemma

Diabetic foot is a clinical manifestation of diabetes with a wide range of symptoms, including ulceration, osteomyelitis, osteoarticular destruction, and gangrene, as a consequence of advanced disease. Some diabetic foot cases present general indications for amputation, including dead limb, threat to the patient’s life, pain, loss of function, or nuisance. Various tools have been introduced to help decision-making in amputation for diabetic foot. However, it remains a conundrum because diabetic foot involves multiple pathomechanisms and factors that hinder its outcomes. Sociocultural issues often impede treatment from the patient’s side. We reviewed different perspectives in diabetic foot management, particularly related to amputation. In addition to deciding whether to amputate, physicians should address amputation level, timing, and ways to avoid patient deconditioning. Surgeons should not be autocratic in these circumstances and should be aware of beneficence and maleficence when considering whether to amputate. The main goal should be improving the patients’ quality of life rather than preserving the limb as much as possible.

Racial and ethnic amputation level disparities in veterans undergoing incident dysvascular lower extremity amputation

BACKGROUND

The choice of incident amputation level can have a profound effect on clinical outcomes. Amputations at the transmetatarsal (TM) or transtibial (TT) levels result in greater preservation of function and mobility, whereas transfemoral (TF) amputations typically result in a greater adverse impact. Prior investigations have explored racial/ethnic and regional variation in incident amputation level. This study overcomes some of the methodological limitations seen in prior research through the use of a large national, multiyear veteran sample and by including only those who have undergone an incident amputation.

OBJECTIVES

(1) Determine if there are national/regional differences in the frequency of incident TF amputation compared with TM and TT amputation, (2) Determine if race/ethnicity and geographic region are associated with incident TF amputation level, and (3) Determine if racial/ethnic disparities of incident TF amputation differ by the presence of diabetes or prior revascularization.

DESIGN

Retrospective cohort study of veterans undergoing an incident dysvascular lower extremity amputation.

SETTING

One hundred ten Veterans Affairs (VA) Medical Centers.

PARTICIPANTS

Seven thousand two hundred ninety-six Veterans undergoing incident unilateral dysvascular lower extremity amputation identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database (2005-2014).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Incident amputation level.

RESULTS

The White, Black, and Hispanic risk for an incident TF amputation was 31% (n = 1356), 35% (n = 810), and 46% (n = 293), respectively. In the Continental region, Blacks who had not had a prior revascularization were more likely to undergo a TF amputation compared to Whites both with and without diabetes (odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.1, 1.9 and OR = 1.5; 95% CI, 1.1, 2.1, respectively). In the Southeast region, Hispanics compared with Whites were at increased odds of undergoing a TF amputation, irrespective of a diabetes or a prior revascularization (ORs ≥ 2.9).

CONCLUSIONS

Racial and ethnic disparities exist in choice of proximal compared with distal amputation in specific VA geographic regions.

Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems

INTRODUCTION

The aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional health administrative databases.

RESEARCH DESIGN AND METHODS

We carried out a population-based cohort study including patients with diabetes residing in the Lazio region and undergoing a primary amputation in the period 2012-2015. Each individual was followed up for at least 2 years. Kaplan-Meier analysis was used to evaluate long-term survival; Cox proportional regression models were applied to identify factors associated with all-cause mortality.

RESULTS

The cohort included 1053 patients, 72% were male, 63% aged ≥65 years, and 519 (49%) died by the end of follow-up. Mortality rates at 1 and 4 years were, respectively, 33% and 65% for major LEA and 18% and 45% for minor LEA. Significant risk factors for mortality were age ≥65, diabetes-related cardiovascular complications, and chronic renal disease for patients with minor LEA, and age ≥75 years, chronic renal disease and antidepressant drug consumption for subjects with major LEA.

CONCLUSIONS

The present study confirms the high mortality rates described in patients with diabetes after non-traumatic LEA. It shows differences between minor and major LEA in terms of mortality rates and related risk factors. The study highlights the role of depression as specific risk factor for death in patients with diabetes after major LEA and suggests including its definition and management in strategies to reduce the high mortality rate observed in this group of patients.

Transcatheter Arterial Infusion of Autologous CD133(+) Cells for Diabetic Peripheral Artery Disease

Microvascular lesion in diabetic peripheral arterial disease (PAD) still cannot be resolved by current surgical and interventional technique. Endothelial cells have the therapeutic potential to cure microvascular lesion. To evaluate the efficacy and immune-regulatory impact of intra-arterial infusion of autologous CD133(+) cells, we recruited 53 patients with diabetic PAD (27 of CD133(+) group and 26 of control group). CD133(+) cells enriched from patients' PB-MNCs were reinfused intra-arterially. The ulcer healing followed up till 18 months was 100% (3/3) in CD133(+) group and 60% (3/5) in control group. The amputation rate was 0 (0/27) in CD133(+) group and 11.54% (3/26) in control group. Compared with the control group, TcPO2 and ABI showed obvious improvement at 18 months and significant increasing VEGF and decreasing IL-6 level in the CD133(+) group within 4 weeks. A reducing trend of proangiogenesis and anti-inflammatory regulation function at 4 weeks after the cells infusion was also found. These results indicated that autologous CD133(+) cell treatment can effectively improve the perfusion of morbid limb and exert proangiogenesis and anti-inflammatory immune-regulatory impacts by paracrine on tissue microenvironment. The CD133(+) progenitor cell therapy may be repeated at a fixed interval according to cell life span and immune-regulatory function.

Danhong Promotes Angiogenesis in Diabetic Mice after Critical Limb Ischemia by Activation of CSE-H 2 S-VEGF Axis

The aim of this paper is to investigate effect and mechanism of Danhong injection (DH) on angiogenesis in the diabetic hind limb ischemia mouse model. Thirty diabetic hind limb ischemic model mice and ten normal mice, established by intraperitoneal (i.p.) injection of streptozotocin (STZ) or PBS and ligation/excision of femoral artery, and then twenty diabetic hind limb ischemic model mice of all were evenly randomized to saline (control, n = 10) and DH i.p. injection (2 mL/kg weight for 7 days, n = 10) groups. Limb perfusion recovery and femoral blood hydrogen sulfide (H₂S) and vessel regeneration and lower limb vascular endothelial growth factor (VEGF)/cystathionine γ-lyase (CSE) expression were evaluated during intervention and after euthanasia, respectively. DH i.p. increased ischemic limb perfusion and promoted collateral circulation generation without decreasing blood glucose level. Increased local CSE-H₂S-VEGF expression contributed to beneficial effects of DH injection. In conclusion, activation of local CSE-H₂S-VEGF axis might participate in proangiogenesis effects of DH injection in diabetic hind limb ischemia model mice, suggesting a potential therapy for diabetic patients with critical limb ischemia.

Long-term outcomes of infrainguinal bypass surgery for patients with diabetes mellitus and tissue loss

Purpose

To determine the long-term outcomes of patients with diabetes mellitus (DM) and tissue loss who have undergone infrainguinal bypass surgery (IBS).

Methods

We retrospectively reviewed the medical records of 91 patients with DM and tissue loss who underwent IBS between July 2003 and December 2013. We determined the rates of overall survival (OS), amputation-free survival (AFS), limb salvage (LS), and graft patency (GP). In addition, we evaluated data to identify risk factors that affected long-term outcomes.

Results

The mean age of patients was 66 ± 8 years, and 78 patients (85.7%) were men. The locations of tissue loss were toe on 76 limbs (71.6%), heel on 6 limbs (5.7%) and others on 24 limbs (22.6%). Single lesions were found in 81 limbs (76.4%). According to categorization by distal anastomosis artery, there were 57 popliteal (53.8%) and 49 infrapopliteal bypasses (46.2%). Among infrapopliteal bypasses, 5 cases (10.2%) were sequential bypasses. The OS at 1, 3, and 5 years was 90.5%, 70.9%, and 44.2%, respectively. At 1, 3, and 5 years, the LS was 92.1%, 88.9%, 88.9%, respectively; and AFS was 84.4%, 67.6%, 45.7%, respectively. At 1, 3, and 5 years, the GP was 84.8%, 74.5%, and 69.8%, respectively. Renal failure was a negative predictor for OS, and female gender was a negative predictor for GP.

Conclusion

IBS for patients with DM and tissue loss led to acceptable OS, AFS, LS, and GP. Active revascularization for patients with DM and tissue loss can reduce the risk of major amputation.

Successful Treatment of a Patient With Complicated Diabetic Foot Wound: A Case Report

Foot ulceration is one of the most serious complications of diabetes mellitus and may lead to amputation of the lower extremity. Timely prophylaxis and treatment of diabetic foot ulceration are important to maintain a good quality of life. This article reports a complicated diabetic patient with severe limb-threatening necrotizing infection. We successfully applied endovascular stent insertion, digit amputation, negative pressure wound therapy, and advanced dressings in different wound phases to achieve definitive wound healing after 12 months of treatment. Based on this case report, we would like to emphasize the importance of combined multiple therapies and patient compliance for severe diabetic foot ulcers.