Commentary: Wound-Directed Revascularization for the Treatment of Diabetic Foot Ulcers: Comments on a Newly Proposed Algorithm

A focused review on hyaluronic acid contained nanofiber formulations for diabetic wound healing

The significant clinical challenge presented by diabetic wounds is due to their impaired healing process and increased risk of complications. It is estimated that a foot ulcer will develop at some point in the lives of 15-25 % of diabetic patients. Serious complications, including infection and amputation, are often led to by these wounds. In the field of tissue engineering and regenerative medicine, nanofiber-based wound dressings have emerged in recent years as promising therapeutic strategies for diabetic wound healing. Hyaluronic acid (HA), among various nanofiber materials, has gained considerable attention due to its unique properties, including biocompatibility, biodegradability, and excellent moisture retention capacity. By promoting skin hydration and controlling inflammation, a crucial role in wound healing is played by HA. Wounds are also helped to heal faster by HA through the regulation of inflammation levels and signaling the body to build more blood vessels in the damaged area. Great potential in various applications, including wound healing, has been shown by the development and use of nanofiber formulations in medicine. However, challenges and limitations associated with nanofibers in medicine exist, such as reproducibility, proper characterization, and biological evaluation. By providing a biomimetic environment that enhances re-epithelialization and facilitates the delivery of active substances, nanofibers promote wound healing. In accelerating wound healing, promising results have been shown by HA-contained nanofiber formulations in diabetic wounds. Key strategies employed by these formulations include revascularization, modulation of the inflammation microenvironment, delivery of active substances, photothermal nanofibers, and nanoparticle-loaded fabrics. Particularly crucial is revascularization as it restores blood flow to the wound area, promoting healing. Wound healing can also be enhanced by modulating the inflammation microenvironment through controlling inflammation levels. Future perspectives in this field involve addressing the current challenges and limitations of nanofiber technology and further optimizing HA-contained nanofiber formulations for improved efficacy in diabetic wound healing. This includes exploring new fabrication techniques, enhancing the biocompatibility and biodegradability of nanofibers, and developing multifunctional nanofibers for targeted drug delivery. Not only does writing a review in the field of nanofiber-based wound dressings, particularly those containing hyaluronic acid, allow us to consolidate our current knowledge and understanding but also broadens our horizons. An opportunity is provided to delve deeper into the intricacies of this innovative therapeutic strategy, explore its potential and limitations, and envision future directions. By doing so, a contribution can be made to the ongoing advancements in tissue engineering and regenerative medicine, ultimately improving the quality of life for patients with diabetic wounds.

Angiosome-guided endovascular revascularization for treatment of diabetic foot ulcers with peripheral artery disease

OBJECTIVE

Because diabetic foot ulcers (DFUs) are difficult to heal and cause huge economic losses to society, accelerating their healing has become extremely important. The purpose of this study was to evaluate the effect of revascularization based on the angiosome concept on DFU.

MATERIALS AND METHODS

Between January 2018 and July 2020, 112 consecutive legs with DFUs in 111 patients who were discharged from the vascular surgery department of our hospital were retrospectively evaluated. The legs were assigned to two groups depending on whether direct arterial flow to the foot ulcer based on the angiosome concept was achieved. Comparisons of the ulcer healing rate, mean time to ulcer healing, major amputation rate, survival rate, and major amputation-free survival rate between the angiosome direct revascularization (DR) and angiosome indirect revascularization (IR) groups were performed.

RESULTS

DR was achieved in 71 legs (63%) compared with IR in 41 legs. The ulcer healing rate (70.4% in the DR group vs. 34.1% in the IR group, P < 0.01), the mean time to ulcer healing (7.01 ± 4.26 months vs. 10.09 ± 3.24months, P < 0.01), the survival rate (90.1% vs. 53.7%, P < 0.01), and the major amputation-free survival rate (81.7% vs. 48.8%, P < 0.01) were significantly higher in the DR group than in the IR group. Undergoing DR did not significantly reduce the major amputations rate compared with IR (13.4% and 34.1%, respectively, P = 0.15), but there might be a trend. In multivariate models, DR remained a significant predictor for ulcer healing (HR, 7.07; 95% confidence interval, 6.54-7.60, P < 0.01). Opening multiple infrapopliteal arteries in the DR group compared with restoring only one infrapopliteal artery did not significantly improve the the ulcer healing rate (P = 0.59), the mean time to ulcer healing (P = 0.70), major amputation rate (P = 0.83), the survival rate (P = 0.31), and the major amputation-free survival rate(P = 0.40).

CONCLUSIONS

Attaining a direct arterial flow based on the angiosome concept may be important for ulcer healing, survival, and amputation-free survival in diabetic foot patients. Opening multiple infrapopliteal arteries in DR patients may not improve the ulcer healing, survival, major amputation or amputation-free survival compared with single DR vessel patency.