SLR - June 2019 - Jennifer A. Skolnik
Reference: Butt T, Lilja E, Örneholm H, Apelqvist J, Gottsäter A, Eneroth M, Acosta S. Amputation-Free Survival in Patients with Diabetes Mellitus and Peripheral Arterial Disease with Heel Ulcer. Vascular and Endovascular Surgery. 2019 Feb; 52, 118–125.Scientific Literature Review
Reviewed By: Jennifer A. Skolnik, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Treating patients with diabetic foot ulcerations with concomitant peripheral vascular disease is part of daily practice for today’s podiatric surgeons. Although many of these wounds can be difficult to treat, patients living with diabetes as well as ischemia and heel ulcerations can be exceptionally challenging to treat, putting this population at a higher likelihood to undergo major amputation. Treatment of these ulcerations often involves a multidisciplinary approach, including podiatric and vascular surgeons and other specialists. The purpose of the present study was to assess differences in amputation-free survival in patients who underwent open versus endovascular intervention in patients with heel ulcerations with diabetes mellitus and peripheral arterial disease. These authors hypothesized that better outcomes would be noted after open vascular surgery.
Methods: A retrospective review was performed from January 1, 1983 to December 31, 2013 of a total of 4,273 patients who presented to a multidisciplinary diabetic foot clinic in Sweden with a foot ulcer. Those with heel ulcerations who had undergone vascular surgical intervention were included in the present study. During the study period, 127 limbs with heel ulceration had undergone intervention, 97 having endovascular surgery and 30 having open vascular surgery performed. Outcomes of both endovascular and open surgery were compared for those patients with heel ulceration at one and three years, including major amputation, death and amputation-free survival. Statistical analysis was performed to analyze differences in outcomes in patients undergoing open versus endovascular interventions.
Results: Nonhealing heel ulcers were correlated to major amputation at three years. Major amputation rates were higher in patients who underwent revascularization at two years compared to those who did not undergo operation. Patients who had revascularization were more frequently current smokers and had ischemic heart disease and severe peripheral vascular disease compared to those who did not have vascular surgery. Amputation-free survival was greater in patients who had an open vascular procedure as compared to those who had undergone an endovascular procedure. Having open vascular surgery and previous vascular surgery were independent factors that were correlated with a greater amputation-free survival. There were no statistically significant differences in mortality rate at one or three years when comparing the open to the endovascular groups.
Conclusions: The authors note that based on their findings, open revascularization surgery in patients living with diabetes and peripheral artery disease and heel ulcerations is more durable than endovascular therapy in regards to amputation-free survival. They argue that given the favorable results regarding open interventions, even with the propensity to perform endovascular procedures in recent decades, practitioners should consider open procedures as they may better treat those in the study population with heel ulcers. This article highlights the importance of a multidisciplinary approach to limb salvage particularly as it pertains to the treatment of heel ulcerations and stresses the importance of considering open revascularization whenever appropriate to help optimize outcomes of limb salvage, especially in patients living with diabetes and difficult-to-treat heel ulcerations.