SLR - March 2012 - Thomas Chambers
Reference: Faglia E, Clerici G, Losa S, Tavano D, Caminiti M, Miramonti M, Solalvico F, Airoldi F. Limb Revascularization Feasibility in Diabetic Patients With Critical Limb Ischemia: Results From a Cohort of 344 Consecutive Unselected Diabetic Patients in 2009. Diab Res Clin Pract (2011), doi:10.1016/j.diabres.2011.10.033
Scientific Literature Review
Reviewed by: Thomas Chambers, DPM
Residency Program: Southern Arizona VA Healthcare System
Podiatric Relevance:
Schemia to the lower extremity is often a problem when treating diabetic foot wounds. This article looked at 344 consecutive diabetic patients to determine the feasibility of angioplasty or bypass grafting to aide in restoring vascularity to the extremity.
Methods:
All diabetics admitted to the Diabetic Foot Center for foot lesions were assessed for critical limb ischemia (CLI) as defined by the author as TcPO2 on the dorsum of the foot at <30 mmHg and ankle pressure < 70 mmHg. All of these patients underwent an arteriography and the results were reviewed by an interventional radiologist, vascular surgeon and diabetologist to determine the feasibility of a revascularization procedure. In patients who were low surgical risks with a long femoral occlusion and patent popliteal arteries, a bypass was performed. In patients with higher risk factors, angioplasties were performed.
Results:
During 2009 a total of 344 patients with 360 limbs that had CLI were evaluated. Twelve limbs had rest pain while the remaining 348 limbs had a foot lesion at the beginning of the study. Angioplasty was performed on 308 limbs increasing the mean TcPO2 from 16.2±13.5 to 43.6±12.9 mmHg. In 303 limbs the angioplasty revascularized at least one artery down to the foot. Forty limbs were unable to be stented so an open bypass graft was used. In these patients the TcPO2 increased from 11.9±9.9 to 52.2±15.7 mm HG. Twelve limbs were determined to not be feasible for revascularization. It was determined that a bypass graft would have been feasible in 220 (61.1 percent of limbs). Major complications included 19 amputations, 8 of which did not get revascularized. Three amputations resulted from the bypass group and eight from the angioplasty group. The mean time of maintenance of vascularity was 16.1±5.7 months. At 30 days, two patients died, after one year a total of 57 patients died.
Conclusions:
This study determined that it is feasible to perform vascular intervention in 86 percent of diabetic patients and that can lead to healing wounds. The amputation and death rates were much lower in the revascularized patients versus those that did not receive intervention. It further showed that the intervention was not always long lasting but was enough to maintain the limb a preponderance of the time. When dealing with a patient that has CLI, vascular intervention is not only a feasible option but an important thing to consider for the long-term care of the patient and that neglecting the vascular concerns of the patient can be detrimental.