SLR - May 2017 - Todd A. Hasenstein
Reference: Tzu-Yen Chang, Shyh-Jou Shieh. Revascularization Surgery: Its Efficacy for Limb Salvage in Diabetic Foot. Ann Plast Surg. 2016 Mar; 76 (Suppl 1): S13–S18.
Reviewed By: Todd A. Hasenstein, DPM
Residency Program: Temple University Hospital; Philadelphia, PA
Podiatric Relevance: A common condition seen in epidemic proportions by foot and ankle surgeons is diabetic foot infection. These infections are commonly complicated with superimposed peripheral vascular disease that requires consultation and a lot of times intervention by our vascular surgery colleagues. It has been well demonstrated that without adequate perfusion, a patient is at an increased risk of developing nonhealing wounds and infections or undergoing revisional surgical procedure, including minor and/or major amputations. This article examines the effectiveness of revascularization with respect to limb salvage in patients with diabetic foot and critical limb ischemia.
Methods: A level IV retrospective study was preformed over eight years (2006–2013) for patients who were admitted for vascular invention and some form of “diabetic foot disease.” Diabetic foot disease was defined utilizing a novel scoring scale. There was a total of 42 patients included, who either underwent revascularization via angioplasty (36, 86 percent) or bypass (6, 14 percent). Of the angioplasty group, nine of 36 (25 percent) patients had stents placed. Intraoperative findings of occlusion levels were recorded, as well as the postoperative results after recanalization. Rates of major amputation were then evaluated as the primary outcome. Whereas mortality and other minor complications were examined as secondary outcomes.
Results: Of the 42 patients included in this study, 19 (45 percent) underwent major amputations, 15 (36 percent) had successful limb salvage, four (9.5 percent) were lost follow-up and four (9.5 percent) died during the follow-up period. The location of the foot wounds were as follows: toes (30; 71.4 percent), foot (10; 23.8 percent) and leg (1; 2.4 percent). Intraoperative lesion levels were as follows: suprapopliteal (13; 31 percent), infrapopliteal (4; 9 percent) and combined (25; 60 percent). There was no significant difference in the location of the foot wounds, the severity of the wounds or the location of the arterial occlusion between the amputation and salvage groups. Similarly, there was no significant difference among these two groups with respect to comorbidities. However, not statistically significant, there was a tendency for longer duration of diabetes, presence of ESRD, worse wound severity and infrapopliteal occlusions to be higher in the amputation cohort. Nevertheless, none of these were statistically predictive of amputation versus salvageability of the lower extremity. Five (12 percent) of all the patients underwent repeat angioplasty for restenosis. Patency rate of the original revascularization at six months and one year was 91 percent and 71 percent, respectively.
Conclusion: Diabetes is currently an epidemic in many developed countries and is starting to emerge in developed counties to become a modern-day pandemic. Literature has described up to 25 percent of people living with diabetes will develop an ulceration at some point in their lifetime, and diabetes is currently the leading cause of lower-extremity amputations. A major contributing factor to both is inadequate prefusion to the lower extremity. This ischemia is due to diabetic arterial changes in the macro and microcirculatory systems. Macrocirculation can be improved by either endovascular or open-vascular procedure; however, in this article, neither showed any statistical significates to the results of limb salvage versus amputation. There was a small correlation, although not statistically significant, to longer duration of diabetes, presence of ESRD, worse wound severity and infrapopliteal occlusions leading to higher rates of amputation. Although not statistically significant, one or more of these could be a true correlation, but this article had too small of a sample size to be sure. This is a major limitation to the study, and it should be followed up on in the future once adequate sample sizes are achievable. Another important limitation to this study is the fact that it was retrospective in nature. A prospective study would be more optimal, however, impossible to achieve a blind study, due to incision. Additional limitation is selection bias, both in selection of the inclusion criteria (successfully revascularization) and individual surgeon’s procedure selection given severity of disease. This paper did not really demonstrate the effectiveness of revascularization in limb salvages, but it adds to the body of knowledge and can guide future studies in the right direction.