Peripheral arterial disease and revascularization of the diabetic foot

Abstract

Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches.

Wound Closure in Smoking Peripheral Arterial Disease Patients With Treatment-Refractory Ulcerations

“…Nonclosed wounds in such patients represent a prominent risk factor for infection leading to hospitalization and lower limb amputation. 4,9 …”

“…1 Even with a multidisciplinary approach that includes advanced therapies with consistent standard of care (SOC) measures such as infection control, debridement, offloading, revascularization, compression and the promotion of patient normoglycemia, a nonhealing or treatment refractory wound may occur in as many as one-third of cases. 1-4 …”

“…4 Nearly three-fourths of such wounds result in major amputation due to inadequate healing. 4,20 Even with the available advanced wound care products, technologies and improved methods of accurate diagnosis, prolonged duration of treatment and an increased morbidity related to infection and amputation continue to occur. 2,3,25,26 …”

The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

“…Although it is unclear if these benefits are applicable to a subgroup of patients with co-morbid diabetes [23], in whom the characteristics of PAD differ substantially from those without diabetes (Table 1), the results of a recently published meta-analysis [24] focusing solely on angioplasty interventions in this previously unexamined patient group had resonated with these findings.…”

Hard-to-heal diabetes-related foot ulcers: current challenges and future prospects

“…91 Despite some variability in results, the increased accessibility to endovascular procedures provides a window of hope for healing of DFUs even if the resultant increased perfusion is temporary. However, many patients will continue to experience slow healing and frequent re-ulceration due to failure of the stent 100 and the progressive nature of the PAD. For patients with critical limb ischemia for whom revascularization is unsafe or not appropriate, for example, in severely frail patients or in those whose life expectancy is <6-12 months 101 or those who decline intervention, there is evidence that healing can still be achieved.…”