The utilisation of vascular limb salvage services in the assessment and management of chronic limb‐threatening ischaemia and diabetic foot ulceration: A systematic review

Abstract

Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.

Transverse Tibial Bone Transport Enhances Distraction Osteogenesis and Vascularization in the Treatment of Diabetic Foot

“…For Grade 4, there is partial foot gangrene in diabetic foot 5 . For the treatment of Wagner Stage four, negative‐pressure wound therapy, interventional therapy, antibiotics, vascular reconstruction, and amputation can be chosen 6 , 7 , 8 , 9 , 10 , 11 .…”

Can a rapid-access vascular limb salvage service improve one-year amputation outcomes for patients with chronic limb-threatening ischaemia?

“…Furthermore, individual models vary greatly in scope, design and size; from individual ‘hot’ clinics specialising solely in DFUs, to dedicated multi-aetiology wound-care services. 11 Within the United Kingdom, focussing on new models of care is highly relevant given the particularly challenging targets recently published within the new VSGBI PAD QIF. 7…”

“…To date, not only are examples of these services within the literature limited, but many have key methodological weakness, which affects the validity of their conclusion. 11 Furthermore, no studies have investigated the effect of limb salvage services on times-to-treatment. The aims of this study are therefore to, a) describe the service provided by the VaLS clinic, b) evaluate the 12-months limb salvage outcomes for patients managed within the clinic’s first year of operation and c) investigate the effect of limb salvage services on times-to-treatment.…”

Gene therapy targeting inflammatory pericytes corrects angiopathy during diabetic wound healing

“…Diabetic angiopathy refers to the dysfunction and impairment of the arteries throughout the body, caused by diabetic status. Diabetic angiopathy affects both microvascular system in feet, fingers, toes, eyes, and kidneys, and macrovascular system in limbs ( 1 ).…”