SLR - October 2014 - Zach Farley

Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes

Reference: T. Elgzyri, J. Larsson, P. Nyberg, J. Thorne, K-F. Eriksson, J. Apelqvist. Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes. Eur J Vasc Endovasc Surg. 2014 Oct; 48(4): 440-6.      

Scientific Literature Review

Reviewed By: Zach Farley, DPM
Residency Program: Florida Hospital East, Orlando, FL

Podiatric Relevance: Diabetic foot ulcerations are a common pathology in the world of the podiatric physician. It is essential that the physician understand the physiological processes involved in wound healing so that he or she can minimize the duration of treatment for the patient.  It is also important that the physician assesses the patient’s ability to heal via adequate blood flow to the wound. More than often, the patient may benefit from revascularization in order to expedite the treatment process. The authors of this article are trying to examine the relationship between time to revascularization and the probability of healing without amputation with patients who have a diabetic foot ulcer and ischemia to the affected limb.

Methods: A total of 1,151 consecutive patients with limb ischemia and diabetic foot ulceration were admitted to a multidisciplinary foot center from 1984-2006.  Wagner grade 1-5, at or below the ankle was the scale of choice for grading the ulcerations. Of these patients, 478 were included and had either percutaneous transluminal angioplasty (PTA) or some type of vascular reconstructive surgery. Three of the 475 patients were lost in follow up. Patients with diabetes mellitus and systolic toe pressure less than 45mmHg and or systolic ankle pressure less than 80 were included.  Rest pain was defined as severe persistent pain localized to the foot and relieved by dependency.

Results: Of the 475 patients , 305 healed without major amputation, 217 healed primarily and 88 healed after minor amputation. Seventy-six of the patients healed after a major amputation and 92 died unhealed.  Shorter time to revascularization, Wagner grade less than three reached during follow up and presence of intermittent claudication were related to higher probability of healing without major amputation. The presence of peripheral edema was related to lower probability of healing. 

Conclusion: The authors concluded that a shorter time frame from first presentation at the foot team to revascularization, predicted a better healing probability without major amputation. Findings were the same for PTA and reconstructive surgery.  In patients with inadequate blood flow and ulcers that have been present for greater than six weeks with no signs of clinical improvement will most likely benefit from revascularization. The physician should be cognizant of the healing potential through revascularization in patients with diabetes and severe peripheral ischemia to improve the outcome of the foot ulcer.

Educational Opportunities