SLR - September 2022 - Aaron Abraham, DPM (PGY-2)
Reference: Hou X, Guo P, Cai F, Lin Y, Zhang J. Angiosome-Guided Endovascular Revascularization for Treatment of Diabetic Foot Ulcers with Peripheral Artery Disease. Ann Vasc Surg. 2022 Mar 4:S0890-5096(22)00087-5. doi: 10.1016/j.avsg.2022.02.012.Level of Evidence: Retrospective Review (Level of Evidence III)
Scientific Literature Review
Reviewed by: Aaron Abraham, DPM (PGY-2)
Residency Program: The Jewish Hospital – Mercy Health, Cincinnati, OH
Podiatric Relevance: Most of the problems that diabetics have with their feet can be traced back to some sort of vascular disease. These problems become ever so evident in the case of serious infections when patients may need an amputation to clear the source of infection. If there is poor blood flow, any amputation would likely not heal and end up forming a chronic non-healing wound. In these scenarios, vascular intervention is often necessary to ensure there is enough blood flow to not only heal an amputation but to keep the lower extremity adequately perfused. The authors in this article wanted to evaluate the effect of revascularization based on the angiosome concept on diabetic foot ulcers compared to the traditional vascular intervention.
Methods: Patient data was collected retrospectively from their department from January 2018 to July 2020. There was a total of 111 patients with a diabetic foot and 112 legs were included in the study, with 67 males and 45 females. Patients were assigned to the direct revascularization (DR) group or the indirect revascularization (IR) group and the WIFI classification was applied to evaluate the overall condition of the affected limb. DR was achieved in 71 legs; meanwhile, IR was achieved in 41 legs. Any patient that had undergone revascularization in the past 6 months, major amputations, dialysis history or incomplete information were excluded
Results:
- Ulcer healing rate: 70.4 percent and 34.1 percent in the DR and IR group respectively
- Mean time to ulcer healing: 7.01 ± 4.26 and 10.09 ± 3.24 in the DR and IR group respectively
- Major amputation-free survival rate: 81.7 and 48.8 percent in the DR and IR group respectively
- DR didn’t significantly reduce the major amputations rate compared to IR, 13.4 and 34.1 percent respectively.
- No statistical significance was found between DR and IR.
Conclusions: Diabetics with PAD have impaired collateral circulation and normally lack a complete dorsalis pedis arch or collaterals of the peroneal artery in the foot thus making it hard to heal DFU’s. In my opinion, I feel that the DR is a great option if you’re dealing with a singular wound with an isolated infection. However, when dealing with a wound infection with PAD I believe that only opening one vessel with DR may not fully open blood flow to the entire foot and lead to more ulcerations later down the line. IR helps to increase the skin perfusion pressure on both the dorsal and plantar surface; and though the blood flow provided by IR may be insufficient to heal the ulcer, it can maintain tissue vitality to a certain extent and avoid major amputation. I think DR and IR are both great ways of revascularizing a patient’s foot and each can be used effectively in the right situation. Knowing the strengths of DR and IR will allow me to have a more intuitive conversation with a vascular surgeon so that we can come up with the most beneficial treatment plan for a patient in the long term.