Foot ulceration and gangrene are important causes of morbidity in diabetic patients. Healing of such lesions requires surgical debridement of the infected and necrotic tissue, and restoration of pulsatile blood flow to the foot. As occlusive atherosclerosis of the tibial arteries is particularly common in diabetic patients, infrapopliteal revascularisation is often required. This has traditionally been accomplished by transluminal angioplasty or surgical bypass, with moderately good results. More recently, subintimal angioplasty has been proposed as an alternative, minimally invasive treatment to recanalise long arterial occlusions, with promising patency rates even in small vessels. Advanced reconstructive techniques, including local or free tissue flaps can be used to accelerate healing of large foot wounds after successful revascularisation. Treatment of diabetic tibial artery disease is challenging and requires an aggressive multidisciplinary approach, with co-operation between diabetologists, interventional radiologists, vascular and plastic surgeons.
Bainton D., Sweetnam P., Baker I., Elwood P.Peripheral vascular disease: consequence for survival and association with risk factors in the Speedwell prospective heart study. Br Heart J1994;72:128-32.
2.
Brand FN, Abbott RD, Kannel WBDiabetes, intermittent claudication, and risk of cardiovascular events. The Framingham study. Diabetes1989; 38:504-9.
3.
Gensler SW, Haimovici H., Hoffert P., Steinman C., Beneventano TCStudy of vascular lesions in diabetic, nondiabetic patients. Clinical, arteriographic, and surgical considerations. Arch Surg1965 ;91:617-22.
4.
Williams DRR.Hospital admissions of diabetic patients: information from hospital activity analysis. Diabet Med1985;2:27-32.
5.
World Health Organisation (Europe) and International Diabetes Federation (Europe).Diabetes care and research in Europe: the Saint Vincent declaration. Diabet Med1990;7:360.
6.
Dawson I., Keller BP, Brand R., Pesch-Batenburg J., Hajo van Bockel J.Late outcomes of limb loss after failed infrainguinal bypass. J Vasc Surg1995; 21:613-22.
7.
Antiplatelet Trialists' Collaboration. Collaborative overview of randomized trials of antiplatelet therapy-I: prevention of death, myocardial infarction and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ1994;308:81-106.
8.
Kmietowicz Z.Statins are the new aspirin, Oxford researchers say. BMJ2001;323:1145.
9.
Menzoian JO, LaMorte WW, Paniszyn CC et al. Symptomatology and anatomic patterns of peripheral vascular disease: differing impact of smoking and diabetes. Ann Vasc Surg1989;3:224-8.
10.
Schneider PA , Caps MT, Ogawa DY, Hayman ESIntraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene. J Vasc Surg2001;33:955-62.
11.
Parsons RE, Suggs WD, Lee JJ, Sanchez LA, Lyon RT, Veith FJPercutaneous transluminal angioplasty for the treatment of limb threatening ischemia: do the results justify an attempt before bypass grafting?J Vasc Surg1998;28:1066-71.
12.
Golledge J. , Ferguson K., Ellis M. et al. Outcome of femoropopliteal angioplasty . Ann Surg1999;229:146-53.
13.
Bull PG, Mendel H., Hold M., Schlegl A., Denck H.Distal popliteal and tibioperoneal transluminal angioplasty: long-term follow-up . J Vasc Interv Radiol1992;3:45-53.
14.
Clark TW, Groffsky JL, Soulen MCPredictors of long-term patency after femoropopliteal angioplasty: results from the STAR registry. J Vasc Interv Radiol2001;12:923-33.
15.
Bolia A., Miles KA, Brennan J., Bell PRPercutaneous transluminal angioplasty of occlusions of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol1990;13:357-63.
16.
London NJ, Srinivasan R., Naylor AR, Hartshorne T., Ratliff DA, Bell PR, Bolia A.Subintimal angioplasty of femoropopliteal artery occlusions: the long-term results. Eur J Vasc Surg1994;8:148-55.
17.
Vraux H., Hammer F., Verhelst R., Goffette P., Vandeleene B.Subintimal angioplasty of tibial vessel occlusions in the treatment of critical limb ischaemia: mid-term results. Eur J Vasc Endovasc Surg2000;20:441-6.
18.
McCarthy RJ , Neary W., Roobottom C., Tottle A., Ashley S.Short-term results of femoropopliteal subintimal angioplasty. Br J Surg2000;87: 1361-5.
19.
Ingle H., Nasim A., Bolia A. et al. Role of subintimal angioplasty of isolated infragenicular vessels in lower limb ischaemia. J Endovasc Therapy (in press).
20.
Misare BD, Pomposelli FB, Gibbons GW, Campbell DR, Freeman DV, LoGerfo FWInfrapopliteal bypasses to severely, unclampable outflow arteries: two year results. J Vasc Surg1996;24:6-16.
21.
Verhelst R. , Bruneau M., Nicolas AL et al. Popliteal-to-distal bypass grafts for limb salvage. Ann Vasc Surg1997;11:505-9.
22.
Biancari F. , Kantonen I., Alback A., Ihlberg L., Lehtola A., Lepantalo M.Popliteal-to-distal bypass grafts for critical leg ischaemia. J Cardiovasc Surg2000;41:281-6.
23.
Seeger JM, Coe DA, Harward TRS.The truth about arm veins for infrainguinal bypass. In: Veith FJ (ed.) Current critical problems in vascular surgery. Volume 5. QMP Inc1993, St Luis (USA).
24.
Bergan JJ, Veith FJ, Bernhard VM et al. Randomization of autogenous vein and polytetrafluorethylene grafts in femoral-distal reconstruction. Surgery1982;92:921-30.
25.
Faries PL, Logerfo FW, Arora S. et al. Arm vein conduit is superior to composite prosthetic-autogenous grafts in lower extremity revascularization. J Vasc Surg2000;31:1119-27.
26.
Raby KE, Goldman L., Creager MA et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med1989;321:1296-300.
27.
Mangano DT, Browner WS, Hollenberg M., London MJ, Tubau JF, Tateo IMAssociation of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med1990 ;323:1781-8.
28.
Rubin JR, Persky J., Lukens MC, Plecha EJ, Graham LMFemoral-tibial bypass for calcific arterial disease. Am J Surg1989;158:146-50.
29.
Herrera HR, Geary J., Whitehead P., Evangelisti S.Revascularization of the lower extremity with omentum. Clin Plast Surg1991;18:491-5.
30.
Karp NS, Kasabian AK, Siebert JW, Eidelman Y., Colen S.Microvascular free-flap salvage of the diabetic foot: a 5-year experience . Plast Reconstr Surg1994;94:834-40.
31.
Vermassen FE , van Landuyt K.Combined vascular reconstruction and free flap transfer in diabetic arterial disease. Diabetes Metab Res Rev2000;16(suppl 1):S33-6.
