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Revascularization for Foot Salvage inDiabetic Critical foot IschaemiaM K Yii, FRAC* and N C Hew, M Surg (UKM)*"', *Department of SUl"gery, Sali"awak GeneralHospital, Kuching, Sarawak, *"Armed Forces Hospital, Terendak Camp, Melaka

Diabetes increases the risk of arterial occlusive disease ofthe lower limbs by 7 to 20 times!. In some patients thedisease progresses rapidly to critical ischaemia and themajor amputation risk is 15 to 70 times higher than ina non-diabetic'3. In Malaysia the prevalence of diabetesis rising with increasing urbanisation and lifestylechanges45. It is to be expected that more patients willpresent with critical limb ischaemia in the future. TheSociety of Vascular Surgery/International Society forCardiovascular Surgery (SVS/ISCVS) reporting standardsdefine chronic critical limb ischaemia (CLl) as either thepresence of rest pain that requires moderate ro stronganalgesia for at least 3 weeks with objective evidence ofdiffuse pedal ischaemia (resting ankle pressure

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These referrals came mainly from the respective statesthough occasionally referrals from neighbouring stateswere also accepted. Acute limb ischaemia withsymptoms less than 3 weeks and diabetic neuropathiculceration/lesions were excluded from this study. Theperiod of the study covered 2 years (August 1996 to July1998). Clinical historical details included age, sex,ethnic origin, presence of medical co-morbidities andsmoking habit. All patients with the diagnosis ofcritical foot ischaemia underwent diagnosticangiography for the possibility of revascularization tosave the limbs. Digital subtraction angiography (DSA)was available to the first author (MKy) while routineangiography (RA) was the only option available to. theother. The preoperative arterial outflows were noted.Patients were offered exploratory surgery if no outflowartery was visualized. Patients with associated infectionof the necrotic area (gangrene or ulcer) were treated withbroad spectrum antibiotic until specific organisms werecultured. Indications for operative interventions wererecorded. Postoperative outcomes and follow-upespecially with respect to the complications, mortaliry,graft patency rate and limb salvage were recorded. Allrevascularizations were for limb/foot salvage. Partialamputation of the foot (such as toe or transmetatarsalamputation) with retention of a sufficiently functionalfoot remnant to allow standing and walking without aprosthesis was regarded as successful limb/foot salvage6

ResultsA total of 32 patients were reviewed in the 24 monthsstudy period. There were 16 male and 16 femalepatients. The median age was 64 years (range 34 to 80years) with co-morbidities present in 56% of them.

Atherosclerotic risk factors included smoking in 10patients, hypertension in 8 patients with 14 patientshaving ischaemic heart disease and 4 patients havingchronic renal impairment. The indications forrevascularization were ischaemic rest pain in 3 patients(9%), gangrene in 20 patients (63%) and non-healingulcer in 9 patients (28%). Associated infection of thenecrotic area (gangrene or ulceration) occurred in 13cases (41%).Angiography was performed in all patients. In 23 ofthem, an outflow artery judged reconstruct ablepreoperatively was visualised. Successful bypasses werepossible in 22 of these cases (96%). In the remaining 9cases, no reconstructable outflow artery was visualisedand all were performed by the routine angiographictechnique without computerised digital subtraction.Exploration intraoperatively found 7 of these cases to beameanable to bypass (78%).The level of bypasses performed and the conduits used inthese procedures are shown in Table 1. Two patients haddouble sequential bypasses for severe multi-leveldiseases. Ten of the bypasses ended at a single cruralartery of the leg or ankle artery (dorsalis pedis orposterior tibial) at the foot. Autologous veins only wereused in these very distal bypasses. The more proximalbypasses to the popliteal artery and above wereperformed with either prosthetic grafts or autologousveins. Associated amputations with successful footsalvage included toe amputations in 9 patients andtransmetatarsal amputations in 6 patients. All thesepatients ambulated successfully without the assistanceof limb prostheses except for minor foot waremodifications.

Table IBypass ProceduresIleo-femoral bypassesFemoro-popliteal (Above knee)Femoro-popliteal (Below knee)Femoro-tibialPopliteal-pedal

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Level of Bypasses and the Conduits UsedNumber

77728

Synthetic Grafts / Autologous Veins7/05/22/50/20/8

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Early result:;Three patients died perioperatively. Two had acutemyocardial infarctions and one died of acute on chronicrenal failure. This was despite optimal managementwith pre-angiographic hydration, minimal contrast withdigital subtraction angiography and intraoperativediuresis. Eight patients underwent major amputations.In three of these, no bypass was possible and the majoramputations were offered as primary treatment for thecritical ischaemia. In the other 5 cases, one had failedbypass graft and could not be salvaged. In the remaining4 cases, the bypass grafts were patent bu t persistentgross sepsis led to major amputations at knee level.

The primary patency rate of the bypasses at one year was90.5%. No further major amputation was required eventhough two bypasses ceased to function and the limbshave no further recurrent lesions.

Foot complications in the diabetic patients remain one ofthe most expensive morbidities to treat as shown in theUnited States and Britain,,8. The risk of major amputationis 15 to 70 times higher than the general population"). Itis important to institute appropriate management rightfrom the initial contact to reduce further morbidity,especially major amputation and mortality9. Theprevalent rates of diabetes in Malaysia have risen from anestimate of 2% in 1980's ro over 8% in certain groups asthe standard of living continues to improve and withincreasing urbanisation4" . As such the incidence ofdiabetic foot complications is expected to rise.Peripheral arterial occlusive disease is common in thediabetic patients' and remains one of the most importantaetiological factors in the diabetic foot complications apartfrom peripheral neuropathy and sepsis. It is still thecommonly held misconception among many medicalpractitioners that diabetic patients suffer from 'smallvessel' disease or microangiopathy and hence vascularreconstructive surgery is rarely possible, Recent review hasshown that although there is no doubt that there ismicrovascular circulatory disturbance, there exists no firmevidence from the literature of surgically significantocclusive 'small-vessel' disease in diabetic patients to

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account for the diabetic foot complications lO Rather mostischaemia is due to macrovascular disease. Macrovascularocclusive disease in the diabetic patients has certaincharacteristic differences when compared to non-diabeticocclusive atherosclerotic disease. Although larger proximalvessels are affected as shown in this study (iliac and femoralartery bypasses), in a large proportion of diabetic patientsmedium-sized arteries (tibial vessels) are thepredominantly diseased segments with relative sparing ofthe proximal larger and distallpedal vessels makingvascular reconstructions possiblell It is therefore notuncommon to have diabetic critical foot ischaemiapresenting with palpable popliteal pulses and absent anklepulses. Angiographic imaging will often confirm patencyin the foot artery and hence the possibility of reconstructivesurgeryll,12,1J. This study confirms that revascularization ofthe foot is feasible in many diabetic patients.The result from our small series is comparable to largerseries from the literature review. The perioperativemortality of 9% was within the reported range of 0 to9%. Taylor and Porter reviewed the results of lowerextremity bypass in diabetic patients and showed thatthe surgical mortality was 2.2% with 9.7%perioperative complications. One, 3 and 5 year variousgraft patency rates were in the range of 72 to 92 %, 57to 85% and 51 to 85% respectively. These results werenot significantly different from results in non-diabeticpatients l2 . The comparable patency rates at one monthand one year were 96% and 90% respectively in ourseries. Policy of aggressive surgical revascularization asin the experience of the New England DeaconessHospital in Boston yielded very encouraging results inreducing all amputation rates ,),14,15. Of 402 explorationsfor dorsalis pedis arterial bypass, successfulrevascularization in 95.5% was achieved. Theperioperative death was 1 .8% and cardiac morbidity was5.4%. Primary and secondary graft patency rates andlimb salvage were 92.5%, 97.4%, and 97.9% at onemonth and 68%, 82% and 87% at 5 years respectivelylJ.Preoperative angiography especially digital subcractionangiography (DSA) remains the investigation of choicein planning reconstructive surgery. Our series showedthat visualisation of the outflow arteries increased thelikelihood of successful bypass (96%). This was againdemonstrated in the series by Pomposelli et al wheresuccessful bypasses were carried out in 98.6 % when a

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patent dorsalis pedis artery was demonstratedpreoperatively in contrast to only 57% success rate whensurgical explorations were performed on the basis of aDoppler signal alone13.Primary amputation is often offered as the primarymodality of treatment in diabetic critical foot ischaemiccomplication in the past. We believe such a policy isnow inappropriate as progresses made in the field ofradiology, anaesthesia and surgery in this country allowreconstructive vascular procedures for limb salvage to beperformed with safety. The loss of 4 limbs in thepresence of patent bypass grafts as a result of persistentsepsis in this small series further stressed the urgency ininstituting appropriate management early. Patient

1. Beach KW, Brunzell JD , Strandness DE Jr. Prevalence ofsevere arteriosclerosis obliterans in patients with diabetesmellitus. Relation to smoking and form of therapy.Arteriosclerosis 1982; 2: 275-80.

2. Most RS, Sinnock P. The epidemiology of lowerextremity amputations in diabetic individuals. DiabetesCares 1983; 6: 87-91.

3. Waugh NR . Amputations in diabetic patients - a reviewof rates, relative risks and resource use. CommunityMedicine 1988; 10: 279-88.

4. Mustaffa BE. Diabetes melli tus in peninsular Malaysia:ethnic differences in prevalence and complications. AnnAcad Med Singapore 1985; 14: 272-76.

5. Ali 0 , Tan TT, Sakinah 0 , Khalid BA, Wu LL, Ng ML.Prevalence of NIDDM and impaired glucose tolerance inaborigines and Malays in Malaysia and their relationshipto sociodemographic, health and nutritional factors.Diabetes Care 1993; 16: 68-75.

6. Rutherford RB, Baker D, Ernst C, et al. Recommendedstandards for reports dealing with lower extremityischemia: Revised version. J Vasc Surg 1997; 26: 17-38.

7. Williams DR. Hospital admissions of diabetic patients:information from hospital activity analysis. Diabetes Med1985; 2: 27-32.

8. Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P,Showstack JA. Lower-extremity amputation in peoplewith diabetes. Epidemiology and prevention. DiabetesCare 1989; 12: 24-31.

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education and team work remain the key to successfullymanage the complicated diabetic foot with earlyrecognition of potential problems '6 .

Vascular reconstructive surgery is feasible in themajority of diabetic critical foot ischaemia in this series.This may require very distal bypass into the foot andresults are encouraging as in many centres. Successfulfoot salvage requires early intervention before theestablishment of gross sepsis. When appropriate itshould be offered to all patients rather than primarymajor amputation.

9. Gibbons GW, Marcaccio EJ Jr, Burgess AM, et al.Improved quality of diabetic foot care, 1984 vs 1990.Reduced length of stay and costs, insufficientreimbursement. Arch Surg 1993; 128: 576-81.

10. Stonebridge PA, Murie JA. Infrainguinalrevascularization in the diabetic patient. Br J Surg 1993;80: 1237-41.

11. Menzoian JO, LaMorte WW , Paniszyn CC, et al.Symptomatology and anatomic patterns of peripheralvascular disease: differing impact of smoking anddiabetes. Ann Vasc Surg 1989; 3: 224-28.

12. Taylor L, Porter J. Results of lower extremity bypass inthe diabetic patient. Semin Vasc Surg 1992; 5: 226-33.

13. Pomposelli FB Jr, Marcaccio EJ, Gibbons GW, et al.Dorsalis pedis arterial bypass: durable limb salvage forfoot ischemia in patients with diabetes mellirus. J VascSurg 1995; 21: 375-84.

14. LeGerfo FW, Gibbons GW, Pomposelli FB, et al. Trendsin the care of the diabetic foot: Expanded role of arterialreconstruction. Arch Surg 1992; 127: 617-21.

15. Pomposelli FB Jr, Jepsen SJ, Gibbons GW, et al. Aflexible approach to infrapopliteal vein grafts in patientswith diabetes mellitus. Arch Surg 1991; 126: 724-29.

16. Thomson FJ, Veves A, Ashe H, et al. A team approach todiabetic foot care: the Manchester experience. The Foot1991; 2: 75-82.

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