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Surgical treatment for diabetic foot
revascularization
Surgical treatment for diabetic foot
revascularization
Dr. Moustafa Abd Elhamid ElshalSpecialist of Vascular Surgery ,Endovascular Intervention
Surgeries and Diabetic Foot managementNational Institute Of Diabetes and Endocrinology (NIDE)
Cairo - Egypt
Tele : 0113437474 - 0106011656
2010
Dr. Moustafa Abd Elhamid ElshalSpecialist of Vascular Surgery ,Endovascular Intervention
Surgeries and Diabetic Foot managementNational Institute Of Diabetes and Endocrinology (NIDE)
Cairo - Egypt
Tele : 0113437474 - 0106011656
2010
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Epidemiological DataEpidemiological DataEpidemiological DataEpidemiological Data
Prevalence 7% to 15% in themiddle aged and theelderly(Cuschieri 2002)
20% in over 75(Hiatt 1995)
Coronary artery diseasecoexist in 68% & Strokecoexist in 42% (Ness &Aronow 1999)
Classified along with other
cardiovascular diseases it isthe commonest cause ofmortality in UK. (Males300/100,000/yr, andFemales 190/100,000/yr)
Prevalence 7% to 15% in themiddle aged and theelderly(Cuschieri 2002)
20% in over 75(Hiatt 1995)
Coronary artery diseasecoexist in 68% & Strokecoexist in 42% (Ness &Aronow 1999)
Classified along with other
cardiovascular diseases it isthe commonest cause ofmortality in UK. (Males300/100,000/yr, andFemales 190/100,000/yr)
Amputation rate within oneyear of diagnosis is 10-40%(Dormandy 1999)
Mortality after amputation:
1 year = 20%5 years = 40% - 70%
10 years = 80% - 95%
Second most common cause ofdisability in the UK (WHO)
Prevalent in deprived areas
Amputation rate within oneyear of diagnosis is 10-40%(Dormandy 1999)
Mortality after amputation:
1 year = 20%5 years = 40% - 70%
10 years = 80% - 95%
Second most common cause of
disability in the UK (WHO)
Prevalent in deprived areas
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NEUROPATHYNEUROPATHYNEUROPATHYNEUROPATHY
Thickening of nutrient vessels of nerves leading to N. ischemiaThickening of nutrient vessels of nerves leading to N. ischemia
Increased activity of sorbitol pathway , demyelination and impairedIncreased activity of sorbitol pathway , demyelination and impaired
velocity of peripheral n decreasing its conductionvelocity of peripheral n decreasing its conduction
Autonomic system affection leads to shutting of the arterio-venousAutonomic system affection leads to shutting of the arterio-venous
communications and decreased tissue perfusion even if normal Bl.communications and decreased tissue perfusion even if normal Bl.
SupplySupply
Diminished nocioceptive reflex leading to diminished response toDiminished nocioceptive reflex leading to diminished response to
inflammationinflammation
Motor neuropathy decreases the N. stimulation of the intrinsic musclesMotor neuropathy decreases the N. stimulation of the intrinsic muscles
of the foot leading to its atrophy.of the foot leading to its atrophy.
Waisting of these muscles fails to maintain joint stability (charcot Joint)Waisting of these muscles fails to maintain joint stability (charcot Joint)
Foot deformity creates abnormal pressure areas and ulcersFoot deformity creates abnormal pressure areas and ulcers
Peripheral sensory neuropathy produces abolition of pain reflex leadingPeripheral sensory neuropathy produces abolition of pain reflex leadingto more ulcers, and ligament stretching and foot deformityto more ulcers, and ligament stretching and foot deformity
Thickening of nutrient vessels of nerves leading to N. ischemiaThickening of nutrient vessels of nerves leading to N. ischemia
Increased activity of sorbitol pathway , demyelination and impairedIncreased activity of sorbitol pathway , demyelination and impaired
velocity of peripheral n decreasing its conductionvelocity of peripheral n decreasing its conduction
Autonomic system affection leads to shutting of the arterio-venousAutonomic system affection leads to shutting of the arterio-venous
communications and decreased tissue perfusion even if normal Bl.communications and decreased tissue perfusion even if normal Bl.
SupplySupply
Diminished nocioceptive reflex leading to diminished response toDiminished nocioceptive reflex leading to diminished response to
inflammationinflammation
Motor neuropathy decreases the N. stimulation of the intrinsic musclesMotor neuropathy decreases the N. stimulation of the intrinsic muscles
of the foot leading to its atrophy.of the foot leading to its atrophy.
Waisting of these muscles fails to maintain joint stability (charcot Joint)Waisting of these muscles fails to maintain joint stability (charcot Joint)
Foot deformity creates abnormal pressure areas and ulcersFoot deformity creates abnormal pressure areas and ulcers
Peripheral sensory neuropathy produces abolition of pain reflex leadingPeripheral sensory neuropathy produces abolition of pain reflex leading
to more ulcers, and ligament stretching and foot deformityto more ulcers, and ligament stretching and foot deformity
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InfectionInfectionInfectionInfection
Risk of infection is higher with hyperglycemia due toRisk of infection is higher with hyperglycemia due to
suppression of the immunity systemsuppression of the immunity system
Diabetic albuminuria decreases tissue nutritionDiabetic albuminuria decreases tissue nutrition
Infection increases metabolism and oxygen consumptionInfection increases metabolism and oxygen consumption
Osteomyelitis due to penetrating infected ulcerOsteomyelitis due to penetrating infected ulcer
Risk of infection is higher with hyperglycemia due toRisk of infection is higher with hyperglycemia due to
suppression of the immunity systemsuppression of the immunity system
Diabetic albuminuria decreases tissue nutritionDiabetic albuminuria decreases tissue nutrition
Infection increases metabolism and oxygen consumptionInfection increases metabolism and oxygen consumption
Osteomyelitis due to penetrating infected ulcerOsteomyelitis due to penetrating infected ulcer
IschemiaIschemiaIschemiaIschemia Inadequate circulation increase tissueInadequate circulation increase tissue
necrosis and exacerbate infectionnecrosis and exacerbate infection
Macro vascularMacro vascular MicrovascularMicrovascular
Inadequate circulation increase tissueInadequate circulation increase tissue
necrosis and exacerbate infectionnecrosis and exacerbate infection
Macro vascularMacro vascular MicrovascularMicrovascular
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Risk FactorsRisk Factors
Non-modifiable:1. Age (mid & older)
2. Male gender(upto age 65)
3. Family history of
hyperlipidaemia(1:500)
4. Race (e.g,African-AmericansOR=2.3) Criqui
2005.
Non-modifiable:1. Age (mid & older)
2. Male gender(upto age 65)
3. Family history of
hyperlipidaemia(1:500)
4. Race (e.g,African-AmericansOR=2.3) Criqui
2005.
Modifiable:1. High blood pressure
2. Diabetes
3. Smoking (Buergersdisease)
4. Hyperlipidaemia
5. Obesity
6. Excessive alcohol
7. Sedentary life8. Stress & depression
9. Trauma
Modifiable:
1. High blood pressure
2. Diabetes
3. Smoking (Buergersdisease)
4. Hyperlipidaemia
5. Obesity
6. Excessive alcohol
7. Sedentary life8. Stress & depression
9. Trauma
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Intermittent ClaudicationIntermittent ClaudicationIntermittent ClaudicationIntermittent Claudication
Pain in the legs onwalking a certaindistance.
Associatedcardiovascular
morbidity
Disability (socialconsequences)
Dependence on
medicines. May require surgery
15% requireamputation within 1year (Martson 2006)
Pain in the legs onwalking a certaindistance.
Associatedcardiovascular
morbidity Disability (social
consequences)
Dependence on
medicines. May require surgery
15% requireamputation within 1year (Martson 2006)
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Critical IschaemiaCritical IschaemiaCritical IschaemiaCritical Ischaemia
Rest pain (ABI
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UlcersUlcersUlcersUlcers
500,000 with recurrent legulcers in UK (10% arterial)
Disability
Sepsis
Frequent hospitalzation
Surgical procedures
Amputation
Death
500,000 with recurrent legulcers in UK (10% arterial)
Disability
Sepsis
Frequent hospitalzation
Surgical procedures
Amputation
Death
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GangreneGangreneGangreneGangrene
Amputation
High risk of mortality
due to associated CVD.
Mortality 20%(1 yr), 40-
70%(5yr), 80-95%(10yr).
Burden on resources
Amputation
High risk of mortality
due to associated CVD.
Mortality 20%(1 yr), 40-
70%(5yr), 80-95%(10yr).
Burden on resources
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LUMBAR SYMPATHECTOMY
1912 Leriche - Jaboulay
only alternative to amputation
MECHANISM:
t Increase blood flow by abolishing basal and reflexarteriolar constriction
t Alteration of pain impulse transmission
Temporary but significant
LUMBAR SYMPATHECTOMY
1912 Leriche - Jaboulay
only alternative to amputation
MECHANISM:
t Increase blood flow by abolishing basal and reflexarteriolar constriction
t Alteration of pain impulse transmission
Temporary but significant
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1960s direct vascularisation took over
INSITU VEINOUS BYPASS BECAME A VULGAR STANDARDTECHNIQUE
Distal peroneal bypass become a routine technique and
bypass to pedal arteries became unexceptionnel
1960s direct vascularisation took over
INSITU VEINOUS BYPASS BECAME A VULGAR STANDARDTECHNIQUE
Distal peroneal bypass become a routine technique and
bypass to pedal arteries became unexceptionnel
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1st author Year Graft N CLI% Tibial bypass 1 yr% 3 yr% 5 yr%
J. Gonzales-FAJARDO1ry patency rateLimb salvage
1998 165 100% 100%7882
6472
5770
Panayiotopoulos1ry patency rate2ry patency rateLimb salvage rate
1997 109 100% 82% (55vein)---
274553
---
Luther1ry patency rate2ry patency rateLimb salvage rate
1997 187 100% 100%57-
81
47-
71
Sayers1ry patency rate2ry patency rateLimb salvage rate
1993 78 62% 77%3363-
296467
Bergamini1ry patency rate2ry patency rateLimb salvage rate
1991 361 93% 68%739094
668590
638186
Rutherford1ry patency rate2ry patency rate
1988 170 98% 100%85-
78-
--
Shah- Diabetic
1ry patency rate2ry patency rate - Non Diabetic
1ry patency rate2ry patency rate
1988387
294
8596
8799
7786
8194
7472
7670
Patency and limb salvage using venous graft in femoro-below knee bypass
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Inflow state
Distal runoff and patency of pedal vessels
Primary and secondary procedures
Site of distal anastomosis
Availability of venous material
Technical feasibility
Age and gender Diabetes
Renal failure
Inflow state
Distal runoff and patency of pedal vessels
Primary and secondary procedures
Site of distal anastomosis
Availability of venous material
Technical feasibility
Age and gender
Diabetes
Renal failure
Limitations of Surgical techniqueLimitations of Surgical technique
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Venous material is the corner stone of these surgeries.
Synthetic graft cannot perform as the vein at the level
of tibial arteries anastomosis
Venous material is the corner stone of these surgeries.
Synthetic graft cannot perform as the vein at the level
of tibial arteries anastomosis
Lack of venous materialLack of venous material
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Our team experience from 2000-2005
28 distal tibial bypass (ankle level)
- 0% perioperative mortality
- 6 late deaths (cardiac and renal)
-12 pts (minor amput. Infected toes)
Primary graft patency 89.2 %
- 3 intraop occlusion needing revision
Secondary patency 75 % (2 years)
- 7 occluded during follow up needing majoramputation in 6 AK and 1 BK amputation
Limb salvage rate 75 % at 2 years and 64% at the end of the
study (5 years)
Our team experience from 2000-2005
28 distal tibial bypass (ankle level)
- 0% perioperative mortality
- 6 late deaths (cardiac and renal)
-12 pts (minor amput. Infected toes)
Primary graft patency 89.2 %
- 3 intraop occlusion needing revision
Secondary patency 75 % (2 years)
- 7 occluded during follow up needing majoramputation in 6 AK and 1 BK amputation
Limb salvage rate 75 % at 2 years and 64% at the end of the
study (5 years)
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Delayed healing in 8 patient- 4 of these patients progressed favorably
- 2 presented tissue necrosis treated by our
plastic surgeon
( free radial graft from the right upper limb withsuccessful healing)
2 patients manifested bypass erosion and 2ry
hemorrhage which necessitated above knee
amputation at 2 and 5 months
Delayed healing in 8 patient- 4 of these patients progressed favorably
- 2 presented tissue necrosis treated by our
plastic surgeon
( free radial graft from the right upper limb withsuccessful healing)
2 patients manifested bypass erosion and 2ry
hemorrhage which necessitated above knee
amputation at 2 and 5 months
ComplicationsComplications
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Post opertaive infection
3 patients at 2, 3, and 6 months
2 patients treated medically with aggressive repeated daily
dressings
1 patient developed septicemia with failure to control the
infection and necessitated above knee amputation over a
patent bypass.
Post opertaive infection
3 patients at 2, 3, and 6 months
2 patients treated medically with aggressive repeated daily
dressings
1 patient developed septicemia with failure to control the
infection and necessitated above knee amputation over a
patent bypass.
ComplicationsComplications
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Right poplito posterior tibial venous bypassRight poplito posterior tibial venous bypass
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Perfect knowledge of all possible techniques
He must operate under supervision for at least 20
cases before operating them alone.
These techniques are time consuming and need apatient surgeon
Complete understanding of the importance to
accomplish this difficult task.
In a specialized center, two surgeons may
operate together reducing this operating time
Perfect knowledge of all possible techniques
He must operate under supervision for at least 20
cases before operating them alone.
These techniques are time consuming and need apatient surgeon
Complete understanding of the importance to
accomplish this difficult task.
In a specialized center, two surgeons may
operate together reducing this operating time
High training skillsHigh training skills
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Tibial endovascular techniqueTibial endovascular technique
Revascularization of multiple lesions at a timeRevascularization of multiple lesions at a time Shorter timeShorter time
No wounds in fragile patientsNo wounds in fragile patients
Less risk of infection in diabetic and Stage IV ptsLess risk of infection in diabetic and Stage IV pts
No risk for anesthesiaNo risk for anesthesia
No arterial clamping and shorter ischemia timeNo arterial clamping and shorter ischemia time
No external dissection traumaNo external dissection trauma
- SubintimalSubintimal- Balloon angioplastyBalloon angioplasty- StentingStenting- Balloon angioplasty andBalloon angioplasty and
rare stentingrare stenting
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CONCLUSIONCONCLUSIONCONCLUSIONCONCLUSION
Treatement of diabetic foot need multidisciplinary approach Prevention has better results than interventions
Angioplasty in patients with multi-segmental and longocclusions of the lower limb arteries is a feasible, safe, andeffective procedure more advantage than surgery
Open surgical procedures have been largely replaced in ourinstitute by angioplasty with a better outcome. They areactually reserved for lesions technically unsuitable forendovascular procedures
Treatement of diabetic foot need multidisciplinary approach Prevention has better results than interventions
Angioplasty in patients with multi-segmental and longocclusions of the lower limb arteries is a feasible, safe, andeffective procedure more advantage than surgery
Open surgical procedures have been largely replaced in ourinstitute by angioplasty with a better outcome. They areactually reserved for lesions technically unsuitable forendovascular procedures
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