Adapting To New Paradigm Shifts In Treating Patients With Diabetes And Peripheral Vascular Disease

Guy R. Pupp, DPM, FACFAS

Assessing The Impact Of Endovascular Advances For High-Risk Patients With Diabetes

Big strides were accomplished with the aggressive new breed of endovascular specialists who systematically developed techniques and equipment to improve blood flow in the lower extremities of high-risk patients. I was fortunate to become involved with them in their early pioneer days utilizing their developing technologies and ability to get tissue perfusion to the lower extremities through minimally invasive approaches. This was especially true in our patients with diabetes who had a tendency for hard calcified plaque in the below-the-knee trifurcation of the anterior tibial artery and the peroneal trunk, which divides into the peroneal artery and posterior tibial arteries.

   Indeed, the development of the orbital atherectomy to shave this calcified plaque helped establish blood flow to the feet.6 This opened a wide door for those sick patients with multiple comorbidities and severe deformities who would be relegated to a wheelchair or bed with the associated untoward epidemiology of increased mortality, social and psychological changes, financial challenges and increased threat of amputations with associated incidence of contralateral limb loss. This patient population now had hope. Support groups such as Save a Leg, Save a Life arose to educate both medical and laypeople about new advances in technology to decrease the number of needless major lower extremity amputations and awareness of comorbidities that can exist with peripheral arterial disease, avoiding events such as myocardial infarction and cerebrovascular accident.

   We also became aware of the importance of direct tissue perfusion to a specific diseased area with utilization of the angiosome concept.7 There are now tissue maps with corresponding arterial inflow that offer more specific direction in our interventionalist’s revascularization attempts whether he or she chose laser therapy, cryotherapy, atherectomy or stenting the diseased intima.

In Conclusion

The utilization of technology such as external fixation and endovascular advances in a multispecialty team environment has changed and improved limb salvage. Unfortunately, there are shortcomings and limitations. Not every patient is a candidate and one must ensure appropriate patient selection with multiple evaluations, appropriate consultations and extensive education. We have had our best successes when we have included patients and their family as team members.

   Unfortunately, new technology has the potential for abuse by multiple specialities for many reasons including financial reasons, peer pressure and professional reputation. Utilizing these new approaches such as external fixation and endovascular surgery requires special training and experience. Certainly, we need to recognize there is a learning curve to becoming proficient with new technology.

   I certainly feel that a team approach should be a universally accepted for successful limb preservation. It is mandatory that the team members share a passion for limb preservation and are familiar and experienced with contemporary technology in their respective fields. The multidisciplinary team members are not necessarily tenants in the same medical building, neighbors, relatives, or members of the same church, synagogue or mosque. What they do share is a passion for understanding the associated epidemiology of diabetes, critical limb ischemia and the sequelae of major lower extremity amputation.

   Dr. Pupp is a member of the Residency Training Committee at Providence Hospital in Southfield, Mich. He is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in foot and ankle surgery by the American Board of Podiatric Surgery. He is the Chairman of the Board of Directors for the Save a Leg, Save a Life Foundation.

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