Adapting To New Paradigm Shifts In Treating Patients With Diabetes And Peripheral Vascular Disease
The past few years have produced a plethora of studies, publications and lectures on the combination of diabetes and peripheral vascular disease, and their impact upon the lower extremities. One recent study looking at over 600 patients with diabetic foot ulcers and severe peripheral arterial disease (PAD) who did not have revascularization found that one-third of patients died unhealed.1
I have been fortunate to be involved with a group of leaders in various associated specialties that deal with these devastating pathologies. I have long had an interest in limb preservation and reconstructive foot and ankle surgery. I was the director of an outstanding clinic (Kern Hospital in Warren, Mich.) for many years with the advantage of meeting and interacting with multiple specialists in a symbiotic relationship. This was a teaching clinic and I had the opportunity to train many fine residents who have subsequently become leaders in our profession. Our clinic also had a significant referral base from a large geographical area that allowed us to be exposed to a vast range of pathology.
There has always been a great working relationship with our vascular surgeons. This enabled us to treat patients who were at risk for major amputation and a debilitating lifestyle. We had considerable success due to the academic and passionate performance of our team. Unfortunately, due to significant comorbidities, many patients, especially those with critical limb ischemia, had compromised health to the extent in which the risks of treatment advances outweighed the benefits. Many of our patients were too old or too sick for major “open” bypass surgeries and they were excluded from treatment. The morbidity and mortality of extensive bypass of the lower extremity was high.
Often, our clinic was the patient’s “last hope” to save a limb and return to an ambulatory status. However, we were forced to be very cautious with proper patient selection due to many other factors. Many of our patients required non-weightbearing status for extended time periods postoperatively. Our patient profile was challenging as many were obese, experienced motor and sensory neuropathy, and had difficulty managing crutches and walkers in an attempt to allow our surgical procedures to heal. For example, for many patients, we would perform bone grafting with internal fixation in order to help heal multiplanar osteotomy and arthrodesis sites.
Fortunately, advances in external fixation allowed more reliable fixation attempts with patients enjoying “limited, guarded weightbearing” with a walker or crutches postoperatively during the healing process. The use of external fixation allowed for more aggressive attempts at limb salvage. We also learned that “functional” limb preservation was our ultimate goal and were always cognizant of the “next day” or what the patient’s status would be after treatment and healing. We learned that a transmetatarsal amputation (TMA) was desirable to saving two toes or that selected tendon lengthening and transfer could give “good results,” even in notoriously “bad result” levels of foot amputation such as amputations at the Chopart joint level.2-5
I would constantly remind the residents that the best teacher in medicine is “Doctor Retrospect.” Evidence-based medicine helped us make better decisions although anecdotal treatment by an experienced, honest academic seemed too many times to be equally appropriate in our high-risk patient group who suffered with diabetes and associated comorbidities such as Charcot neuroarthropathy with soft and hard tissue disintegration and critical limb ischemia.
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.
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.
1. Elgzyri T, Larsson J, Thorne J, Eriksson KF, Apelqvist J. Outcome of ischemic foot ulcer in diabetic patients who had no invasive vascular intervention. Eur J Vasc Endovasc Surg. 2013;46(1):110-7.
2. Borkosky SL, Roukis TS. Incidence of repeat amputation after partial first ray amputation associated with diabetes mellitus and peripheral neuropathy: an 11-year review. J Foot Ankle Surg. 2013;52(3):335-8.
3. Kadukammakal J, Yau S, Urbas W. Assessment of partial first-ray resections and their tendency to progress to transmetatarsal amputations: a retrospective study. J Am Podiatr Med Assoc. 2012;102(5):412-6.
4. Colen LB, Kim CJ, Grant WP, Yeh JT, Hind B. Achilles tendon lengthening: friend or foe in the diabetic foot? Plast Reconstr Surg. 2013;131(1):37e-43e.
5. Sanders LJ. Transmetatarsal and midfoot amputations. Clin Podiatr Med Surg. 1997;14(4):741-62.
6. Adams GL, Khanna PK, Staniloae CS, Abraham JP, Sparrow EM. Optimal techniques with the Diamondback 360º System achieve effective results for the treatment of peripheral arterial disease. J Cardiovasc Transl Res. 2011;4(2):220-9.
7. Soderstrom M, Alback A, Biancari F, Lappalainen K, Lepantalo M, Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers. J Vasc Surg. 2013;57(2):427-35.