Current Concepts In Treating Ischemic Foot Ulcers

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In the photo above, note the presence of an ulcer in a patient with diabetes following a transmetatarsal amputation. (Photo courtesy of Marc Brenner, DPM)
As shown above, the cool-tip laser (Spectranetics) ablates both plaque and clot. (Photo courtesy of David E. Allie, MD)
Here one can see the SilverHawk (FoxHollow Technologies) catheter. (Photo courtesy of David E. Allie, MD)
Current Concepts In Treating Ischemic Foot Ulcers
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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

     Dr. Allie strongly suggests a bypass or percutaneous interventional procedure prior to considering amputation unless an obvious abscess or necrotizing fasciitis is present. He also recommends conservative, limited amputations when indicated as these procedures give the patient maximum opportunity to preserve tissue and function. Although he has advocated systemic hyperbaric oxygen (HBO) therapy, Dr. Allie has found 70 to 80 percent of the elderly CLI patients will have a contraindication or will not tolerate systemic HBO (due to CHF, pulmonary issues, etc.). He relates positive experiences with local extremity or topical oxygen therapy, noting he is encouraged with recent work at Ohio State where researchers are trying to provide the “science” of why this therapy works.

     Avoiding amputation is possible with newer endovascular therapies, according to Dr. Zarrinmakan. He says one should perform revascularization as soon as one diagnoses an ischemic ulcer.

     Dr. Brenner notes that one always obtains the best results in diabetic ischemic feet with multidisciplinary collaboration, including cardiology, internal medicine, vascular specialists, interventional radiology and podiatry. As revascularization procedures improve, Dr. Brenner believes there will be more cases of successful diabetic limb salvage and lower amputation rates.

     Dr. Allie is the Director of Cardiothoracic and Endovascular Surgery at Cardiovascular Institute of the South in Lafayette, La., and the Southwest Medical Center in Lafayette, La.

     Dr. Brenner is a Fellow and Past President of the American Society of Podiatric Dermatology. He is also the President of the Institute of Diabetic Foot Research, and is on the medical staff of the Long Island Jewish Medical Center in New Hyde Park, N.Y.

     Dr. Karlock (shown at the right) is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.

     Dr. Zarrinmakan is a Fellow of the American College of Surgery. He practices cardiothoracic and vascular surgery in Warren, Ohio.




References:

1. Boykin JV, Baylis C. Homocysteine— A Stealth Mediator of Impaired Wound Healing: A Preliminary Study. WOUNDS 2006;18(4):101-116.
2. Allie DE, et. al. Critical limb ischemia: a global epidemic: a critical analysis of current treatment unmasks the clinical and economic costs of CLI. EuroIntervention Journal 2005, 1(1):75-84.
3. Dall Paola L. Treating diabetic foot ulcers with super-oxidized water. WOUNDS supplement 19(1):14-16, January 2006.
4. Allie DE, et. al. Adjunctive Bioengineered Bi-layered Cell Therapy (Apligraf®) With Excimer Laser Revascularization Improves Wound Healing and Limb Salvage in Critical Limb Ischemia. Vascular Disease Management 3(1):185-192, January/February 2006.
5. Allie DE, et. al. Novel treatment strategy for leg and sternal wound complications after coronary artery bypass graft surgery: Bioengineered Apligraf. Annals of Thoracic Surgery 72(2):673-678, 2004.



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