Emerging Vascular Approaches For Healing Diabetic Ulcers

By David E. Allie, MD

Given the severe ramifications associated with the combination of critical limb ischemia (CLI) and diabetic foot ulcers, this author emphasizes the potential impact of revascularization procedures in reducing the number of lower extremity ampulations. Accordingly, he offers a closer looks at recent advances in this arena and their place within the armentarium for CLI It is vital to review the “non-surgical revascularization toolbox” for lower extremity treatments for critical limb ischemia (CLI). Consider an analysis of the most recent United States and European data on the number of amputations performed every year. Approximately 160,000 to 180,000 lower extremity amputations are performed every year in the U.S. and a 10 percent yearly increase in these numbers has been projected as well. In Europe, it has been estimated that 40,000 to 50,000 lower extremity amputations occur each year.1-2 It is been estimated that 80 percent of all amputations are preceded by a diabetic foot ulcer (DFU) and that most DFUs are preventable.    Still, worldwide there is an amputation in a patient with diabetes every 30 seconds. This underscores the association of DFU and CLI.3 Within one year of being diagnosed with CLI, 40 to 50 percent of the now 21 million U.S. patients with diabetes will experience a major amputation and 30 to 40 percent will die.1-2,4 Moreover, 30 to 50 percent of diabetic amputees will face contralateral CLI and undergo a second limb amputation within three to five years of ipsilateral amputation.1-2 It has been estimated that the total cost of treating CLI in the U.S. alone is $10 to $20 billion per year and that just a 25 percent reduction in amputations could save the U.S. healthcare system $2.9 to $3 billion yearly.1-2

Emphasizing The Importance Of Vascular Evaluation

In an analysis of 417 U.S. CLI patients, 67 percent had a primary amputation as initial CLI treatment and less than one half (49 percent) had any diagnostic vascular evaluation with only 34 percent having an ABI and 16 percent having angiography.1    Digital subtraction angiography (DSA) is still considered the imaging “gold standard” but one must perform it with a commitment to visualize all infrainguinal and pedal vessels and the procedure has inherent risks. Magnetic resonance angiography has also been advocated but it has significant limitations including artifacts (stents, pacemakers, etc.).    Recently 16-64 channel non-invasive CT angiography (CTA) has become available and is now my non-invasive tool of choice in the diagnosis and, importantly, the treatment planning of CLI. It has the advantages of speed (< 30-second scan), safety (arm vein access), simplicity (outpatient < 10-15 minute procedure), fewer complications (hemorrhage, emboli, etc.), superior imaging and resolution, three-dimensionality and overall lower costs.5 CT angiography has the potential to identify revascularization anatomy and targets often missed with traditional DSA. Indeed, CTA has revolutionized how we diagnose, plan and treat CLI. It belongs on the top shelf in our CLI tool box.    Given the recent improvements in non-invasive CTA vascular imaging and the safety of DSA, it is my opinion that no CLI patient should be scheduled for an amputation without at least CTA vascular imaging and preferably have limb salvage DSA beforehand. Indeed, our healthcare industry’s next challenge should be to change our “pathway to amputation” to a “pathway of revascularization,” especially with the dramatic improvement in infrapopliteal diagnostic and revascularization treatment options over the last three years. Let us take a closer look at these improvements in treatment.

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