Diabetischer Fuß – wann kommt die IR ins Spiel? (Zertifizierung: Modul A Spezialkurs)

Diabetic foot (DF) is recognized as one of the most serious complications of diabetic disease. Up to 70% of all lower-leg amputations are performed in patients with diabetes. The best way to prevent amputation in diabetic patients is ulcer healing. Optimal wound care, antibiotics, off loading and other techniques should all be applied in daily practise to achieve ulcer healing. Active revascularisation in patients with diabetic peripheral disease plays a crucial role in achieving ulcer healing. Non-surgical revascularisation options for DF have expanded over the last decade and have become a prominent tool to prevent amputation. Revascularisation is by no means a stand-alone procedure and a multidisciplinaire approach is essential for a good outcome.

The vascular disease in diabetic patients is mostly localized in the lower leg arteries and shows long segmental occlusions while atherosclerosis often shows short focal lesions.

Crucial is temporary increase in blood flow to the lesion era to support ulcer healing. When the lesion is cured, the skin closed, the extra blood supply is no longer needed to keep the skin intact. That is why limb salvage is always reported much higher than the patency of the recanalisation.

Every patient with a DF should be investigated for PAD. A simple test like palpation of the peripheral pulses is often enough to rule out PAD. If there is uncertainty an Ankle/Brachial index < 0.9 is suspect for PAD. The traditional non-invasive parameters for critical ischemia like ankle and toe pressure and transcutaneous oxygen, are of less value in diabetic patients. Only if revascularisation is considered diagnostic imaging is required

As endovascular treatment of arterial diabetic foot lesions is currently first choice and mainly concentrated in the below the knee arteries. Treating long segmental diabetic lesions requires a dedicated centre with ample experience as this kind of treatments. Each procedure is tailored to the patient's needs, possibilities and clinical situation. Endovascular treatment for diabetic patients should thereforeonly be performed in dedicated centres. End point of the treatment is ulcer healing and in the same token limb salvage.

The choice between endovascular or open surgery is often the outcome of a team discussion. Local expertise plays an important role in these discussions. High risk for surgery, non-availability of good venous material for a conduit, no segments for surgical anatomises or poor outflow are often additional reasons to choose for an endovascular solution. But local anatomy hardly plays a key role in experienced hands. The understanding that in diabetic patients “time is tissue” has the consequence that treatment of an infected ulcer in diabetic patients should be handled as an emergency procedure, to be dealt with preferable within 24 hours.

Straight-line pulsatile flow to the foot is the most optimal outcome, but if this is not possible other solutions should be looked for. There are no specific morphological guidelines to decide for endovascular, basically most lesions can be treated endovascular. Preferable the artery supplying the ulcer region should be revascularised, however opening up collateral pathways can sometimes be enough to obtain good clinical success. The theory of so called “angiosomes”, specific arteries that supply very well describes area's in the foot has gained a lot of attention recently. One has to realize that this angiosomes are first and for all a representation of normal anatomy in non-diseased vessels.

The outcome of both surgery and endovascular are broadly spoken the same for the endpoints ulcer healing and limb salvage and between 78 – 85%. Patency of bypass surgery is however reported to be better than endovascular. This is not a major issue for consideration as ulcer healing with subsequent limb salvage almost always takes place in a period within 6 – 9 months. Any patency beyond ulcer healing is often not needed as these diabetic patients do mostly not suffer from rest pain. An endovascular intervention normally has a patency that is enough to obtain the final goal of ulcer healing. That is why limb salvage after endovascular treatment is always reported to be 20% higher than actual patency.

Most new techniques, like setenting or drug eleuting techniques, have not proven in any clinical trail to improve the already very high percentage of ulcer healing or the limb salvage after plain old balloon angioplasty. For the time being the extra costs of these new devices are often not justified.. The IR plays a central role in the team discussion, in selecting patients for endovascular treatment and the right set of devices. Centralisation in diabetic foot centres is therefore probably the best guaranty for the best outcome.

Lernziele:

To learn about diagnosis and indication for endovascular treatment of diabetic foot. To learn about the role of IR.

To learn about revascularisation technique in diabetic foot disease. To learn about treatment outcome

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