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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_896_Библиотеки_им_академика_М_И_Перельмана

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24 Lower Extremity Arterial Reconstruction inPatients withDiabetes Mellitus: Principles ofTreatment
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Fig. 24.16 Graft patency (a) and limb salvage (b) for diabetic and non-diabetic patients undergoing lower extremity bypass and followed for at least 5 years. Adapted from Akbari et al. Arch Surg. 2000:135;452–6
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cantly impact 1-year outcomes and was therefore not included as a predictor of increased clinical risk. Despite the isolated PREVENT III ndings showing comparable results for distal bypass, patients with infrapopliteal targets or who lack high quality venous conduit should be considered “ana­tomic high risk” [114]. This anatomic risk classication arose from the observation that patients undergoing infrap­opliteal bypass had lower rates of freedom from major adverse limb events (MALE) (74% vs. 81%, p = 0.004). These events include above ankle amputation or major rein­tervention at 1-year follow-up or perioperative death. However, there were no differences in mortality or amputation- free survival at 1-year follow-up based on ana­tomic risk criteria. Taken together, these data suggest that diabetes is unlikely to impart an independent risk of worse outcomes following bypass surgery. Distal bypass is very common in diabetics and is a highly technically challenging surgical procedure. As a result, there is a moderately increased risk of complications in patients undergoing distal bypass, but no difference in limb salvage or mortality.
Technical precision in the performance of tibial and pedal bypass in the diabetic population is absolutely essential to success. A review of arteriograms at our institution imaging the entire lower extremity circulation in patients evaluated for revascularization demonstrated that in 10% of cases a pedal vessel, usually the dorsalis pedis, is the only suitable outow. In another 15% of patients, the dorsalis pedis appears to be a better-quality outow target than other patent but diseased tibial vessels. As a result, we began performing bypasses to the dorsalis pedis artery for limb preservation in situations where no more proximal bypass option existed [118]. We have reported our experience with vein bypass grafts to the dorsalis pedis artery in excess of 1000 proce­dures with follow up extending beyond 10years [66]. At 5years, graft patency was 63% and limb salvage was 78%;
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however, patient survival was less than 50%. Approximately 60% of patients requiring pedal bypass present with some degree of foot infection, and this raises concerns about plac­ing an arterial graft in such close proximity to infected tis­sues. This, however, has not proved hazardous provided that active, spreading sepsis is controlled prior to surgery [119]. Our results have compared favorably with other reports of pedal level arterial reconstruction and are comparable to or better than results now routinely reported for popliteal and tibial artery reconstructions [83, 120–124] [Fig. 24.15].
In advanced cases of distal ischemia, or in cases of failed pedal bypass, patients may have no available outow vessel other than the lateral tarsal branch of the dorsalis pedis artery or the lateral or medial plantar branches of the posterior tib­ial artery [Fig. 24.17]. In our series of 98 tarsal and plantar bypasses, 30-day mortality was 1% and early graft failure, within 30days, occurred in 11%. In this group, secondary graft patency was 70% at 1year and 50% at 5years. Limb salvage was nearly 70% at 5years [125]. These results are encouraging regarding limb salvage in a group of patients that are all too often advised that limb amputation is the only option by physicians who do not consider extreme distal bypass as a treatment option [Fig. 24.18].
Young patients with juvenile onset Type 1 diabetes mel­litus may develop ischemic foot complications from prema­ture atherosclerosis. In distinction to older patients, atherosclerosis in this group is rapidly progressive and asso­ciated with a worse prognosis [3, 119, 126]. Younger patients undergoing revascularization have been found to be at increased risk for perioperative complications, have an increased rate of multiple revascularization procedures, and have more frequent progression to extremity amputation. We reviewed all patients under 40years of age who underwent infrainguinal revascularization at our institution from 1990 to 2000 [127]. Fifty-one patients undergoing 76 lower
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Fig. 24.17 Preoperative anteroposterior (a) and lateral (b) arteriogram of the foot of a patient undergoing a plantar artery bypass
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Fig. 24.18 Primary patency (a) and limb salvage (b) for patients undergoing bypasses to the dorsalis pedis artery and to the plantar/tarsal arteries.
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Adapted from Hughes, et al. J Vasc Surg. 2004;40(6):1149–57
extremity revascularizations were identied. Type 1 diabetes mellitus was very prevalent, affecting over 94% of patients. During the follow-up period, 11.8% of patients required additional ipsilateral revascularization, 31.3% required a contralateral bypass graft, and in 23.5% major amputation was ultimately necessary. The success rate for secondary
procedures was marginal when compared to the primary pro­cedures. The primary patency rate, secondary patency rate, and limb salvage rates were 66.7%, 62.5%, and 77.8% respectively at 1year and 44.4%, 41.7%, and 64.8% respec­tively, at 5years. Long term survival was 75% at 5years. The results are inferior to those of our older patients where graft
Dorsalis Pedi Plantar/Tarsal
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patency and limb salvage approach 80% and 90% at 5years. The worse outcomes may be due to a more aggressive and rapidly progressive form of atherosclerosis or may be a con­sequence of the relatively high incidence of dialysis­dependent renal failure in these patients. Like patients on chronic hemodialysis, the observed results are inferior to more “typical” patients and attempts to salvage failed recon­structions were rarely successful. These facts must be dis­cussed frankly with the patient prior to initiating therapy, and treatment should be individualized based on the clinical situ­ation with the realization that, for some patients, amputation may be the best rst treatment.
Chronic kidney disease is a complication of longstanding diabetes. As a result, vascular surgeons are often confronted with revascularization decisions in patients with diabetes and ESRD. In the past, patients on hemodialysis have been deemed to be at too a high risk for surgical bypass. In 2002, we reported our experience with 146 ESRD patients under­going lower extremity bypass in 177 limbs [28]. Notably, 92% of the study population had comorbid diabetes mellitus and the cause for hemodialysis was DM in 88%. The 30-day mortality rate was found to be 5%, reecting acceptable peri­operative safety. However, overall survival rates at 1, 3, and 5 years were 60%, 18%, and 5%. Despite this, the 3-year limb salvage rate was 80% suggesting that patients died from causes unrelated to the status of the bypass. Multivariable analysis identied age and number of years on dialysis as predictive of worse outcomes. Similar single center studies have demonstrated comparable survival and limb salvage rates [42]. Subsequently, a meta-analysis of infrainguinal bypass in more than 1000 ESRD patients was performed [128]. The perioperative mortality rate was found to be 8.8%. The estimated 5-year primary patency rate was 50.4%, sec­ondary patency 50.8%, limb salvage 66.6%, and overall sur­vival 27.5%. In patients with ESRD, bypass can result in limb salvage, but limited overall survival is to be expected.
Recommendations
For diabetic patients with chronic limb threatening ischemia, we believe the WIfI system should be used to assign an ini­tial stage of disease [9]. If limb salvage is attempted, then wound care, infection control, and revascularization are all essential. A diagnostic arteriogram will allow evaluation of anatomic disease distribution using the GLASS classica­tion to plan for endovascular or surgical intervention. An individualized approach should be used to choose whether to initially pursue endovascular or open surgical treatment, accounting for patient risk, limb severity, anatomy, and dura­bility of revascularization required. In general, BEST-CLI conrms that surgical bypass is preferred in patients with good quality greater saphenous vein conduit and life expec-
tancy ≥2 years. Bypass is also favored for advanced WIfI stage and/or multi-level or extensive occlusive disease. Endovascular therapy is preferable in patients with high sur­gical risk and limited life expectancy. Endovascular tech­niques are also more appropriate when high quality vein conduit is unavailable and when the occlusion or stenosis is at a single level. Future studies on revascularization for CLTI should similarly account for WifI and GLASS staging to allow for accurate comparison of outcomes in this complex, heterogeneous patient population.
Despite the fact that the prevalence of diabetes has increased markedly in recent years, improvements in revas­cularization techniques and increased utilization of preventa­tive care have resulted in a dramatic decrease in the rate of lower extremity amputations [129]. In order to maintain this trend, vascular disease specialists must be procient in all forms of revascularization. The breadth of endovascular and surgical options for limb salvage in the diabetic patient has expanded to the point where treatment plans are highly indi­vidualized and combinations of techniques are common.
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24 Lower Extremity Arterial Reconstruction inPatients withDiabetes Mellitus: Principles ofTreatment
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Reconstruction oftheDiabetic Foot
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EricShiah, AmyChen, RyanP.Cauley, andArriyanS.Dowlatshahi
25
Abstract
The diabetic foot syndrome of vasculopathy, neuropathy, foot ulceration, and deformity can be surgically challenging to the reconstructive surgeon. Primary objectives are to achieve joint stability, restore function, and improve appear­ance. Within the overall scope of surgical management, soft tissue reconstructive surgeons play an essential role in wound care, debridement, and ap surgery for coverage for non-healing wounds. Soft tissue decits must be closed to protect underlying structures from infection. Adequate blood ow and debridement of wounds down to clean healthy tissue are mandatory before reconstruction. During soft tissue reconstruction, tightness of closure, depth and location of defect, bulkiness of donor aps, and donor site morbidity are carefully considered. Given the multi-faceted etiology of the diabetic foot and the complexities involved in managing non-healing wounds, a team approach is criti­cal to the success of diabetic limb reconstruction. This chap­ter focuses on wound assessment, adequate debridement, and the various options for wound closure or coverage involved in soft tissue reconstruction of the diabetic foot.
Introduction
The diabetic foot syndrome manifests as a constellation of diabetes related-disease processes resulting in peripheral neuropathies, peripheral arterial disease, ulcer, infections, osteopenia, Charcot arthropathy, and amputation. An esti­mated 1.6 million people were living with the loss of a limb in 2005, and this number is projected to at least double by 2050 [1, 2]. Around 85% of diabetes-related amputations are preceded by an ulcer [3, 4].
E. Shiah · A. Chen · R. P. Cauley · A. S. Dowlatshahi (*) Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA e-mail: adowlats@bidmc.harvard.edu
The multifactorial causes of diabetic foot syndrome necessitate the need for a multidisciplinary team to treat and manage complications. A primary care physician and endo­crinologist should be involved for primary and preventative management of the diabetic foot. For complications ranging from ulcerations to the need for salvage, involvement of infectious disease specialists, podiatrists, vascular surgeons, orthopedic surgeons, and plastic surgeons has been shown to improve ulcer healing, amputation rates, and quality of life [5, 6]. Advances in endovascular interventions and Charcot neuroarthropathy reconstruction approaches also have con­tributed immensely to improved outcomes and reduced sur­gical risks [7–9]. This chapter will focus on soft tissue reconstructive approaches for the diabetic foot.
Early Diagnosis
Diabetic foot wounds occur after repetitive injury to an insensate and biomechanically unstable foot. The combina­tion of inadequate blood ow, ineffective immune system, and impaired wound healing leads to higher risk of an acute wound conversion to a chronic one. Thus, an earlier diagno­sis with assessment of risk factors is vital in inhibiting its progression [10]. Unfortunately, many late-progression cases end up requiring soft tissue reconstruction, in which most can be accomplished with simple techniques and roughly 10% with complex ap reconstruction.
Pre-operative Assessment
The rst step in soft tissue management of a diabetic foot wound includes assessment of wound features and blood ow to the foot. Evidence of infected or necrotic tissue warrants urgent or emergent excisional debridement until a clean and healthy wound base is established. Prompt and aggressive sur­gical intervention have been to found to decrease length of hos­pital stay and need for higher amputation levels [11]. Active
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 A. Veves et al. (eds.), The Diabetic Foot, Contemporary Diabetes, https://doi.org/10.1007/978-3-031-55715-6_25
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infection in the form of cellulitis or osteomyelitis should also ideally be treated with culture-guided antibiotic therapy, with involvement of infectious disease specialists. The depth of the appropriately debrided wound should then be assessed with the determination of exposed tissue structures, as well as missing structures that may result in tendon imbalances, post-operative foot deformities, and pressures ulcers [12]. Negative pressure wound therapy can be used to shorten healing time and time to denitive reconstruction if needed [13].
Appropriate wound healing requires sufcient blood sup­ply which can primarily be assessed with palpation of distal pulses and the ankle-brachial index. Doppler ultrasonography has become a standardized approach to evaluate the arterial tree of the limb and foot [14, 15]. Questionable blood ow necessitates the need for a formal arteriogram or CT angio­gram, especially when planning for ap reconstruction. There should be a low threshold for consultation with a vas­cular surgeon regarding pre-reconstruction revascularization to optimize post-operative healing and prevent amputation.
Screening for neuropathy is also an essential part of the pre­operative assessment. Loss of protective sensation, dened as a pressure threshold of 10 g of force perpendicular to the skin (5.07 Semmes-Weinstein monolament), can progress to bio­mechanical changes in the foot and ankle. Loss of motor and autonomic components of nerves in diabetic peripheral neurop­athy results in atrophy of intrinsic muscles and anhidrosis [16]. Repetitive undetected trauma will gradually lead to permanent degenerative changes and deformities, also known as a Charcot foot, although other theories including increased bone resorp­tion and a chronic inammatory state have been proposed [17]. Sensory testing with monolaments should include at least ten
sites of the foot for improved sensitivity and specicity, while testing with a tuning fork should be performed at the lateral mal­leolus and rst metatarsal head [18, 19]. The etiology of diabetes- associated neuropathies is typically related to micro­vascular damage starting peripherally in a stocking- glove distri­bution; however, there are less common presentations such as radiculopathies that follow a dermatomal distribution [20].
Achieving Adequate Debridement
Indications
Debridement is a major component of wound management and is dened as the removal of necrotic material, eschar, devitalized tissue, slough, pus, hematomas, foreign bodies, debris, bone fragments, or bioburden from a wound with the objective to promote wound healing [21]. A wound with good vascular supply can support more aggressive debridement, while wounds with reduced vascular supply should be con­sidered for revascularization prior to debridement. Concerns for underlying infection warrant urgent debridement regard­less of vascular supply status to remove sources of sepsis and decrease bacterial burden causing local infection [22].
Techniques
Debridement techniques can be temporarily staged or used in combination (Table25.1). Sharp surgical debridement can be performed as a clinic procedure or the operating room
Table 25.1 Debridement techniques
Debridement method Advantages Limitations Mechanical • Quickest method
• Minimal training required
• Lowest cost and use of resources
• Convenient and easy to perform (including at home)
Sharp/surgical • Efcient in wounds with layers
of necrotic tissue
• Low cost and use of resources (bedside)
• Allows for selective debridement
Aqueous jet lavage • Flexible combinations of solutions
(saline, antiseptics) and modes of action
• Allows for selective debridement
Ultrasound- assisted • Selective and immediate
• Option for gentle and maintenance debridement
Larval therapy • Reduces pain, bacteria, and malodor
• Low cost and use of resources
• Low risk of injury to healthy tissue
Autolytic • Easy to perform
• Low cost and use of resources
• No damage to healthy tissue
• Minimal to no pain
• May be painful during dressing changes
• Wound remains open with risk of infection
• Inadequate for wounds with signicant necrosis or hard eschar
• Risk of infection
• Needs prior assessment of vascular status and use of anticoagulants
• Wide resection may require sedation/operating room
• Requires lavage equipment
• Hydrosurgery may require special expertise
• May require sedation for procedures
• Risk of aerosol spread of infection
• May require specialist training
• Caution in patients with vascular abnormalities, coagulopathies, or prior radiation
• Not recommended as a sole method
• May be painful
• Contraindicated in wounds with exposed vessels or decreased perfusion
• Risk of allergic reaction
• Contraindicated in infected wounds
• Time consuming
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depending on how extensive of a debridement procedure is required. Nonviable tissue should be removed down to bleed­ing tissue, restarting the phases of wound healing with a new acute wound. For more supercial wounds, wet-to-dry dress­ings can be used to facilitate initial wound management, ongoing gentle debridement, or healing by secondary inten­tion. General limitations include frequent (at least once daily) dressing changes and associated pain.
Aqueous high-pressure lavage utilizes jet streams of water or saline solution for debridement while concurrently irrigating the wound. For grossly contaminated wounds, the lavage solution can be combined with diluted antiseptics such as povidone-iodine. Ultrasound-assisted wound debridement can be used as an alternative, although more costly than simple excisional debridement [23–25]. Ultrasonic energy is delivered through direct contact with the wound bed or through an atomized solution, allowing the removal of non-viable tissue and biolm without damaging healthy tissue. It has been shown to reduce bacterial load, increase healing rate, and reduce wound size over a 6-week treatment period [26–28]. Lastly, larval therapy is re­emerging as a form of mechanical debridement particularly for non-surgical candidates with chronic intractable wounds infected with antibiotic-resistant strains of bacteria [29, 30]. Larvae are applied in loose or biobag form and should not be used in wounds with exposed neurovascular structures.
Autolytic debridement utilizes occlusive or semi- occlusive moist dressings, such as hydrogels and hydrocolloids, to cre­ate a moist wound environment that is optimized for endoge­nous proteolytic enzymes and macrophage activity. This method of debridement is relatively slow and is typically reserved as a pre-debridement measure for non- infected wounds with only small amounts of non-viable tissue.
Negative Pressure Wound Therapy
Since its rst application in clinical practice in 1993, nega­tive pressure wound therapy (NPWT) has been widely uti­lized for various acute and chronic wounds, including diabetic foot ulcers. NPWT promotes wound healing by removing bacterial products, reducing edema, approximat­ing wound edges, and facilitating granulation tissue prolif­eration. Multiple committees, including the Tucson Expert Consensus Conference on V.A.C. Therapy and the Tissue Repair of Burns and Trauma Committee, have provided evidence- based guidelines for the best clinical applications to support formation of standardized treatment schemes [31–
34]. This includes use of NPWT only after infection, bleed-
ing, and ischemia are controlled with an ankle-brachial-index range of 0.9–1.3. The recommended pressure range is between −80 and −125mmHg [35]. NPWT dressings should be replaced every 3–5 days to prevent granulation tissue
growing into the foam material, and a comprehensive evalu­ation of its effects should be conducted every few weeks. Continuous mode is most commonly used as intermittent pressure therapy can cause signicant pain from tissue defor­mation that occurs with every on-off cycle.
In addition to adequately debrided wounds, there are many other applications of NPWT for complex diabetic foot wounds [13]. If bone or tendon are exposed, NPWT can pro­mote granulation tissue formation in preparation for a skin ap or skin graft. Wounds with osteomyelitis but adequately debrided soft tissue can temporarily be treated with NPWT while systemic antibiotic therapy is allowed to take effect. Close observation is required during dressing changes for local infection, in which NPWT should be stopped or resumed after debridement. NPWT is also used after skin graft or dermal equivalent graft surgery to immobilize the graft, promote vascularization, and manage wound exudate.
Soft Tissue Reconstruction
Soft tissue reconstruction of the diabetic foot follows the principles of the reconstructive ladder. This includes a vari­ety of techniques including primary closure, skin grafting, local or regional aps, and free tissue transfer. Closure is ide­ally achieved by the simplest effective technique. This sec­tion will review the spectrum of closure options available for the diabetic foot. Additionally, reconstructive approaches will be discussed based on location of the defect, as there are many biomechanical considerations of each part of the foot that ultimately affect selection of the closure modality.
Once the soft tissue defect has been adequately debrided and granulation tissue is forming, the wound can be assessed for closure. Signs of decreasing wound inammation, marked by the subsidence of key inammatory signs “rubor” (redness), “calor” (heat), “tumor” (swelling), and “dolor” (pain), indicate wound readiness for closure [36]. Wrinkling of skin around the defect correlates with resolution of inam­mation and is accompanied by a reduction of pain, swelling, and induration.
Secondary Intention andDelayed Primary Closure
Primary closure is rarely utilized but can be considered if there is skin redundancy, and limited dead space. Wound readiness must be carefully considered, as well as tension on the closure. In the setting of baseline ischemia, primary closure under ten­sion can threaten the viability of the foot as a whole.
Secondary intention is the simplest form of wound clo­sure in the reconstructive ladder and can be coupled with NPWT, synthetic skin substitutes, growth factors, or hyper-
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