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J. Ceja Solorio and J. M. Giurini
Fig. 23.33 (a, b) The
percutaneous technique
(Hoke) uses two medial stab
incisions and one lateral
incision. The ankle is
dorsiexed to allow for
lengthening of the Achilles
tendon
a b
Fig. 23.34 The open Achilles tendon lengthening creates incisions in
the tendon proximally and distally. The tendon is then lengthened in the
frontal plane
tected for approximately 6weeks in a splint or brace that
maintains the ankle joint at 90°.
It is also acceptable to lengthen the tendon via a gastrocnemius recession as described by Strayer. In this procedure,
the incision is made more proximally and along the medial
side of the tendon. The incision should be made at or near the
Fig. 23.35 Gastrocnemius recession (Strayer) is an alternate technique to address a tight Achilles tendon for diabetic foot ulcerations and
Charcot reconstructive surgery
myotendinous junction of the gastrocnemius muscle and the
Achilles tendon. The tendon is separated from the bers of
the soleus muscle which are on the anterior surface of the
Achilles. Once separated, the Achilles tendon is isolated and
is transected transversely (Fig. 23.35). Once transected, a
gentle dorsiexory force is applied to the foot to stretch the
23 Surgical Treatment oftheUlcerated Foot
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429
Achilles. It is important to identify and avoid the sural nerve
which runs along the lateral side of the Achilles tendon. The
main advantage of the gastroc recession over the Hoke procedure is there is less weakening of the tendon. However,
this may not be signicant in this patient population.
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Lower Extremity Arterial
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Reconstruction inPatients
withDiabetes Mellitus: Principles
ofTreatment
SophieX.Wang andMarkC.Wyers
24
Abstract
A successful revascularization strategy must be individualized to each individual patient’s presentation. Peripheral
arterial disease (PAD) should be appropriately staged and
foot infection treated to obtain source control. Diagnostic
angiography provides the most detailed anatomic information and is essential to determining the best revascularization strategy.
Revascularization aims to restore inline pulsatile ow
to the foot. Balloon angioplasty is the standard modality
of treatment in the infrapopliteal arteries, the most common site of occlusive disease in diabetes. Stents and drugcoated technology are not well studied nor widely used in
the tibial arteries. Surgical bypass is preferred for extensive, multi-level occlusive disease. Ipsilateral greater
saphenous vein is the optimal autogenous conduit. Nonautogenous conduits have poor patency and are suboptimal for longer healing time.
Selection of the optimal revascularization strategy for
limb salvage in diabetic patients must be individualized
based on each patient’s surgical risk, limb severity, and
anatomic pattern of disease.
tibial arteries below the knee. The historic assumption that
gangrene, non-healing ulcers and incomplete healing of
minor amputations results from microvascular occlusion—
so called small vessel disease—has been refuted in multiple
studies [2–7]. Unfortunately, this unsupported notion has
resulted, for less experienced surgeons, in a pessimistic attitude towards treatment of ischemia with a bias towards early
amputation. Limb salvage and wound healing in diabetic
foot ulcer patients are often possible but require early vascular assessment and rigor in revascularization, ideally before
advanced infection or tissue loss is present. Even with signicant bone and soft tissue destruction, a multidisciplinary
approach towards debridement and foot reconstruction,
together with prompt revascularization, can result in preservation of a viable walking platform. The development of a
more thorough understanding of PAD etiology and anatomic
distribution has coincided with advances in minimally invasive, endovascular techniques, and renements in the performance of surgical bypass. As a result, there are highly
effective means of limb salvage in diabetic patients with arterial insufciency that can be tailored to suit the individual
situation.
Introduction
Understanding the complex interplay of peripheral neuropathy, ischemia, and infection in the diabetic foot ulcer patient
is essential to limb salvage. Lower extremity peripheral arterial disease (PAD) is one of the most signicant factors contributing to major amputation in this population [1]. An
important principle in the treatment of diabetic vascular disease is recognizing that the most common cause is macrovascular atherosclerotic occlusive disease, usually involving the
S. X. Wang · M. C. Wyers (*)
Division of Vascular and Endovascular Surgery, Beth Israel
Deaconess Medical Center, Boston, MA, USA
e-mail: mwyers@bidmc.harvard.edu
© 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_24
Patient Evaluation
Assessment ofIschemia, Wound, andInfection
The presence and severity of PAD may be assessed in several
ways, as discussed in Chap. 4. The simplest is through a
detailed history and physical exam. The history may reveal
symptoms of intermittent claudication, rest pain, or foot
ulceration. A foot exam is performed to identify wounds or
ulcers. Pedal pulses are palpated to assess distal perfusion. A
combination of history with physical exam ndings can lead
to a basic classication of PAD as asymptomatic, intermittent claudication, or chronic limb-threatening ischemia
(CLTI). CLTI is further classied as ischemic rest pain, foot
ulcer lasting longer than 2weeks, or gangrene and will be the
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Table 24.1 Wound, ischemia, and foot infection classication of peripheral arterial disease
Score Wound Ischemia Foot infection
0 No ulcer
No gangrene
1 Small ulcer
No gangrene
2 Deep ulcer with exposed bone/joint/tendon
or
Gangrenous changes limited to digits
3 Extensive wound
or
Extensive gangrene
ABI≥0.80
Ankle pressure>100mm hg
TP≥60mmHg
ABI 0.6–0.79
Ankle pressure 70–100mmHg
TP 40–59mmHgg
ABI 0.4–0.59
Ankle pressure 50–70mmHg
TP 30–39mmHg
ABI≤0.39
Ankle pressure 30–39mmHg
TP<30mmHg
No symptoms or signs of infection
Local infection with≤2cm surrounding erythema
Local infection with>2cm surrounding erythema
or
Involving structures deeper than skin
Local infection with signs of systemic inammatory
response syndrome (SIRS)
S. X. Wang and M. C. Wyers
primary focus of this chapter as it represents an absolute
indication for revascularization in order to prevent limb loss.
The Rutherford classication system has been widely
used to categorize symptomatic limb ischemia [8]. In this
system, a score from 1 to 6 is assigned based on symptoms,
physical ndings, and hemodynamic parameters. The rst
three categories describe patients with long, moderate, and
short-distance claudication. The remaining categories
describe patients with critical limb ischemia (CLI): category
4—ischemic rest pain, category 5—minor tissue loss, category 6—major tissue loss. Interestingly, hemodynamic
parameters may not correlate with clinical symptoms. The
Rutherford classication is useful for stratifying those
patients (Rutherford 3–6) at much higher risk for amputation
without revascularization. This original clinical categorization of CLI patients, however, was intended for patients
without diabetes, and makes no attempt to incorporate the
complexity of concurrent infection and neuropathy commonly seen in diabetic patients [9].
In an effort to address the decits of the Rutherford clas-
sication system, the Society for Vascular Surgery (SVS)
introduced the Wound, Ischemia and foot Infection (WIfI)
classication with the goal of providing a more comprehensive clinical staging system [9]. Similar to the TNM staging
system for cancer, the WIfI system stages limbs based on
three variables: (1) Wound extent (based on clinical ndings), (2) Ischemia (based on hemodynamic parameters such
as ankle-brachial index, toe pressure or trans-cutaneous tissue oxygenation), and (3) severity of concurrent foot
Infection (based on clinical ndings of infection). Patients
are scored within each category and then assigned a stage
1–4 with stage 4 representing the most severe limbthreatening ischemia [Table 24.1].
The WI clinical stage provides a framework for guiding
the decision to revascularize, clearly delineating which
patients are at high risk for amputation and would benet
from revascularization [Fig. 24.1]. WIfI staging recognizes
the synergistic effect of vascular insufciency and infection,
as even a mildly ischemic limb with severe infection is at
high risk of amputation. This staging system encourages
surgeons to be aggressive for any degree of ischemia more
than mild (ABI 0.6–0.79 or toe pressure 40–59mmHg) or
for larger wounds once infection is controlled. The WIfI
system has been widely validated as a predictor of wound
healing time and clinically relevant endpoints following
endovascular intervention [10, 11]. [Fig. 24.2]. Modications
in the WIfI system such as the novel WIfI composite score
(graded 0–9, which weighs all components equally) and
novel WIfI mean score (graded 0–3, which allows for inclusion of limbs with missing data) have also been used to predict amputation and reintervention in patients undergoing
revascularization [12].
An important strength of the WIfI system is that a patient’s
status or clinical stage can be restaged. That is, it recognizes
that wound healing can be prolonged and that patients have a
high risk of developing new wounds, infections, restenosis,
or outright revascularization failure. When there is a change
in clinical status, such as stalled wound healing, WIfI can be
reapplied to reassess the risk of amputation and potential
benet from further revascularization regularly. Such clinical
changes would not be identied or tracked in systems that
focus only on amputation-free survival. In this way, the WIfI
system allows for a more nuanced evaluation of outcomes as
well as clinical staging.
An understanding of the WIfI system and its clinical relevance is important for risk stratication in patients with diabetic foot ulcers. The complexity of the system reects the
wide range of presentations in patients with PAD and diabetes. It is our experience that correction of hemodynamic
abnormalities will only lead to successful limb salvage if
there is appropriate wound care and control of infection.
Multidisciplinary care, addressing all these aspects, is essential. If a patient with chronic limb threatening ischemia is
thought to be a candidate for limb preservation, revascularization is typically pursued following control of foot infection.
Control ofInfection Prior toRevascularization
Patients with an unsalvageable foot due to medical comorbidities, pre-existing non-ambulatory status, and extensive
necrosis from infection, or ischemia (WIfI clinical stage 5)
a
24 Lower Extremity Arterial Reconstruction inPatients withDiabetes Mellitus: Principles ofTreatment
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Fig. 24.1 Expert consensus
on (a) estimated risk of
amputation at 1year and (b)
estimated benet of
revascularization based on
WifI score. (Adapted from
Mills etal. J Vasc Surg.
2014;59(1):220–234)
b
435
may require primary limb amputation. However, in patients
with an appropriate risk prole, proper control of active,
spreading infection should be accomplished prior to arterial
[14] [Fig. 24.3]. Such debridements are performed with the
goal of preserving sufcient tissue to allow for later reconstruction and closure.
intervention. Practically speaking, foot debridement is only
given priority over revascularization in order to control wet
gangrene, deep space abscess, or severe infection. Patients
Pre-Operative Evaluation ofPatient Risk
without symptoms or signs of local or systemic infection do
not need to be started on antibiotics. In patients with infected
wounds, antibiotics may be initiated based on guidelines
adapted by the SVS and formulated by the Infectious
Diseases Society of America (IDSA). [9, 13] Once culture
data is available, antibiotic coverage can then be appropriately adjusted. In addition, those patients with abscess formation, septic arthritis, or necrotizing fasciitis should
undergo prompt incision, drainage, and debridement including partial open toe, ray, or forefoot amputation as indicated
Frailty
Certain patients such as those who are non-ambulatory or bedridden, and have no likelihood of successful rehabilitation,
may not be appropriate for arterial reconstruction. Similarly,
patients with severe exion contractures of the knee or hip are
poor candidates for arterial reconstruction. Patients with endstage diseases such as terminal cancer, those with very short
life expectancy, or similarly lethal comorbidities, have high
complication rates with vascular reconstruction and may be
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Fig. 24.2 WifI composite score predicts worse amputation-free survival following endovascular infrapopliteal intervention. (From Darling
JD, etal. J Vasc Surg. 2016;64(3):616–22)
S. X. Wang and M. C. Wyers
better-served by primary amputation, and while patients with
tissue loss and age>80years are considered to be at high risk
when pursuing surgical bypass [15], age alone is not a contraindication to arterial reconstruction. Frailty indices may be
more sensitive indicators of a patient’s physiologic age and
estimated survival, therefore providing a better assessment of
which elderly patients are more likely to benet from revascularization [16, 17]. Various frailty indices have been used to
predict treatment strategy and outcomes after both open and
endovascular revascularization [18, 19].
Cardiac Disease
Patients with limb ischemia who present with active coronary artery disease (CAD) such as unstable or severe angina,
decompensated congestive heart failure, signicant arrhythmias, or severe valvular disease may benet from further cardiac evaluation prior to arterial bypass surgery [20–22].
When indicated, these patients typically undergo preoperative echocardiography with nuclear stress testing. Coronary
angiography and percutaneous coronary intervention may
also be necessary though additional antiplatelet medications
may be required post-intervention which impact surgical
timing and bleeding risk. In patients with active coronary
artery disease, these interventions must be planned carefully.
However, in the absence of active symptoms, a patient with
stable coronary disease does not require preoperative cardiac
workup prior to revascularization [20]. The exception is in
patients with elevated cardiac risk and poor functional capacity (<4 MET equivalents) who may have unstable coronary
artery disease without symptoms and therefore may benet
from preoperative cardiac testing and intervention [22]. In
patients with high cardiac risk, endovascular interventions
are thought to carry a lower risk of perioperative adverse cardiac event and, as a result, may be preferred.
Fig. 24.3 Photographs of the left foot in a patient with diabetes who
presented with marked swelling and erythema of the forefoot. There
was palpable crepitus and malodorous drainage owing to infection with
gas- forming bacteria
Renal Insuciency
Patients with limb ischemia in the setting of renal failure
present particular challenges. Withholding or delaying contrast arteriography in patients with diabetes and compromised
renal function is usually unnecessary. If there are extreme
concerns about renal function, duplex ultrasound imaging,
magnetic resonance angiography, and CO2 or gadolinium
angiography are imaging alternatives that can sometimes provide adequate information to plan arterial reconstruction or to
allow for more limited and selective contrast arteriography of
the tibial and pedal vessels [23]. When acute renal insufciency develops, sometimes as a result of contrast-induced
nephropathy after diagnostic angiography, surgery should be
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delayed until renal function stabilizes or returns to baseline.
Most such patients will demonstrate a transient rise in serum
creatinine in the absence of other symptoms. It is rare that
such patients will become anuric or require hemodialysis.
Patients with chronic, dialysis-dependent renal failure
(end-stage renal disease [ESRD]) can safely undergo arterial
reconstruction. Many ESRD patients have severe, advanced
atherosclerosis and have target arteries that are often heavily
calcied. Gangrene and tissue loss are frequently present and
the healing response in such patients is poor, even with
restoration of pulsatile arterial blood ow to the foot. Some
ESRD patients will require amputation even with patent arterial bypass grafts. Several studies have demonstrated that
while reasonable, graft patency and limb salvage rates in these
patients are lower than in patients without ESRD [24–27]. Our
own study of 146 patients with ESRD undergoing arterial
reconstruction for critical limb ischemia demonstrated graft
patency and limb salvage rates of 68% and 80%, respectively,
at 3 years [28]. Perioperative mortality rate was reasonably
low at 3%; however, long-term survival was poor with only
18% or patients alive after 3years. Other studies have documented higher perioperative mortality rates (9–18%) and
lower limb salvage rates (65–70% at 1year) in this population.
Despite this, revascularization is still a reasonable option for
ESRD patients with critical limb ischemia rather than primary
amputation in well selected patients [29, 30]. Clinical judgment is paramount when considering arterial bypass for limb
ischemia in the dialysis patient. Until further studies clarifying
the role of bypass surgery in this patient population are available, treatment plans must be individualized.
Anatomic Imaging Prior toRevascularization
Vein Mapping
It is our preference to obtain bilateral lower extremity venous
mapping in patients being considered for revascularization.
Vein mapping entails duplex ultrasound evaluation of the
greater and small saphenous veins and provides information on
patency, diameter, wall thickening, and intraluminal webs or
thrombus. When leg vein is not available or is not suitable, arm
vein mapping should be performed in search of an acceptable
cephalic or basilic vein. Single segment cephalic vein, harvested from the wrist to the level near the cephalic arch, usually
provides enough length to reach from the common femoral to
the proximal tibial arteries. When the forearm cephalic vein is
not of adequate quality, a single segment of upper arm cephalic
and basilic vein can be harvested as a loop including the median
cubital vein [31]. Our preference is that the vein, whether
saphenous or other, be larger than 3mm in diameter and free of
evidence of wall thickening. Vein mapping is typically performed with a gentle tourniquet placed on the proximal aspect
of the extremity to dilate the vein distally.
CTA
While non-invasive vascular studies are excellent for determining which patients are likely to be candidates for revascularization, additional anatomic information may be
required for operative planning. Computed tomography
angiography (CTA) has become an important adjunct in this
regard. In patients with PAD, CTA performs well, with sensitivity and specicity rates as high as 95% and 96%, respectively, for detection of >50% stenosis or occlusion [32, 33].
However, contrast administration is required which exposes
patients to the risk of contrast-induced nephropathy. This
risk is further exacerbated by coincidental renal insufciency
which is often associated with diabetes [34, 35]. Furthermore,
CTA imaging can be compromised in patients with extensive
vessel calcication, commonly seen in diabetic patients [36].
In general CTA is very good at evaluating iliac inow and the
majority of the femoral-popliteal segment but has limitations
in the tibial segment because of calcication, small vessel
diameter, and frequently mis-timed contrast bolus.
MRA
Magnetic resonance angiography (MRA) is typically performed with the use of intravenous gadolinium-based contrast agents. In this setting, sensitivity and specicity for
detection of >50% stenosis or occlusion may be as high as
95% and 97%, respectively [37]. The advantages of MRA
are that it is noninvasive and images are less likely to be
degraded by vessel calcication [38]. The disadvantages are
that gadolinium-based contrast exposure carries a small risk
of nephrogenic systemic brosis (particularly in patients
with chronic renal insufciency) [39]. Additionally, patients
with implanted metallic devices, such as pacemakers, may
not be able to undergo MRA.In general, MR spatial resolution is inferior to modern multidetector CTA.
Diagnostic Digital Subtraction Angiography
In our experience, arteriography is the gold standard imaging
modality because it provides the most anatomic detail and
allows for immediate endovascular intervention when indicated [38]. The benets of arteriography should be weighed
against the risk of arterial access-related complications and,
similar to CTA, iodinated contrast exposure. Using the techniques described below, however, we are able to use smaller
volumes of contrast for diagnostic arteriography than the
amount required for CTA in the majority of cases.
We routinely obtain arterial access using ultrasound guidance as it has been associated with decreased access-related
complications [40, 41]. Contralateral, retrograde access is
most commonly obtained using a 4-French sheath. A side- hole
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injection catheter is then advanced to the level of the L1-L2
vertebral interspace and an aortogram is performed using
diluted contrast to delineate the anatomy of the abdominal
aorta and its branches. A catheter is then advanced over the
aortic bifurcation and unilateral lower extremity arteriography
is obtained in stages using digital subtraction techniques. It is
crucial to visualize the entire tibial and pedal circulation since
the former is the most common location of signicant occlusive lesions in patients with diabetes and the latter is an important potential site for placement of the distal anastomosis when
performing bypass surgery. Thorough delineation of vascular
anatomy of the foot requires both a lateral and anteriorposterior view [Fig. 24.4].
As previously discussed, acute renal failure is a concern
in diabetic patients undergoing contrast arteriography, especially in those with pre-existing renal insufciency. When
renal failure does occur, it is almost always reversible, but
may delay arterial reconstruction surgery for several days
while the creatinine returns to baseline [42, 43]. Arteriography
and percutaneous interventions may be performed safely
even in patients with baseline renal insufciency by following several basic precautions. CO2 angiography may be used
to image the aortoiliac and femoropopliteal segments but is
usually not adequate for tibial artery anatomy [Fig. 24.5].
Iodinated contrast is routinely diluted with saline to limit the
amount used (usually to 1/2 or 1/3 strength). This dilute contrast can be used to perform focused angiography of the tibial and pedal stations. Dilute gadolinium can also be
administered in small volumes but should be used cautiously
S. X. Wang and M. C. Wyers
PR
PT
PR
PT
DP
Fig. 24.4 Unsubtracted, lateral (left) and subtracted anterior-posterior
(right) view of the left foot showing a patent peroneal artery (PR) with
lling of the posterior tibial artery (PT) via collaterals from the peroneal. The distal anterior tibial artery is also reconstituted from peroneal
artery collaterals with outow into a patent dorsalis pedis (DP)
DP
ab cd
Fig. 24.5 (a, b) CO2 angiogram showing patent femoropopliteal segments with (c) occlusion of the tibioperoneal trunk and distal anterior tibial
artery. (d) Good outow onto the posterior tibial and peroneal, which collateralizes onto a dorsalis pedis
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