DIABETIC FOOT COMPLICATIONS
CASE 1
•A 69 years old female with long history of DFI with chronic ulcers of right foot and PVD in the past; presenting in the Diabetic Foot Clinic with recurrent ulcer of the Rt foot for the last 2 weeks with rest pain.
•PMHx
DM-II, HTN, CVS, PVD
Had Right CFA Endarterectomy 5 years ago
•Physical Examination
Absent pedal pulses
Rt forefoot tender to touch
Large ulcer on the plantar aspect of the big toe
Diagnostic Angiogram :
•Vein mapping of LL
Absence of suitable autologous vein on either side
•Questions:
1.Discuss your management plan with clarifying pros and cons.
Endovascular, via contralateral trans-femoral approach iliac angioplasty then fem pop below the knee by ringed graft
based on the given information, it is an infected ischemic diabetic foot with tissue loss
my suggested management plan will include
Then after debridement if there is a good bleeding from the wound bed I will go for VAC dressing after eradication of infection and follow up
If it is ischemic, with no chance to heel without revascularization, Based on the images provided, and inflow disease in CIA and CFA (endarterictomized before) I will go for ilio- profunda bypass to increase the inflow to profunda which will increase the collaterals to below the knee, ( with or without profunda to ATA bypass with an arm vein if present)
keep in mind the risk of limb loss at above knee level
in terms of angioplasty, I think it is too risky to try angioplasty in CFA after endartrectomy, and tasc D occluded SFA with p2 run off
The patient has tissue loss and mutli level PVD.
She needs straight line blood flow.
For Inflow: She needs Redo Rt CFAE and EIA angioplasty and stenting
For outflow: Options:
1) Rt CFA to BTK Pop bypass using either arm vein or synthetic graft with vein Cuff
2) Endovascular Recanalisation, debulking device +/- stenting
The patient did not have a suitable arm vein
The patient had a hybrid approach.
Rt CFAE by bovine patch with retrograde Rt EIA stenting
The sheath was flipped downwards
Intraluminal Recanalisation with re-entry at P3 segment.
Debulking using Phoenix atherectomy and DCB.
dissection in the popliteal, stented with Supera
POBA of ATA origin
Choices should be based on:
Always have a bail out plan
Detailed hx
Full labs
Foot x rays
Hydration started empirical antibiotics
Cardiac assessment and anaesthiae
Discussion with pt and familly possible intervention and complication
Best option for thise pt is hybrid
1. Redo CFE with iliac angioplasty and distal SFA angioplasty using DCB DES
Pros
Durable prcedure than endo alone
Can correct CFA at same time
No need for bypass as pt has no autologus veins
Cons
More complication as redo groin
Need of anaesthiae
Cost
Other options
2. redo CFE iliac angioplasty and CFA to POP bypass with endartectomy use prosthetic graft
3. Endo only use atherectomy device
After good revasculraization debridment with bone and tissue culture for sensivity
1.Discuss your management plan with clarifying pros and cons
I will begin with full history taking and proper examination including examination of the foot for pus from the wound, peripheral pulsation, ABI and toe pressure index.
I will go for full lab including CBC ,CRP , Liver function, kidney function, HbA1c and coagulation profile.
I will ask for EchoCardiogram or stress echo or cardio pulmonary function test and consult Anathesia team for risk assessment
I will ask for foot X Ray to detect osteomyelitis.
Revascularization followed by Urgent surgical debridment.
If the patient is fit for surgery I will go for trial of Endovascular angioplasty by contralateral access with possibility of bypass by synthetic ringed graft to the distal anterior tibial artery if failed angioplasty.
Endo is more preferable over bypass as the patient has histor of CFA endarterectomy so there’re severe adhesions in the groin, no available saphenous vein for graft, there’s ongoing foot infection and possibility to open the three distal vessels during endo.
The long segment occlusion decrease the chances of success during endo and the bypass remains the only available option for revascularization.
Followed by Surgical debridment of the foot to ensure healthy tissue for healing
Discuss your management plan with clarifying pros and cons?
Based on the above, She is a CLTI patient
After assessment of
-ABPI bilaterally, mobility status (motor/cognitive residuals after CVS?), Ultra-sound mapping of UL veins, Peri-operative patient’s risk assessment,
and getting full lab bloods, ECG, Echo, ESR, CRP, plain foot radiography, wound swab for culture and sensitivity if there is any ulcer discharge.
Revascularization option:
1-Endovascular, via contralateral trans-femoral approach,
DCB of CFA, fem-pop segment, Balloon dilatation and stenting of tight stenotic EIA,
Pros:
1- Endo seems favorable as she doesn’t have suitable autologous vein on either side, she has multiple co-morbiditis, multi-level PAD lesions.
2-Avoiding the hostile groin, which likely to have higher incidence of wound complications in open groin surgical approach.
Cons:
1- She has a long occlusive Fem-pop lesion, challenging to pass, and even after passing the lesion, she may need extra vessel prep tools like atherectomy or lithotripsy devices (cost? availability? risk of distal emboli?)
2- she has single ATA tibial distal run-off, however her planter big toe ulcer angiosome is PTA territory, so even after FP disese TTT, it may help releiving her rest pain yet it only will provide indirect revascularization to the ulcer. Healing will likely to be depending on collaterals and pedal arch anatomy, which may be reassessed after correction of her inflow disease.
3- Dissection of pop-tibial segment during intervention, may risk turning the limb into desert foot anatomy, even with BTK stent, it may affect future surgical bypass options.
2- 2nd option:Hybrid approach
DCB of CFA, balloon dilatation and stenting of EIA
then distal bypass using spliced arm vein (if found suitable).
Welcome to Week 3 lecture
Paper for Critical appraisal
https://www.jvascsurg.org/article/S0741-5214(13)01515-2/fulltext