A NEW STRATEGY : PERIPHERAL

ENDOVASCULAR SURGERY FOR

ARTERIAL DISEASE IN DIABETIC
FOOT ULCER

dr. M Ali Shodiq, Sp.BTKV

Cardiac Thoracic and Vascular Surgery Department
Kariadi Hospital Semarang
Diabetic Foot

Definition:
Infection, ulceration or destruction of
deep tissues associated with
neurological abnormalities & various
degrees of peripheral vascular
diseases in the lower limb

(based on WHO definition)

Epidemiology

 4% -10% is the prevalence of foot

ulcer in diabetics

 40% - 60% of all non traumatic lower

limb amputation

 85% of diabetic related foot

amputation are preceded by foot ulcer
 Social & Economic Factors
 Diabetic foot complications are
expensive :
 Cost of healing 7000-10000 USD
 Healing with amp. 43000-63000 USD
 4 weeks dressing cost 11000 USD

 Scarce information regarding long term

prognosis
Diabetic Foot Ulcer Treatment
Modalities
 Microbiological control
 Wound control
 Vascular control
 Mechanical control
 Metabolic control
 Educational control
 Independent Risk Factors for PAD*

Relative Risk vs the General Population

Reduced Increased

Diabetes 4.05

Smoking
2.55

Hypertension 1.51
1.10
Total cholesterol (10 mg/dL)

Newman AB, et al. Circulation. 2013;88:837-845

PAD in DIABETES MELLITUS
 Rutherford Classification

 Stage 0 – Asymptomatic
 Stage 1 – Mild Claudication
 Stage 2 – Moderate Claudication
 Stage 3 – Severe Claudication
 Stage 4 – Rest Pain
 Stage 5 – Ischemic ulceration not exceeding the
digits of the foot
 Stage 6 – Severe Ischemic ulcers or gangrene

Stage 3-6 Critical Limb Ischemia ( CLI )

 Candidate for revascularization
Clinical Presentation of CLI

 Rest Pain - Usually when limb is elevated and

relieved with dependency

 Ulceration – Distal areas of extremities such as tip

of toes, severe pain, dry, poor vascularity

 Gangrene – Devitalized tissue

Algorithm CLI in Diabetes Mellitus

CLI confirmed

Not revasc Candidate for Not revasc

Candidate revasc candidate

Intolerable
Stable pain or
Angiogram Pain/
lesion
Infection

Endovascular
Medical
or Surgical Amputation
treatment
treatment
 REVASCULARIZATION

1. Trombo endarterectomy  profunda plasty

2. Bypass with grafts :  venous
 synthetic
3. Endovascular surgery
4. Ballooning and stenting PTA/PTAS
 Endovascular
Interventional Options

 Angiogram required to formulate “game

plan”
 Must evaluate inflow and outflow, usually
multi-level disease
 Treat inflow lesions first (PTA)
 Must optimize risk factors and anti platelet
therapies
Common Iliac Artery
Superficial Femoral Artery
Anterior Tibial Artery
Anterior Tibial lesion in CLI
Chronic Total Occlusion
Subintimal Approach
Athrectomy
Filter
Goals Treatment

Pain Relief
Heal Wounds

Save a LIMB Save a Life

Promote /
Protect
Mobility
Before and After