TY - JOUR
T1 - Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease
T2 - A systematic review
AU - Forsythe, Rachael O.
AU - Apelqvist, Jan
AU - Boyko, Edward J.
AU - Fitridge, Robert
AU - Hong, Joon P.
AU - Katsanos, Konstantinos
AU - Mills, Joseph L.
AU - Nikol, Sigrid
AU - Reekers, Jim
AU - Venermo, Maarit
AU - Zierler, R. Eugene
AU - Hinchliffe, Robert J.
AU - Schaper, Nicolaas C.
N1 - Funding Information:
We would like to thank the following external experts for their review of our PICOs for clinical relevance: Stephan Morbach (Germany), Heidi Corcoran (Hongkong), Vilma Urbančič (Slovenia), Rica Tanaka (Japan), Florian Dick (Switzerland), Taha Wassila (Egypt), Abdul Basit (Pakistan), Yamile Jubiz (Colombia), Sriram Narayanan (Singapore), Eduardo Alvarez (Cuba). We would like to thank Benjamin A. Lipsky (on behalf of the IWGDF editorial board) and Toby Richards (independent external expert) for their peer review of the manuscript. In addition, we thank Jack Brownrigg for his input into the previous version of this systematic review.
Funding Information:
Production of the 2019 IWGDF Guidelines was supported by unrestricted grants from: Molnlycke Healthcare, Acelity, ConvaTec, Urgo Medical, Edixomed, Klaveness, Reapplix, Podartis, Aurealis, SoftOx, Woundcare Circle, and Essity. These sponsors did not have any communication related to the systematic reviews of the literature or related to the guidelines with working group members during the writing of the guidelines, and have not seen any guideline or guideline‐related document before publication.
Publisher Copyright:
© 2020 John Wiley & Sons Ltd
PY - 2020/3
Y1 - 2020/3
N2 - In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30days, 10% vs 9% at 1 year and 13% vs 9% at 2years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2years and 47% (39-71%) at 5years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
AB - In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30days, 10% vs 9% at 1 year and 13% vs 9% at 2years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2years and 47% (39-71%) at 5years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
KW - amputation
KW - diabetes
KW - diabetic foot
KW - endovascular treatment
KW - foot ulcer
KW - mortality
KW - peripheral artery disease
KW - revascularisation
KW - vascular surgery
KW - PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY
KW - CRITICAL LIMB ISCHEMIA
KW - ENDOVASCULAR REVASCULARIZATION
KW - VEIN BYPASS
KW - LEG BASIL
KW - ANGIOSOME
KW - OUTCOMES
KW - PREDICTION
KW - SURGERY
U2 - 10.1002/dmrr.3279
DO - 10.1002/dmrr.3279
M3 - (Systematic) Review article
C2 - 32176439
SN - 1520-7552
VL - 36
JO - Diabetes-metabolism Research and Reviews
JF - Diabetes-metabolism Research and Reviews
IS - S1
ER -