Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review

Rachael O. Forsythe*, Jan Apelqvist, Edward J. Boyko, Robert Fitridge, Joon P. Hong, Konstantinos Katsanos, Joseph L. Mills, Sigrid Nikol, Jim Reekers, Maarit Venermo, R. Eugene Zierler, Robert J. Hinchliffe, Nicolaas C. Schaper

*Corresponding author for this work

Research output: Contribution to journal(Systematic) Review article peer-review

Abstract

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.

Original languageEnglish
Number of pages9
JournalDiabetes-metabolism Research and Reviews
Volume36
Issue numberS1
DOIs
Publication statusPublished - Mar 2020

Keywords

  • amputation
  • diabetes
  • diabetic foot
  • endovascular treatment
  • foot ulcer
  • mortality
  • peripheral artery disease
  • revascularisation
  • vascular surgery
  • PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY
  • CRITICAL LIMB ISCHEMIA
  • ENDOVASCULAR REVASCULARIZATION
  • VEIN BYPASS
  • LEG BASIL
  • ANGIOSOME
  • OUTCOMES
  • PREDICTION
  • SURGERY

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