Diabetic foot: alternative techniques to amputation

A complication of Diabetes Mellitus can lead to diabetic foot. It affects patients with peripheral neuropathy or peripheral arterial disease (PAD). When an ulcer appears, alternatives prior to amputation should be considered.

Diabetic foot is a complication of Diabetes Mellitus and affects patients with Peripheral Neuropathy and/or Peripheral Arterial Disease (PAD). Some patients do not experience the first symptoms of the disease and when it manifests itself, it is already in the form of ulcers or necrotic tissue. This is when it should be properly evaluated to avoid amputation.

Experts in Angiology and Vascular Surgery only indicate primary amputation of the limb in the case of systemic infection with septic shock (severe infection resulting in dangerous arterial hypotension) or extensive irreversible necrosis of the entire foot. It should be clarified that amputation is a potentially disabling process, considered worldwide as a significant public health problem.

People with diabetes have a 20-40 times higher risk of amputation than people without diabetes. Together with diabetic retinopathy (an ocular complication of diabetes caused by a deterioration of the blood vessels supplying the retina), amputation of a lower limb can be used as an indicator of poor health outcome. In addition, minor or major amputation of the diabetic lower extremity, as well as the repercussions on quality of life, entails a considerable mortality risk: approximately 10% die perioperatively, 30% at the end of the first year, 50% after three years, and after five years, mortality rises to 70%.

Alternative techniques to amputation

Revascularization

The majority of cases in the Vascular Surgery Department are patients with PAD and ulcers who are evaluated for the need for revascularization (operative alternative prior to amputation) and the method of revascularization according to certain clinical criteria:

  • ulcer healing potential (reversible/irreversibility of the tissues)
  • the local condition of the foot and the residual functionality of the foot after healing
  • the vascular anatomy and the general condition of the patient
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There are also contraindications for revascularization, such as short life expectancy of less than three months, psychiatric disorders, knee retraction (chronic antalgic position), chronic “bedridden” and non-ambulatory patients.

Regarding the choice of revascularization method, percutaneous angioplasty (minimally invasive procedure performed under local anesthesia) is a feasible and technically effective method in patients with PAD. This technique reduces complications and increases the limb salvage range. In addition, although long-term patency remains higher with bypass, angioplasty is a method that can be repeated if restenosis or occlusions (coronary obstruction and narrowing) are present, and can even occur if bypass fails.

Endovascular techniques

It has been shown that, in patients at high surgical risk, critical ischemia can be successfully treated with endovascular techniques. The strategy has been shown to be well tolerated, with low mortality, lower costs and, above all, a shorter length of hospital stay. It is especially this last parameter that many studies highlight as the main cost-effectiveness difference between the two techniques, given that patients undergoing conventional surgery have longer length of stay, especially due to postoperative complications arising from the fact that they are patients with high co-morbidity.