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Lower Extremity Arterial Reconstruction in Patients with Diabetes Mellitus: Principles of Treatment

  • Douglas W. Jones
  • Mark C. Wyers
Chapter
Part of the Contemporary Diabetes book series (CDI)

Abstract

In patients with peripheral arterial disease (PAD), optimizing the chances for successful revascularization requires careful consideration of several preoperative factors. PAD should be appropriately staged and any concurrent foot infection should be managed to obtain source control. Evaluation of fitness for revascularization can be assessed in a number of ways, focusing on frailty, cardiac disease, and renal insufficiency. Preoperative imaging may include CTA or MRA; however, diagnostic angiography is the most detailed, and is therefore essential in determining whether a patient is appropriate for any revascularization attempt. Angiography also guides the choice between open or endovascular approaches. The presence of an adequate autologous bypass conduit, determined by preoperative vein mapping, is also important in deciding which revascularization technique to pursue initially.

In the diabetic population, the infrapopliteal arteries are the most common site of occlusive disease. Endovascular techniques rely on crossing these areas and reopening them with balloon angioplasty. A successful procedure results in uninterrupted blood flow to the arteries of the foot. Balloon angioplasty alone is the standard modality of treatment in the infrapopliteal arteries. Bare metal stents, drug-coated balloons, and drug-eluting stents have been studied in this area, but despite promising results, they are not widely available.

Surgical bypass is most commonly performed for extensive, multilevel occlusive disease. Successful bypass requires a healthy inflow artery, a patent distal target artery with in-line flow to the foot, and a high-quality autogenous conduit (typically great saphenous vein). Arm vein bypass can also be performed with good outcomes. Prosthetic conduits are not typically used in bypass of infrapopliteal arteries as results are poor. The breadth of endovascular and surgical options for limb salvage in the diabetic patient has expanded to the point where treatment plans are highly individualized and combinations of techniques are common.

Keywords

Peripheral arterial disease Ischemic tissue loss Preoperative evaluation Diagnostic angiography Endovascular therapy Lower extremity bypass Balloon angioplasty Stents Bypass conduit Endovascular outcomes Surgical bypass outcomes 

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Vascular and Endovascular SurgeryBoston University School of Medicine, Boston Medical CenterBostonUSA
  2. 2.Division of Vascular and Endovascular SurgeryHarvard Medical School, Beth Israel Deaconess Medical CenterBostonUSA

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