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

  • Chapter
  • First Online:
The Diabetic Foot

Part of the book series: Contemporary Diabetes ((CDI))

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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.

Adapted from the prior edition by Bernadette Aulivola and Frank B. Pomposelli Jr.

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Authors and Affiliations

  1. Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA

    Douglas W. Jones MD

  2. Division of Vascular and Endovascular Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Mark C. Wyers MD

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  1. Douglas W. Jones MD
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  2. Mark C. Wyers MD
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Correspondence to Douglas W. Jones MD .

Editor information

Editors and Affiliations

  1. Rongxiang Xu, MD, Professor of Surgery, Harvard Medical School Director, The Rongxiang Xu, MD, Center for Regenerative Therapeutics Research Director, Joslin-Beth Israel Deaconess Foot Center Beth Israel Deaconess Medical Center, Boston, MA, USA

    Aristidis Veves

  2. Chief, Division of Podiatry, Beth Israel Deaconess Medical Center, Associate Professor of Surgery, Harvard Medical School, Co-director, Joslin-Bl Deaconess Diabetic Foot Center Consultant, Joslin Diabetes Center, Boston, MA, USA

    John M. Giurini

  3. Associate Professor of Surgery, Harvard Medical School, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Joslin Diabetes Center, Boston, MA, USA

    Raul J. Guzman

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Jones, D.W., Wyers, M.C. (2018). Lower Extremity Arterial Reconstruction in Patients with Diabetes Mellitus: Principles of Treatment. In: Veves, A., Giurini, J., Guzman, R. (eds) The Diabetic Foot. Contemporary Diabetes. Humana, Cham. https://doi.org/10.1007/978-3-319-89869-8_20

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