It has become Endovascular therapy (Balloon angioplasty) is the first treatment option for diabetic foot recently, as it is currently considered Latest diabetic foot treatment for the year 2023 in Türkiye Where this treatment helps to heal ulcers and reduce the possibility of amputation.
Diabetic foot ulceration (DFU) is recognized as one of the most serious complications of diabetes About 5% of all patients with type II diabetes will develop an arterial diabetic foot ulcer, about 70% diabetic lower leg amputations are performed and 85% of these operations are preceded by diabetesDiabetic foot ulcerTherefore, it is known that ulcer prevention is the best way to prevent amputation, but when ulcers are present, the main result to be achieved is the occurrence of ulcer healing. (1)
Causes of diabetic foot
Diabetic foot is a complex lesion caused by multiple factors. Tissue ischemia, peripheral neuropathy, and infection are the pathological basis of diabetic foot, and are usually combined. Peripheral neuropathy and tissue ischemia act as initiating factors in the pathogenesis, while infection is often secondary. (2)
Peripheral neuropathy in patients with diabetic foot
Diabetic peripheral neuropathy is common in clinical practice and often associated with vascular disease, and includes motor, sensory, and autonomic neuropathies. Sensory neuropathy in the early stages can lead to a defect in sensation, which increases the exposure of the foot to pressure, mechanical and thermal injuries, while motor neuropathy changes the biophysiology of the foot and leads to changes in its anatomical structure, which leads to deformation in it and limited movement of the joints. and changes in the endurance of the foot. (2)
Diabetic foot ulcers
With every increase of 1% in the concentration of hemoglobin in the blood, the risk of peripheral vascular disease increases by 25-28%, and according to the results of a European study, nearly half of diabetic foot cases arise from nerve ulcers - ischemic (neuropathy + ischemia) or ischemic (Ischemia), and ischemia is one of the most important factors that prevent the healing of ulcers, and therefore ischemia is the main cause of the diabetic foot that must be examined first unless there is conclusive evidence of it. (2)
Neuro-ischemic ulcers result from the synergistic effect of peripheral neuropathy and tissue ischemia, which reduces oxygen delivery to the tissues. Macrovascular disease and microvascular disorders impair circulatory flow in the diabetic foot. An important feature of diabetic macroangiopathy is that calcification of the arteries of the lower extremity causes a significant decrease in vascular elasticity. Clinically, it can be considered that neuro-ischemic ulcers and ischemic ulcers share the same etiological factors that require treatment of angioplasty (reopening of blocked blood vessels). (2)
Diabetic foot infections - Diabetic foot infections
Neuro-ischemic diabetic foot ulcers can become infected easily, but infections are rarely the cause of ulcers. In addition, the occurrence of infection is closely related to the possibility of resorting to amputation of the foot, especially in patients with peripheral vascular disease. Deep infections are characterized by osteomyelitis or soft tissue infection spreading along the length of the tendon, which is a direct factor associated with the possibility of amputation and death. Patient outcomes are related to the prevalence of infections and comorbidities and the presence or absence of peripheral vascular disease. (2)
Evaluation and grading of ulcers and infections
In cases of diabetic foot ulcers, the ulcer area, the depth of the affected tissues, associated infections, and tissue necrosis in general must be taken into account. Although there is no unified standard for evaluation, the Wagner classification is commonly used to evaluate these factors at the present time. Diabetic foot infections can be diagnosed based on signs and symptoms of local inflammation including discharge, local redness, swelling and heat, pain, systemic symptoms of fever, leukocytosis, and elevated erythrocyte sedimentation rate. The higher the concentration of CRP in the blood. (2)
Diabetic foot infections often occur secondary to ulcers and may not be associated with them. The extent and degree of infection are important factors affecting prognosis. The risk of amputation and death is often predicted by the presence of extensive infections and a significant systemic inflammatory response. (2)
What are the methods of treating diabetic foot in Türkiye?
There are four options for Diabetic foot gangrene treatment Conservative treatment, primary amputation, surgical vascular bypass, and vascular re-opening. The choice of any of these treatment options should be made by a multidisciplinary team. The choice between surgical and endovascular treatments is made based on the anatomy of the affected area, the patient's condition, and the team's expertise. Healer. (1)
Endovascular treatment (angioplasty) for the diabetic foot in Turkey
Endovascular treatment of neuro-ischaemic diabetic foot ulcers is mainly concentrated in the arteries below the knee. Ulcerations can sometimes appear in the iliac and femoral-poplite region in diabetic patients, but they are less common. For endovascular treatment, we must focus on the treatment of ulcers resulting from injury to the blood vessels below the knee. Diabetic foot ulcers are often long segmental lesions, while lesions resulting from atherosclerosis are often short. (1)
The treatment of long segmental diabetic foot ulcers (endovascular treatment) requires a specialized center with extensive experience because these types of treatments need personal experience. The treatment plan is designed according to the patient’s needs, his clinical condition and the possibilities of applying the treatment. The end point of the treatment plan is ulcer healing. Saving limbs at the same time. (1)
What are the indications of endovascular treatment of the diabetic foot?
Non-healing ulcers with or without infection and gangrene are the indications for percutaneous revascularisation. The inclusion is that the limb is still viable and that the treatment will contribute to the quality of life. A bedridden patient with dementia is therefore not a primary candidate for percutaneous revascularisation. (1)
The choice between percutaneous angioplasty (endovascular treatment) and open surgery is often a result of discussion with the treating team, as there are high risks of open surgery, lack of good venous material for the vessels, lack of surgical anastomosis clips or poor blood flow from the Additional reasons to choose percutaneous angioplasty (endovascular treatment) as a treatment solution.(1)
But currently, in many medical institutions, percutaneous angioplasty (endovascular treatment) is the first choice of treatment. Understanding that “time is the tissue” in patients with diabetes means that treatment of an infected diabetic foot ulcer should be treated as an emergency measure and preferably done within 24 hours.(1)
The method of performing endovascular treatment of the diabetic foot in Türkiye
Endovascular treatment of the leg such as percutaneous angioplasty are specialized techniques that should only be performed after extensive training and experience. This technique is applied by puncturing the skin retrogradely and should never be performed directly over the vascular bifurcations. (1)
For the arteries below the knee the simple balloon revascularization procedure should work well, and only in rare cases can the option of cannula (tube) implantation be considered when prolonged low pressure dilation does not result in good blood flow to the foot. Since the treatment does not aim to keep the blood vessels passable in the long term, cannula implantation should not be started as a treatment because it may prevent re-intervention on the blood vessels again if necessary, and the use of cannulas to treat diabetic foot ulcers is less preferable because diabetic foot lesions are often long. It is not focal compared to atherosclerosis. (1)
The current trend is to perform atherectomy followed by drug-treated balloon angioplasty, with cannula implantation performed only if there is adequate dissection or residual stenosis. Atherectomy can be performed using a laser, guided atherectomy, or rotary atherectomy as all these devices remove a certain amount of atherosclerotic plaque and modulate it, allowing for easy balloon angioplasty (opening of the vessel). (3)
Most atherectomy carries a potential risk of embolism, especially in long lesions, but a filter is recommended when treating long lesions even when used with devices that perform simultaneous aspiration and aspiration.(3)
Calcified blood vessels may impede the passage of the balloon catheter, impairing the angioplasty procedure. A small and short balloon of 2 x 40 mm size can be used to initially dilate difficult-to-pass arteries, followed by angioplasty using a balloon of a larger diameter equal to the size of the affected artery.(3)
The balloon must be pushed forward with a pricking motion because static friction has a greater stopping force than kinetic friction. Crossing narrowed, difficult-to-pass blood vessels requires firm support for the balloon. This can be achieved with a 4F longer than the outer 6-7F vascular sheath that is placed Axially, the balloon placed within the 4F vascular sheath will have strong support to cross the narrowed artery.(3)
Two wires can be placed side by side through the narrowed artery. A “swing balloon dilatation” with the leading edge of the balloon can help pass through the calcified portion of the artery. Other methods that can be used to manipulate the calcified portion to allow passage of the balloon include: Gradual dilatation using a low cross catheter Tapered Plane, Rotary Atherectomy, Laser Atherectomy, and Lithocutomy Device. (3)
Pickling is a technique that uses the posterior end of the wire to strike the calcified part in order to straighten the atherosclerosis. An external puncture with a needle can also straighten the atherosclerosis and allow a balloon to pass through it, thus resealing the blocked artery.(3)
Some calcified arterial atherosclerotic plaques can remain resistant to angioplasty despite the availability of plaque-modifying equipment and techniques, in which cases the plaque/vessel can be intentionally broken using a balloon-expandable covered cannula and secured with a SUPERA cannula once a suitable diameter has been reached.(3)
When to stop & fight another day?
Lower extremity arterial interventions can be complex procedures requiring many hours of surgery, termination of the procedure should be considered if the patient has discomfort under local anesthesia, the patient may move the discomfort and lead to angiography problems making the procedure very difficult.(3)
The angioplasty procedure may require the use of large volumes of contrast material which carries the risk of causing acute kidney injury. It is best to stage an arch-foot intervention as there are many anatomical differences that must be carefully considered before the procedure. Planning the intervention is not only about understanding the anatomy and where the artery is blocked, but may also require ensuring that appropriate equipment is available. Patients' medical comorbidities and how they affect the outcome must be factored into the decision-making process. Appropriate treatment goals must be clearly defined before the angioplasty procedure is initiated. (3)
Results of the latest diabetic foot treatment by angioplasty
Outcomes for both open surgery and endovascular treatment are reported broadly in the same way for diabetic foot ulcer healing and limb saving ranging from 78-85%. However, vascular patency following bypass surgery is better than endovascular treatment, but it is not a major issue because healing of diabetic foot ulcers and subsequent limb salvage almost always occurs within 6-9 months. (1)
There is usually no need for arterial patency beyond healing a diabetic foot ulcer because affected diabetic patients often do not experience pain at rest, and endovascular intervention usually has sufficient arterial patency to achieve the ultimate goal of healing a diabetic foot ulcer, which is why reports of Limb salvage after vascular treatment speaks of a higher 20% percentage than actual vascular patency, so angioplasty in acute ischemic foot is referred to as 'temporary' bypass. (1)
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- JA Reekers and J. Lammer. Diabetic foot and PAD: the endovascular approach. Diabetes Metab Res Rev 2012; 28: 36-39.
- Li M. Guidelines and standards for comprehensive clinical diagnosis and interventional treatment for diabetic foot in China. Journal of Interventional Medicine 2021; 4: 117-129.
- Wong TY Endovascular treatment of diabetic foot ischemic ulcer - Technical review. Journal of Interventional Medicine 2020; 3: 17-26.