Diabetic foot : lower extremity arterial disease and limb salvage

380 Pages·2006·8.11 MB·English

by  Anton N. Sidawy MD

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DIABETIC FOOT
Lower Extremity Arterial
Disease and Limb Salvage
FIRST EDITION
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DIABETIC FOOT
Lower Extremity Arterial
Disease and Limb Salvage
FIRST EDITION
EDITOR
■■■■ ANTON N. SIDAWY, MD, MPH, FACS
Chief, Surgical Services
Veterans Affairs Medical Center
Professor of Surgery
George Washington and Georgetown Universities Medical Centers
Washington, District of Columbia
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First Edition
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Library of Congress Cataloging-in-Publication Data
Diabetic foot : lower extremity arterial disease and limb salvage / editor, Anton N. Sidawy.-- 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7817-6068-2
1. Foot--Blood-vessels--Diseases. 2. Foot--Surgery. 3. Diabetes--Complications.
4. Limb salvage. I. Sidawy, Anton N.
[DNLM: 1. Diabetic Foot. WK 835 D53517 2006]
RD563.D493 2006
617.5'85059--dc22
2005028208
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10 9 8 7 6 5 4 3 2 1
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To Mary, Michelle, and Nicholas
Their patience, support, and inspiration made this contribution possible.
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Contents
Preface ix 12 Nonatherosclerotic Disease of the
Foreword xi Tibial Vessels 135
Contributors xiii Eric D. Adams and Anton N. Sidawy
13 Abnormalities of Microcirculation in Diabetes 145
Christopher J. Abularrage, Anton N. Sidawy,
1 Overview of the Diabetic Foot and
Paul W. White, Jonathan M. Weiswasser,
Limb Salvage 1
and Subodh Arora
Cameron M. Akbari and Anton N. Sidawy
14 Infrapopliteal Arterial Imaging 155
2 Diabetic Neuropathy 11
Anil Hingorani and Enrico Ascher
Jonathan M. Weiswasser and Anton N. Sidawy
15 Embryology of the Arterial System to the
3 Biomechanical Impact on the Etiology and
Lower Extremities 167
Treatment of Neuropathic Ulcerations 19
Joseph Giordano
Charles J. Shuman, Ian H. Beiser, and
Janette Thompson 16 Surgical Approaches, Dissection,
and Control 171
4 Management of Diabetic Foot Ulcers 29
Jamal J. Hoballah and Christopher T. Bunch
David L. Steed
17 Choice of Inflow Vessel for Distal Arterial
5 Management Issues of Diabetes Mellitus and
Bypass 185
Their Effects on the Progression of Disease 37
Paul W. White, Anton N. Sidawy,
Eric S. Nylén
Christopher J. Abularrage,
6 Nonoperative Management of Diabetic Foot Jonathan M. Weiswasser, and Subodh Arora
Infections 43
18 Choice of Outflow Infragenicular Artery 193
Matthew C. Wakefield, Virginia L. Kan, Subodh Arora,
Joseph D. Raffetto and James O. Menzoian
Jonathan M. Weiswasser, and Anton N. Sidawy
19 Autogenous Venous Options and Preparation
7 Operative Management of Diabetic Foot Wounds
of Veins Using Angioscopy 201
and Infections: Maximizing Length and
Sherry D. Scovell and Frank W. LoGerfo
Optimizing Biomechanics 49
Christopher E. Attinger and Karen Kim Evans 20 Tibial Bypasses with Autogenous Tissue 209
R. Clement Darling, III, Benjamin B. Chang,
8 Angiosomes of the Foot and Angiosome-
and Sean P. Roddy
Dependent Healing 75
Christopher E. Attinger, Karen Kim Evans, 21 Distal Bypasses to Inframalleolar Vessels 219
and Ali Mesbahi Manju Kalra and Peter Gloviczki
9 Angiogenesis in Wound Healing 109 22 Prosthetic Infrapopliteal Bypasses 233
Albeir Y. Mousa, Peter Henderson, and K. Craig Kent Evan C. Lipsitz, Frank J. Veith, and Tejas R. Shah
10 The Diabetic Charcot Foot 117 23 Distal Arteriovenous Fistulas in Prosthetic
Robert G. Frykberg and Thomas Zgonis Distal Bypasses 245
Herbert Dardik and Theresa M. Impeduglia
11 Anatomic Distribution of Atherosclerotic Lesions
as Influenced by Diabetes and Other Risk 24 Vein Cuffs, Patches, and Boots in Prosthetic
Factors 129 Distal Bypasses 255
Kendra Magee Merine and Anton N. Sidawy Richard F. Neville
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viii Contents
25 Adjuvant Medical Therapy to Improve Patency 30 Surgical Repair of Vein Graft Stenoses 305
of Infrainguinal Bypasses 265 Michael L. Miller and Joseph L. Mills,Sr.
William Andrew Tierney and Samuel R. Money
31 Secondary Surgical Procedures for
Failed Bypasses 315
26 Infrainguinal Bypass in Patients with Renal
Gautam Shrikhande, Bernadette Aulivola,
Failure 271
and Frank Pomposelli
John C. Lantis, II and Michael S. Conte
32 Thrombolytic Therapy for Failed
27 InfrapoplitealBypass Following Proximal
Bypass Grafts 323
Angioplasty 281
Kenneth Ouriel
Christopher J. Abularrage, Jonathan M. Weiswasser,
Paul W. White, Subodh Arora, and Anton N. Sidawy 33 Percutaneous Transluminal Angioplasty for
Infrainguinal Bypass Grafts 333
28 Surveillance of Distal Bypasses 289 Sean D. O’Donnell, Charles J. Fox,
Gabor A. Winkler, Keith D. Calligaro, Kevin Doerr, Todd E. Rasmussen, and David L. Gillespie
Sandy McAffee-Bennett, and Matthew J. Dougherty
34 Lower Extremity Major Amputations 341
Marc E. Mitchell
29 Infrainguinal Catheter-based Endovascular
Interventions 295
Glenn M. LaMuraglia and Giuseppe R. Nigri Index 351
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Preface
The incidence and prevalence of diabetes mellitus con- While planning the strategy to improve arterial blood
tinue to rise. Over half of all lower extremity amputa- flow using reconstructive surgery or endovascular tech-
tions are performed in diabetics. The topic of the dia- niques, it is important to understand the distribution of
betic foot, including its prevention and management, peripheral arterial disease in these patients. Although the
is of paramount importance to individuals afflicted femoral-popliteal segment is the region most commonly
with this disease. Three factors converge in diabetics to affected, infragenicular occlusive disease in the anterior
form the “perfect storm” that leaves in its wake a foot tibial, posterior tibial, and peroneal arteries is the clas-
badly injured and infected, leading to major amputa- sic distribution in diabetics, and it is the disease most
tion if not appropriately managed. These factors are challenging to correct. It is not unusual to encounter
neuropathy that renders the foot insensate, compro- diabetic patients with ischemic foot lesions having a pal-
mised immunity that increases the propensity for infec- pable popliteal pulse with occlusive disease isolated to
tions, and ischemia due to arterial occlusive disease, the infragenicular arteries of the leg, sparing the arterial
particularly in the tibioperoneal distribution. Most system in the foot, which renders it amenable to suc-
books dealing with the diabetic foot dedicate only a cessful vascular reconstruction. Endovascular techniques
small part to the discussion and management of lower and bypasses to distal tibioperoneal and pedal arteries
extremity arterial disease in these patients. In contrast, are highly demanding, requiring skill and time to per-
while planning this book, I wanted to emphasize arte- form. Placement of femoral-to-tibial or popliteal-to-tib-
rial disease and its management while also addressing ial bypass is a meticulous procedure that distinguishes
other factors that play major roles in lower extremity the surgeon. All aspects of pathophysiology, anatomy,
complications of diabetes. diagnosis, and management of infragenicular disease
The chapters in this book could be organized in two need to be well understood for optimal patient care and
major groups: The first dealing with the diabetic foot are presented in detail in this text. Throughout this
proper, and the next section covering lower extremity book, various terms are used interchangeably to describe
arterial disease and its management in diabetics. the particular distribution of atherosclerotic disease that
However, instead of grouping the chapters as such, I involves the anterior tibial, posterior tibial, and peroneal
felt that their sequence should follow how physicians arteries sparing the pedal vessels; these terms are also
encounter patients with this disease and then proceed used interchangeably to describe bypasses that treat this
with its diagnosis and management. The book con- disease. These terms include: Tibial, tibioperoneal, dis-
cludes with the coverage of major leg amputations to tal, crural, infragenicular, and infrapopliteal.
emphasize that, in these patients, a major amputation It is my hope that this book will further the under-
should be a last-resort procedure. The impact of neu- standing of this disease and its management leading
ropathy and alterations in gait biomechanics on the to optimal limb salvage and functionality. This objec-
formation of foot wounds and Charcot foot seen in tive can only be attained through a multidisciplinary
diabetic patients independent of occlusive arterial dis- team approach that combines the efforts of not only
ease is detailed so that the importance of prevention vascular and reconstructive surgeons but other spe-
can be appreciated. Appropriate wound management cialists, as well. I would like to thank wholeheartedly
and closure techniques are of paramount importance the authors that contributed time and effort to this
to limb salvage. Medical and surgical control of foot project; they indeed represent the multidisciplinary
infections is important in preventing major amputa- approach required for optimal management of this dif-
tions and optimizing length and functionality of foot ficult problem.
amputations. Angiogenesis and the concept of angio-
somes and their role in healing foot lesions are dis- Anton N. Sidawy, MD, MPH, FACS
cussed in detail. Washington, D.C.
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