Overcoming ischemia in the diabetic foot: Minimally invasive treatment options

Abstract

As the global burden of diabetes is rapidly increasing, the incidence of diabetic foot ulcers is continuously increasing as the mean age of the world population increases and the obesity epidemic advances. A significant percentage of diabetic foot ulcers are caused by mixed micro and macro-vascular dysfunction leading to impaired perfusion of foot tissue. Left untreated, chronic limb-threatening ischemia has a poor prognosis and is correlated with limb loss and increased mortality; prompt treatment is required. In this review, the diagnostic challenges in diabetic foot disease are discussed and available data on minimally invasive treatment options such as endovascular revascularization, stem cells, and gene therapy are examined.

Keywords: Critical limb ischemia; Diabetic foot; Endovascular revascularization techniques; Gene and stem cells delivery; Hyperbaric oxygen treatment; Peripheral artery disease.

Figure 1

Wound-directed revascularization. An 81-year-old female patient with long-standing type II diabetes and non-healing wound following minor amputation of the 3^rd, 4^th, and 5^th toe and respective metatarsals. A: Digital subtraction angiography (DSA) demonstrating patent anterior tibial and peroneal arteries, occlusion of the posterior tibial artery from its origin (red line with arrowheads), and significant stenosis of the distal below the ankle posterior tibial artery (red arrow), which supplies the area of the surgical wound. Note that wound healing was not satisfactory even though the anterior tibial artery was patent to the distal foot; B and C: Retrograde revascularization of the posterior tibial artery via the peroneal artery and balloon angioplasty followed by (C) antegrade balloon angioplasty of the below the ankle stenosis via the revascularized posterior tibial artery; D: Final DSA depicting excellent angiographic patency of the treated vessels; E: Complete wound healing noted at 3 mo follow-up.