ICGA provides rapid visual and quantitative information about regional foot perfusion. We believe this is the first report describing quantification of foot perfusion before and after lower extremity revascularization for severe limb ischemia. Further study is warranted to help define the utility of this intriguing new technology to assess perfusion, response to revascularization, and potentially, to predict likelihood of wound healing.

Preventing amputations in persons with lower extremity complications of diabetes is a complex endeavor, particularly in those with concomitant ischemia and tissue loss. Fluorescence angiography (Novadaq SPY system) may provide a tool for objective evaluations of tissue viability in the diabetic foot, which is an important indicator of the ability of the diabetic ulcer to heal adequately. The SPY system uses a low-power laser coupled with a charge-coupled device camera and indocyanine green (ICG) to sequence perfusion at the surface of the skin. We present an illustrated example of the potential utility of ICG fluorescence angiography (ICGFA) before and after vascular intervention in a high-risk limb. ICGFA appeared to reveal demarcation between viable and nonviable tissue and real-time perfusion, specifically capillary fill. ICGFA clarified the extent of necessary debridement and provided an immediate indication of improvement in regional perfusion status following revascularization. Future studies involving ICGFA may include pre- and postdebridement and closure perfusion, comparison of tissue perfusion pre- and post-endovascular therapy, and lower extremity flap viability. Future works will also address the consistency of results with ICGFA by analyzing a larger cohort of patients being treated by our unit.

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality and healthcare costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility, decreased moderate intensity exercise when compared to people with diabetes without ulcers. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year following healing and the majority occurs in the first three months following wound healing. Hence this period after ulceration is called "remission" due to this risk for re-ulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate offloading and monitoring in people with a recently healed foot ulcer, foot reconstruction or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring which can identify dangerous "hot spots" prone to recurrence. By understanding areas at risk, it empowers patients to maximize ulcer-free days and to enable an improved quality of life. There is a current absence of high-quality evidence and standardized clinical algorithms for the post-ulcerative period. This perspective outlines this institution's unified strategy to treat patients in the remission period after ulceration. This approach utilizes the available evidence, identifies patient preferences, and relies on good clinical judgement for the best long-term outcomes for this patient population. Hence this position statement aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patient to ensure a safe transition to footwear and return to activity.

Background: The development of subintimal angioplasty offers an endovascular approach to the treatment of long occlusions not suitable for conventional transluminal angioplasty; it remains, however, the remit of relatively few radiologists in specialist centres. The authors have adopted the technique in view of promising published results. Methods: Between May 1997 and July 2000, 50 patients had attempted subintimal angioplasty (median age 71 (interquartile range (i.q.r.) 61–80) years). Patients were divided into two groups by length of occlusion; 26 patients (group 1) had occlusions greater than 10 cm in length (iliac, one; superficial femory artery (SFA), 24; crural, one) and 24 patients (group 2) had occlusions of less than 10 cm (iliac, five; SFA, five; popliteal, nine; crural, five). The primary technical success rate, ankle: brachial pressure index (ABPI) before and after the procedure, complication rate and symptomatic improvement were recorded for both groups. Results: The groups were well matched for age and indication for intervention. Primary technical success was significantly better for occlusions of less than 10 cm than for the longer lesions (83 versus 50 per cent; P < 0·01) with corresponding significantly greater rises in ABPI (P < 0·05). Complications included one death in each group, one amputation in group 2 and six in group 1, all after failed salvage grafts. Group 1 (> 10 cm) Group 2 (< 10 cm) P Technical success13 of 2620 of 24>0·01*Median (i.q.r.) ABPI change0·135 (−0·07 to 0ë23)0·24 (0·145–0·355)0·046† Conclusion: Subintimal angioplasty gives excellent results for occlusions of less than 10 cm in length irrespective of arterial site. Results for longer lesions are poor, with failed subintimal angioplasty often precipitating urgent distal vascular reconstruction and associated high risk of major amputation. © 2001 British Journal of Surgery Society Ltd

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