Amputation-Free Survival in Patients With Diabetes Mellitus and Peripheral Arterial Disease With Heel Ulcer: Open Versus Endovascular Surgery

Abstract

Background: Heel ulcers in patients with diabetes mellitus (DM) and peripheral arterial disease (PAD) are hard to heal. The aim of the present study was to evaluate the difference in amputation-free survival (AFS) between open and endovascular revascularization in patients with DM, PAD, and heel ulcers. Methods: Retrospective comparative study of results of open versus endovascular surgery in patients with DM, PAD, and heel ulcer presented at the multidisciplinary diabetes foot clinic between 1983 and 2013. Results: Patients with heel ulcers were treated with endovascular intervention (n ¼ 97) and open vascular surgery (n ¼ 30). Kaplan-Meier analysis showed that the AFS was higher in patients undergoing open vascular surgery compared to the endovascular group (P ¼ .009). Multivariate analysis showed that open vascular surgery versus endovascular therapy (hazard ratio 2.1, 95% confidence interval 1.1-3.9; P ¼ .025) was an independent factor associated with higher AFS. The proportion of patients undergoing endovascular therapy in the former (1983-2000) time period was 47% compared to 89% in the latter (2001-2013) time period (P < .001). Conclusion: The AFS was higher after open than endovascular surgery among patients with DM and PAD with heel ulcer. These results suggest that open vascular surgery should be offered more often as opposed to current practice.

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers

“…In this study, we found approximately 20% of patients with heel ulcers, among the whole population, higher than in similar studies. 2-7,11,12 In our cohort of patients with heel ulcers, we reported 60% of healing without amputation, 20% major amputation, and 20% mortality without healing. The outcomes were significantly worse than for patients without heel ulcers, reinforcing the fact that wound location (specifically the heel) could be a variable influencing the possibility of limb salvage.…”

“…The rate of healing reported in previous scientific papers vary between different studies (from 50% to 90%), and in studies where healing time is considered, it is reported that the healing time was between 10 and 33 weeks. 3,7,12-16 The study groups are often not homogeneous due to the number of patients included and the characteristics of DFUs (neuropathic, ischemic, and neuroischemic), whereas our patient cohort consisted only of ischemic patients with several comorbidities that are very hard to manage.…”

“…Butt et al 7 specifically reported the outcomes of patients with ischemic DFUs and CLI comparing endovascular revascularization and open surgery. They found that amputation-free survival was higher in the group managed by open vascular surgery and that open surgery was independently associated with a higher rate of amputation-free survival.…”

“…6 In the case of ischemic DFUs, lower-limb revascularization is required to restore foot perfusion and promote wound healing. However, the best revascularization strategy (open surgery or endovascular approach) is not definitively established, even though Butt et al 7 have recently shown that open surgery is far superior in reducing long-term lower-limb amputations.…”

Diabetes mellitus: an important risk factor for peripheral vascular disease

“…Additionally, increased oxidative stress and endothelial dysfunction could also explain the high restenosis rates in diabetics undergoing percutaneous transluminal angioplasty [45]. Therefore, as DM contributes to restenosis after percutaneous transluminal interventions [46,47], management of PAD with surgical bypass could be considered more durable [10,48].…”