Healing of Ischaemic Tissue Lesions after Infrainguinal Bypass Surgery for Critical Leg Ischaemia

Söderström, Mats; Arvela, E.; Albäck, Anders; Aho, Pekka-Sakari; Lepäntalo, Mauri

doi:10.1016/j.ejvs.2008.01.027

Cited by 49 publications

(42 citation statements)

References 21 publications

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“…The foot ulcer healing time reported in many studies varies widely depending on the patients' characteristics [30,31] and in particular were different for patients with neuropathic or ischaemic ulcers [16,32]. This is probably because in diabetic patients revascularisation can restore normal blood flow in the large vessels, including the pedal arteries, but cannot restore normal microvascular flow [33][34][35]. The fact that the post-revascularisation TcPO 2 in the Isc group was significantly higher than at baseline but remained significantly lower than the TcPO 2 in the Neu group confirms this interpretation.…”

Section: Discussionmentioning

confidence: 99%

Prospective study on microangiopathy in type 2 diabetic foot ulcer

et al. 2016

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Aims/hypothesis We investigated the significance of microangiopathy in the development of foot ulcer, which is still disputed. Methods We assessed microangiopathy by histological analysis of the capillary ultrastructure using transmission electron microscopy and capillary density and arteriolar morphology in paraffin-embedded sections from the skin of type 2 diabetic patients: 30 neuroischaemic patients (Isc) revascularised with peripheral angioplasty and 30 neuropathic patients (Neu) with foot ulcer, compared with ten non-diabetic volunteers. Results In the diabetic patients, capillaries in the dermal papillary layer were fewer (−22.2%, 159 ± 43 vs 205 ± 52 mm 2 in non-diabetic volunteers, p < 0.01). They also showed detrimental remodelling, with a 2.2-fold increase in capillary basement membrane thickness (3.44 ± 1.19 vs 1.53 ± 0.34 μm in non-diabetic volunteers, p < 0.001) and a 57.7% decrease in lumen area (14.6 ± 11.1 vs 34.7 ± 27.5 μm 2 , p < 0.001). No differences were observed between the diabetic Isc or Neu patients. Isc were more prone to develop arteriolar occlusion than Neu (16.8 ± 6.9% vs 6.7 ± 3.7%, respectively, p < 0.001).No patient had been amputated at 30 days and healing time was significantly longer in Isc (180 ± 120 vs 64 ± 50 days in Neu, p < 0.001). Conclusions/interpretation Capillary microangiopathy is present in equal measure in neuroischaemic and neuropathic diabetic foot skin. The predominance of arteriolar occlusions with neuroischaemia indicated the existence of an additional 'small vessel disease' that did not affect an effective revascularisation and did not worsen the prognosis of major amputations but slowed the healing process of the neuroischaemic foot ulcer. Trial registration: ClinicalTrials.gov NCT02610036.

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Section: Discussionmentioning

confidence: 99%

Prospective study on microangiopathy in type 2 diabetic foot ulcer

et al. 2016

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“…Patient loss to follow-up is common (13%-41%) in retrospective data and registry (17)(18)(19). In our small cohort, we managed to record complete data as we followed each patient at our outpatient clinic (multidisciplinary diabetic foot team) at least a year or until death.…”

Section: Discussionmentioning

confidence: 99%

“…the information regarding the probability of complete wound healing after surgical procedures in diabetic patients is limited (19). Hoffmann et al (22) systematically reviewed the literature and identified 1915 papers on revascularization in critical leg ischemia (cLI) with tissue lesions.…”

Section: Discussionmentioning

confidence: 99%

Successful foot salvage with microvascular flaps in diabetic patients

et al. 2014

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Background and Aims: Complex nontraumatic foot lesions often lead to major lower-limb amputation in diabetic patients. We aimed to evaluate outcome of free flap transfer in such cases. Materials and Methods: A total of 11 consecutive diabetic patients, hospitalized between 2007 and 2012 at a university central hospital for a free flap transfer, were followed until September 2013. Amputation-free survival, patient survival, and complete wound healing were defined as primary endpoints. Healing time of tissue lesions was analyzed. All pre- and postoperative data were retrospectively collected from hospital charts. Results: Complete tissue healing at 6 and 12 months after free flap transfer were 55% (6/11) and 82% (9/11), respectively. The median time to complete tissue healing was 123 days (range, 45–207 days). Overall limb salvage, survival, and amputation-free survival rates at 12 months were 90%, 91%, and 82%, respectively. The clinically important endpoint, namely, amputation-free survival with completely healed wounds, was attained in 9 of 11 patients at 1 year. Conclusion: Free tissue transfer enables successful wound healing and limb salvage rather than amputation in selected diabetic patients with difficult-to-heal wounds. Complete healing of tissue lesions is slow even after successful surgery. Preoperative assessment of the condition of patients is the key to success.

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“…Chronic kidney disease, tissue loss and coronary heart disease as well as impaired ambulatory status are predictors of poor outcome, especially after revascularization (26)(27)(28). Despite revascularization, ischaemic lesions have a tendency to heal slowly, especially in diabetics (29).…”

Section: The Problemmentioning

confidence: 99%

The Path from Art to Evidence in Treating Critical Limb Ischaemia — Reflections on 35 Years' Experience

Lepäntalo

2012

Scand J Surg

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despite numerous attempts, chronic critical limb ischaemia (cli) has not been unequivocally defined as yet. its epidemiology is poorly investigated and its prevalence probably higher than anticipated. it is accompanied by high mortality and morbidity irrespective of the way it is treated. its management is very expensive. additionally, the prevailing diabetes epidemic is increasing the need for revascularizations although there is a clear lack of evidence as to when to revascularize an ulcerated diabetic foot. The fast development of endovascular techniques blurs the vision as the window of opportunity for gathering proper evidence keeps narrowing. The notion of endovascular artistry prevails, but attempts to conduct proper studies with clear definitions, strict criteria and appropriate outcome measures in a standardised manner should continue -preferably using propensity scoring if randomised controlled trials are not possible.This review highlights some of the steps leading from art to evidence and illustrates the difficulties encountered along the path. in parallel with this overview, the progress of the treatment for cli in finland is described from the perspective of the work concluded at helsinki University central hospital.

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Healing of Ischaemic Tissue Lesions after Infrainguinal Bypass Surgery for Critical Leg Ischaemia

Abstract: Complete healing of ischemic tissue lesions is slow even after a successful infrainguinal bypass.

Cited by 49 publications

References 21 publications

Prospective study on microangiopathy in type 2 diabetic foot ulcer

Prospective study on microangiopathy in type 2 diabetic foot ulcer

Successful foot salvage with microvascular flaps in diabetic patients

The Path from Art to Evidence in Treating Critical Limb Ischaemia — Reflections on 35 Years' Experience

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