What Can I Do With a Patient With Diabetes and Critically Impaired Limb Perfusion Who Cannot Be Revascularized?

Abstract

A patient with limb-threatening diabetic foot syndrome in whom relevant peripheral arterial occlusive disease is proven should receive arterial revascularization as soon as possible to avoid major amputation. However, 3 conditions may make it impossible to effectively restore limb perfusion: the patient will not profit from arterial revascularization owing to excessive tissue loss or sepsis ("too late"), the patient cannot be revascularized due to severe comorbidities ("too sick"), and arterial reconstruction is impossible because of technical and anatomical shortcomings in a patient who is otherwise fit for operation ("nonreconstructible limb perfusion"). This review outlines the therapeutic options specifically in the third group of patients in whom no technical option for surgical or endovascular revascularization exists.

Limb salvage in diabetic patients with no-option critical limb ischemia: outcomes of a specialized center experience

“…Thirty-five percent of lesions were located proximal to the Lisfranc joint, and 56% showed gangrene. The median transcutaneous oxygen tension was 7 [3][4][5][6][7][8][9][10][11][12][13][14] mmHg. The angiography showed occlusion of all the arteries below the knee in 36 (43%) patients, while only five (6%) had no total occlusive disease below the knee.…”

“…However, revascularization is not always possible. The terms 'no-option' and 'non-reconstructable' CLI have been used for decades to identify those patients unsuitable for revascularization [12]. Today, thanks to the technological improvements especially for endovascular treatment, the percentage of patients not suitable for reperfusion has been decreasing and, as a consequence, the amputation-free survival of CLI patients is improving [13].…”

Lower-extremity amputations in people with and without diabetes in Germany, 2008–2012 – an analysis of more than 30 million inhabitants

“…Major amputations are performed in cases of excessive tissue loss or sepsis 26 or if there are no further surgical or endovascular options for revascularization. They reduce the quality of life considerably and entail high mortality.…”

Use of Integra Dermal Regeneration Template for Limb Salvage in Diabetic Patients With No-Option Critical Limb Ischemia

“…If the amputation takes place as complication of diabetes, morbidity and mortality rates are extremely high; a 5-year mortality rate after an amputation is higher than 45%. [1][2][3][5][6][7][8][9][10][11][12][13][14] In diabetic patients with critical limb ischemia (CLI), a successful revascularization (percutaneous transluminal angioplasty [PTA] or peripheral bypass grafts) reduces the major amputation rates. 11 In some cases, revascularization is not possible, so the term "no-option critical limb ischemia" was born.…”

“…These patients became a real challenge because of the high risk of major amputation and mortality rate they are carrying. [11][12][13][14][15][16] Today the percentage of patients experiencing a failure in lower limb revascularization has decreased, despite being still present. The management of these patients is very difficult, and frequently major amputation is considered the only therapeutic option available.…”