Distal bypass for ischaemic ulcer

A 62-year-old lady with type 1 diabetes of 12 years' duration wore tight shoes and developed an ulcer on the plantar surface of her forefoot after a nail penetrated her shoe. Despite regular podiatry, special shoes and antibiotics the ulcer failed to heal for 7 weeks and became larger (Fig. 4.20a). Her feet were pulseless and her pressure index was 0.4. She did not suffer from intermittent claudication or rest pain. Angiography showed a 10-cm occlusion of the superficial femoral artery and advanced disease of the proximal tibial arteries with reforming of the anterior tibial artery in the lower leg. She underwent femoral/anterior tibial bypass. The ulcer healed in 14 weeks (Fig. 4.20b).

Key points

• Patients with ischaemic ulceration which fails to heal or deteriorates should undergo angiography with a view to angioplasty or arterial bypass

• When angioplasty is not technically possible, arterial bypass should be considered if there is a suitable run-off vessel in the lower leg

• Intermittent claudication and rest pain are often absent in the severely ischaemic diabetic limb.

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