Principles Of Arterial Reconstruction

Patients with diabetes at risk of lower limb amputation because of the presence of a peripheral vascular disease are a growing population because of the higher prevalence of diabetes and to the longer life expectancy of the general population. There is increasing evidence that distal arterial revascularization is effective in preventing major amputations in the population with diabetes (51). The indications for limb revascularization are disabling claudication (not common in patients with diabetes, as previously mentioned) and critical limb ischemia (rest pain or tissue loss), refractive to conservative therapy (52).

Bypass to the tibial or pedal vessels with autogenous veins is the longest experienced technique. In a series of more than 1000 dorsalis pedis bypasses, 5-year secondary potency and limb salvage rates were 62.7 and 78.2%, respectively (53). The increased use of this revascularization option showed to correlate with a decline in the incidence of all levels of amputations. Dorsalis pedis artery bypass can therefore be performed with a high rate of success and low morbidity and mortality, certainly equivalent to that achieved with other lower extremity grafts.

In addition to the traditional approach based on distal bypass surgery, it is gaining importance in terms of feasibility and effectiveness the less invasive approach by percutaneous trasnsluminal angioplasty. This technique allows to dilate also very distal arterial stenosis/obstructions, it can be repeated in case of failure and it allows to spare peripheral veins which might be used in other vascular districts (i.e., the coronary vascular bed) (54,55). In a recently published series of 933 patients with diabetes (mean follow-up 26 ± 15 months) in which this revascularization procedure has been used as a first choice, the 5 years primary patency was 88% (56). Therefore, percutaneous transluminal angioplasty as the first choice revascularisation procedure is feasible, safe, and effective for limb salvage in a high percentage of patients with diabetes.

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