If an ulcer has not responded to optimum treatment within two weeks and ankle brachial pressure index is less than 0.5 and the Doppler waveform is damped, then angiography should ideally be carried out. Angiography can be performed by a Duplex examination, which combines the features of Doppler waveform analysis with ultrasound imaging to produce a picture of arterial flow dynamics and morphology. Alternatively, magnetic resonance angiography can be carried out. In contrast to conventional arteriography, this can be performed, without the need for intra-arterial catheter and potentially nephrotoxic contrast. Severe ischemia can also be confirmed by a transcutaneous oxygen on the dorsum of the foot of less than 30 mmHg or a toe pressure of less than 30 mmHg.
Angioplasty is a valuable treatment to improve arterial flow in the presence of ischemic ulcers and is indicated for the treatment of isolated or multiple stenoses as well as short segment occlusions less than 10 cm in length (60). Endovascular procedures have been shown to be feasible and successful in the tibial and peroneal arteries of the diabetic patient (61). and subintimal angioplasty has also been used to recanalize long arterial occlusions in the tibial arteries (62). Angioplasty must be applied early when tissue loss is not extensive and when arterial stenoses and occlusions are still suitable for this procedure (63). If lesions are too widespread for angioplasty, then arterial bypass may be considered. However, this is a major, sometimes lengthy, operation, not without risk, and is more commonly reserved to treat the foot with severe tissue destruction that cannot be managed without the restoration of pulsatile blood flow.
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