SidFMff.qxd 10/8/05 2:07 PM Page i DIABETIC FOOT Lower Extremity Arterial Disease and Limb Salvage FIRST EDITION SidFMff.qxd 10/8/05 2:07 PM Page ii SidaFMff.qxd 10/25/05 10:59 AM Page iii DIABETIC FOOT Lower Extremity Arterial Disease and Limb Salvage FIRST EDITION EDITOR ■■■■ ANTON N. SIDAWY, MD, MPH, FACS Chief, Surgical Services Veterans Affairs Medical Center Professor of Surgery George Washington and Georgetown Universities Medical Centers Washington, District of Columbia SidFMff.qxd 10/8/05 2:07 PM Page iv Acquisitions Editor:Brian Brown Managing Editor:Julia Seto Project Manager:Fran Gunning Manufacturing Manager:Ben Rivera Marketing Manager:Adam Glazer Design Coordinator: Terry Mallon Production Services:Laserwords Private Limited Printer:Edwards Brothers First Edition ©2006 by Lippincott Williams & Wilkins 530 Walnut Street Philadelphia, PA 19106 www.LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilizing by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Printed in the United States Library of Congress Cataloging-in-Publication Data Diabetic foot : lower extremity arterial disease and limb salvage / editor, Anton N. Sidawy.-- 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 0-7817-6068-2 1. Foot--Blood-vessels--Diseases. 2. Foot--Surgery. 3. Diabetes--Complications. 4. Limb salvage. I. Sidawy, Anton N. [DNLM: 1. Diabetic Foot. WK 835 D53517 2006] RD563.D493 2006 617.5'85059--dc22 2005028208 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. 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Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. 10 9 8 7 6 5 4 3 2 1 SidFMff.qxd 10/8/05 2:07 PM Page v To Mary, Michelle, and Nicholas Their patience, support, and inspiration made this contribution possible. SidFMff.qxd 10/8/05 2:07 PM Page vi SidFMff.qxd 10/8/05 2:07 PM Page vii Contents Preface ix 12 Nonatherosclerotic Disease of the Foreword xi Tibial Vessels 135 Contributors xiii Eric D. Adams and Anton N. Sidawy 13 Abnormalities of Microcirculation in Diabetes 145 Christopher J. Abularrage, Anton N. Sidawy, 1 Overview of the Diabetic Foot and Paul W. White, Jonathan M. Weiswasser, Limb Salvage 1 and Subodh Arora Cameron M. Akbari and Anton N. Sidawy 14 Infrapopliteal Arterial Imaging 155 2 Diabetic Neuropathy 11 Anil Hingorani and Enrico Ascher Jonathan M. Weiswasser and Anton N. Sidawy 15 Embryology of the Arterial System to the 3 Biomechanical Impact on the Etiology and Lower Extremities 167 Treatment of Neuropathic Ulcerations 19 Joseph Giordano Charles J. Shuman, Ian H. Beiser, and Janette Thompson 16 Surgical Approaches, Dissection, and Control 171 4 Management of Diabetic Foot Ulcers 29 Jamal J. Hoballah and Christopher T. Bunch David L. Steed 17 Choice of Inflow Vessel for Distal Arterial 5 Management Issues of Diabetes Mellitus and Bypass 185 Their Effects on the Progression of Disease 37 Paul W. White, Anton N. Sidawy, Eric S. Nylén Christopher J. Abularrage, 6 Nonoperative Management of Diabetic Foot Jonathan M. Weiswasser, and Subodh Arora Infections 43 18 Choice of Outflow Infragenicular Artery 193 Matthew C. Wakefield, Virginia L. Kan, Subodh Arora, Joseph D. Raffetto and James O. Menzoian Jonathan M. Weiswasser, and Anton N. Sidawy 19 Autogenous Venous Options and Preparation 7 Operative Management of Diabetic Foot Wounds of Veins Using Angioscopy 201 and Infections: Maximizing Length and Sherry D. Scovell and Frank W. LoGerfo Optimizing Biomechanics 49 Christopher E. Attinger and Karen Kim Evans 20 Tibial Bypasses with Autogenous Tissue 209 R. Clement Darling, III, Benjamin B. Chang, 8 Angiosomes of the Foot and Angiosome- and Sean P. Roddy Dependent Healing 75 Christopher E. Attinger, Karen Kim Evans, 21 Distal Bypasses to Inframalleolar Vessels 219 and Ali Mesbahi Manju Kalra and Peter Gloviczki 9 Angiogenesis in Wound Healing 109 22 Prosthetic Infrapopliteal Bypasses 233 Albeir Y. Mousa, Peter Henderson, and K. Craig Kent Evan C. Lipsitz, Frank J. Veith, and Tejas R. Shah 10 The Diabetic Charcot Foot 117 23 Distal Arteriovenous Fistulas in Prosthetic Robert G. Frykberg and Thomas Zgonis Distal Bypasses 245 Herbert Dardik and Theresa M. Impeduglia 11 Anatomic Distribution of Atherosclerotic Lesions as Influenced by Diabetes and Other Risk 24 Vein Cuffs, Patches, and Boots in Prosthetic Factors 129 Distal Bypasses 255 Kendra Magee Merine and Anton N. Sidawy Richard F. Neville SidFMff.qxd 10/8/05 2:07 PM Page viii viii Contents 25 Adjuvant Medical Therapy to Improve Patency 30 Surgical Repair of Vein Graft Stenoses 305 of Infrainguinal Bypasses 265 Michael L. Miller and Joseph L. Mills,Sr. William Andrew Tierney and Samuel R. Money 31 Secondary Surgical Procedures for Failed Bypasses 315 26 Infrainguinal Bypass in Patients with Renal Gautam Shrikhande, Bernadette Aulivola, Failure 271 and Frank Pomposelli John C. Lantis, II and Michael S. Conte 32 Thrombolytic Therapy for Failed 27 InfrapoplitealBypass Following Proximal Bypass Grafts 323 Angioplasty 281 Kenneth Ouriel Christopher J. Abularrage, Jonathan M. Weiswasser, Paul W. White, Subodh Arora, and Anton N. Sidawy 33 Percutaneous Transluminal Angioplasty for Infrainguinal Bypass Grafts 333 28 Surveillance of Distal Bypasses 289 Sean D. O’Donnell, Charles J. Fox, Gabor A. Winkler, Keith D. Calligaro, Kevin Doerr, Todd E. Rasmussen, and David L. Gillespie Sandy McAffee-Bennett, and Matthew J. Dougherty 34 Lower Extremity Major Amputations 341 Marc E. Mitchell 29 Infrainguinal Catheter-based Endovascular Interventions 295 Glenn M. LaMuraglia and Giuseppe R. Nigri Index 351 SidaFMff.qxd 10/24/05 10:58 AM Page ix Preface The incidence and prevalence of diabetes mellitus con- While planning the strategy to improve arterial blood tinue to rise. Over half of all lower extremity amputa- flow using reconstructive surgery or endovascular tech- tions are performed in diabetics. The topic of the dia- niques, it is important to understand the distribution of betic foot, including its prevention and management, peripheral arterial disease in these patients. Although the is of paramount importance to individuals afflicted femoral-popliteal segment is the region most commonly with this disease. Three factors converge in diabetics to affected, infragenicular occlusive disease in the anterior form the “perfect storm” that leaves in its wake a foot tibial, posterior tibial, and peroneal arteries is the clas- badly injured and infected, leading to major amputa- sic distribution in diabetics, and it is the disease most tion if not appropriately managed. These factors are challenging to correct. It is not unusual to encounter neuropathy that renders the foot insensate, compro- diabetic patients with ischemic foot lesions having a pal- mised immunity that increases the propensity for infec- pable popliteal pulse with occlusive disease isolated to tions, and ischemia due to arterial occlusive disease, the infragenicular arteries of the leg, sparing the arterial particularly in the tibioperoneal distribution. Most system in the foot, which renders it amenable to suc- books dealing with the diabetic foot dedicate only a cessful vascular reconstruction. Endovascular techniques small part to the discussion and management of lower and bypasses to distal tibioperoneal and pedal arteries extremity arterial disease in these patients. In contrast, are highly demanding, requiring skill and time to per- while planning this book, I wanted to emphasize arte- form. Placement of femoral-to-tibial or popliteal-to-tib- rial disease and its management while also addressing ial bypass is a meticulous procedure that distinguishes other factors that play major roles in lower extremity the surgeon. All aspects of pathophysiology, anatomy, complications of diabetes. diagnosis, and management of infragenicular disease The chapters in this book could be organized in two need to be well understood for optimal patient care and major groups: The first dealing with the diabetic foot are presented in detail in this text. Throughout this proper, and the next section covering lower extremity book, various terms are used interchangeably to describe arterial disease and its management in diabetics. the particular distribution of atherosclerotic disease that However, instead of grouping the chapters as such, I involves the anterior tibial, posterior tibial, and peroneal felt that their sequence should follow how physicians arteries sparing the pedal vessels; these terms are also encounter patients with this disease and then proceed used interchangeably to describe bypasses that treat this with its diagnosis and management. The book con- disease. These terms include: Tibial, tibioperoneal, dis- cludes with the coverage of major leg amputations to tal, crural, infragenicular, and infrapopliteal. emphasize that, in these patients, a major amputation It is my hope that this book will further the under- should be a last-resort procedure. The impact of neu- standing of this disease and its management leading ropathy and alterations in gait biomechanics on the to optimal limb salvage and functionality. This objec- formation of foot wounds and Charcot foot seen in tive can only be attained through a multidisciplinary diabetic patients independent of occlusive arterial dis- team approach that combines the efforts of not only ease is detailed so that the importance of prevention vascular and reconstructive surgeons but other spe- can be appreciated. Appropriate wound management cialists, as well. I would like to thank wholeheartedly and closure techniques are of paramount importance the authors that contributed time and effort to this to limb salvage. Medical and surgical control of foot project; they indeed represent the multidisciplinary infections is important in preventing major amputa- approach required for optimal management of this dif- tions and optimizing length and functionality of foot ficult problem. amputations. Angiogenesis and the concept of angio- somes and their role in healing foot lesions are dis- Anton N. Sidawy, MD, MPH, FACS cussed in detail. Washington, D.C. SidFMff.qxd 10/8/05 2:07 PM Page x