Diabetic Foot Revascularization

Foot problems are a common complication in diabetic patients. Early detection and proper treatment are essential to avoid any poor outcomes such as amputation. One treatment option for diabetic foot is surgery to restore blood flow (revascularization), which can help to save the patient’s limb.

What is Diabetic Foot?

Diabetic foot is caused by poor blood flow and nerve damage in the limbs. Chronic Diabetes can cause Peripheral Arterial occlusive disease which results in claudication pain or ischemic rest pain in legs and the feet with diabetic foot ulcers. Diabetic patients with impaired sensation are unable to feel pain when they have cuts or blisters. In addition, diabetic patients also have impaired blood flow which further delays healing.

The blisters or sores that develop on foot in diabetic patients are called diabetic foot ulcers. The aim of treatment for diabetic foot is to hasten the process of healing of the ulcers and to prevent the ulcers from the becoming more extensive and deeper. If the damage to the foot is extensive, the surgeon may need to amputate the limb or a part of it.

Signs and symptoms of diabetic foot ulcers

If you are a diabetic and feel numbness in your leg, you must regularly inspect your foot for the following changes :

• Cuts, blisters or sores
• Swelling
• Redness
• Pain
• Pus discharge
• Foul smell

If you observe any of the above symptoms on your feet, inform your healthcare provider immediately.

Stages of Diabetic foot ulcers

Diabetic foot ulcers are clinically classified based on Wagner’s foot ulcer classification system which is as follows:

Management of diabetic foot

Until grade 0 to 3, the ulcers can be treated by medical procedures. Above this stage, the wounds become fatal and are less likely to heal. In the last two stages, there are only two options to stop the infection from spreading: revascularization or amputation.

• Amputation: The surgical removal of gangrene is done by removing/cutting off a toe, a limb or a part of the limb. Amputation is necessary if the patient has developed gangrene because gangrenous tissue is dead and is no longer capable of responding to medications. Diabetic foot wounds are responsible for 5–10% of the cases of major or minor amputations.
• Revascularization: Revascularisation is a procedure that restores the blood flow in blocked arteries or veins. Early revascularization can avoid limb amputation for the patient.

Other surgeries that may be needed for diabetic foot are reconstructive foot surgery and other surgeries for soft tissue coverage. In some patients, the bony architecture of their foot may need repair and in some, plastic surgery might be needed to repair the soft tissue of the infected foot area.

Revascularization techniques

After assessing the type and extent of vascular damage, your surgeon may recommend one of the following revascularisation techniques:

• Angioplasty with or without stenting
• Surgical bypass
• Or hybrid procedures combining the two

Angioplasty:

Angioplasty is a procedure to improve blood flow of the arteries that have become narrow or blocked. In most patients, a tiny tube (stent) is placed in the blocked vessel which help to keep the blocked vessels open.

This procedure is usually done under local anaesthesia. Before the surgery, a contrast dye is injected in the blood vessel in your groin which helps to visualise the blood flow and the narrowing in the lower limb blood vessel.

During the surgery, the surgeon would insert a thin flexible tube called a catheter through a needle into a blood vessel in the groin. The tip of the catheter has a small balloon. The catheter is inserted till it reaches the site of blockage. Once the balloon reaches the blockage, it is inflated, and this opens the blood vessels at the site of blockage. Usually, the surgeon places a stent (a small cylindrical mesh) in the blocked blood vessel to keep it open and wide to maintain normal blood flow.

Bypass surgery

This is a surgery in which the flow of the blood is rerouted around a blocked vessel in the limb using a graft. This graft could be a section of a healthy vein of the patient or a man-made graft material.

Before the surgery, you would be given general or spinal anaesthesia. During the procedure, your surgeon would make an incision in the leg around the area of the blocked blood vessels. Next, the artery with the blockage is accessed. A graft is sewn above and below the blocked section of the artery. Once the blood starts flowing through the graft, normal blood flow to the limb is restored.

Prevention of Diabetic foot

If you are a diabetic, whether you have a diabetic foot or not, it is important to take good care of your feet to prevent diabetic foot. Following are some tips:

• Check your feet every day for any cuts or wounds
• Practice to wash your feet everyday with soap and water
• Wear well-fitting footwear
• Trim your toenails regularly
• Protect your feet from heat and cold by applying sunscreen and wearing warm socks accordingly
• Make sure to get your feet checked at your health care visits

Prof Dr S Balakumar

M.S. (General Surgery), M.CH (Vascular Surgery)

Department of Vascular & Endovascular Surgery

Clinical lead and Senior Consult - Vascular Surgeon & Endovascular Surgery