Arterial revascularization in diabetic foot syndrome

Diabetic foot syndrome (DFS) is a complication of diabetes mellitus and the most common cause of major amputations in Germany. In addition to neuropathic alterations, arterial circulatory disorders also play a role which are predominantly due to peripheral arterial occlusive disease (PAOD) of the lower extremity arteries in approximately 50 % of DFS patients. The indications, strategy, techniques and results of endovascular and vascular surgical measures for improvement of the arterial perfusion in DFS are presented. This article is based on an assessment of the current literature and international evidence-based guidelines. All modern procedures of arterial reconstruction and the results are described. Particular emphasis is given to hybrid interventions which allow vascular surgeons to treat multilevel occlusions using a combination of endovascular and open surgical procedures. The advantage of combination interventions, i.e. revascularization with intraoperative angiography and optional percutaneous transluminal angioplasty (PTA), in combination with simultaneous d,bridement or minor amputation, is also described. Using multidisciplinary concepts, in which vascular surgeons, endovascular specialists and radiologists work together, an improvement in arterial perfusion can be achieved in approximately 90 % of the cases of DFS. The amputation rate in patients with DFS can be reduced by up to 80 %. The main cause of major amputations in DFS is PAOD. Endovascular and vascular surgical techniques should be considered as complementary and equivalent. The complexity of the arterial occlusion pattern and the length of the occlusion as well as the competence and technical facilities of the treating vascular specialist are the deciding factors as to whether an open surgical or endovascular approach is used. The vascular surgeon has the greatest treatment spectrum with hybrid interventions.