Diagnostic and therapeutic arterial interventions in the ulcerated diabetic foot.

Whether diabetic foot ulcerations arise from an amalgam of neuro-ischemic factors or because of arterial occlusive disease alone, the arterial circulation must be thoroughly evaluated. Clinical evaluation is foremost, but numerous non-invasive diagnostic options such as duplex ultrasonography and MRA are often enlisted. Contrast arteriography remains unrivaled for delineating the causative occlusive lesions and the possibilities for arterial reconstruction. The principal revascularizations, in our experience, are (1) pedal bypass with autogenous conduits and (2) iliacafemoral endarterectomy. Nearly all diabetic patients (>90%) and a majority of diabetic patients on hemodialysis are candidates for arterial reconstruction, with a resulting three-year limb-salvage rate of 85 to 90%. No matter how good the foot care and the off-loading is, the arterial lesion(s) (5) must be repaired in the overwhelming majority of patients to achieve sustained healing. Unfortunately the five-year survival of these diabetic patients is usually <50%.