This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.
VamosEPBottleAEdmondsMEValabhjiJMajeedAMillettC. Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care. 2010;33(12):2592–2597.
2.
PapanasNMaltezosEEdmondsM. Salvation of the diabetic foot: still a quest for the Holy Grail? Vasa. 2011;40(4):267–269.
3.
PapanasNLazaridesMK. Diabetic foot amputations in Greece: where do we go from here?Int J Low Extrem Wounds. 2011;10(1):4–5.
4.
PapanasNMaltezosE. The diabetic foot: a global threat and a huge challenge for Greece. Hippokratia. 2009;13(4):199–204.
5.
FagliaEClericiGClerissiJ. Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care. 2009;32(5):822–827.
6.
JudeEBEleftheriadouITentolourisN. Peripheral arterial disease in diabetes--a review. Diabet Med. 2010;27(1):4–14.
7.
FagliaEClericiGCaminitiM. Mortality after major amputation in diabetic patients with critical limb ischemia who did and did not undergo previous peripheral revascularization data of a cohort study of 564 consecutive diabetic patients. J Diabetes Complications. 2010;24(4):265–269.
8.
Consensus development conference on diabetic foot wound care. Diabetes Care. 1999;22(8):1354–1360.
9.
FagliaEDalla PaolaLClericiG. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg. 2005;29(6):620–627.
10.
FagliaEManteroMCaminitiM. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med. 2002;252(3):225–232.
11.
GerassimidisTKarkosCDKaramanosDKamparoudisA. Current endovascular management of the ischaemic diabetic foot. Hippokratia. 2008;12(2):67–73.
12.
GrazianiLSilvestroABertoneV. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg. 2007;33(4):453–460.
13.
TsuchiyaMSuzukiEEgawaK. Abnormal peripheral circulation in type 2 diabetic patients with normal ankle-brachial index associates with coronary atherosclerosis, large artery stiffness, and peripheral vascular resistance. Diabetes Res Clin Pract. 2005;70(3):253–262.
14.
TsuchiyaMSuzukiEEgawaK. Stiffness and impaired blood flow in lower-leg arteries are associated with severity of coronary artery calcification among asymptomatic type 2 diabetic patients. Diabetes Care. 2004;27(10):2409–2415.
15.
SuzukiEYoshimuraTOmuraY. Higher arterial stiffness, greater peripheral vascular resistance and lower blood flow in lower-leg arteries are associated with long-term hyperglycaemia in type 2 diabetic patients with normal ankle-brachial index. Diabetes Metab Res Rev. 2009;25(4):363–369.
16.
TimminsLHMeyerCAMorenoMRMooreJE. Effects of stent design and atherosclerotic plaque composition on arterial wall biomechanics. J Endovasc Ther. 2008;15(6):643–654.
17.
CarrozzaJPJrKuntzREFishmanRFBaimDS. Restenosis after arterial injury caused by coronary stenting in patients with diabetes mellitus. Ann Intern Med. 1993;118(5):344–349.
18.
NeubauerBGundersenHJ. Calcifications, narrowing and rugosities of the leg arteries in diabetic patients. Acta Radiol Diagn (Stockh). 1983;24(5):401–413.
19.
MacSweenRN. Diabetic angiopathy. Scott Med J. 1971;16(7):327–335.
20.
de HaasWH."Footnotes" on diabetes, with special reference to calcification of the metatarsal arteries. Folia Med Neerl. 1969;12(5):201–211.
21.
FagliaE. Characteristics of peripheral arterial disease and its relevance to the diabetic population. Int J Low Extrem Wounds. 2011;10(3):152–166.
22.
NorgrenLHiattWRDormandyJA. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(suppl S):S5–S67.
23.
CotroneoARIezziR. The role of "cutting" balloon angioplasty for the treatment of short femoral bifurcation steno-obstructive disease. Cardiovasc Intervent Radiol. 2010;33(5):921–928.
24.
DonasKPPitouliasGASchwindtA. Endovascular treatment of profunda femoris artery obstructive disease: nonsense or useful tool in selected cases?Eur J Vasc Endovasc Surg. 2010;39(3):308–313.
25.
DormandyJARutherfordRB.Management of peripheral arterial disease (PAD). TASC working group. Transatlantic inter-society consensus (TASC). J Vasc Surg. 2000;31(1 pt 2):S1–S296.
26.
LazarisAMTsiamisACFishwickGBoliaABellPR. Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia. J Endovasc Ther. 2004;11(4):447–453.
27.
GrayBHGrantAAKalbaughCA. The impact of isolated tibial disease on outcomes in the critical limb ischemic population. Ann Vasc Surg. 2010;24(8):349–359.
28.
WerneckCCLindsayTF. Tibial angioplasty for limb salvage in high-risk patients and cost analysis. Ann Vasc Surg. 2009;23(5):554–559.
29.
LazarisAMSalasCTsiamisAC. Factors affecting patency of subintimal infrainguinal angioplasty in patients with critical lower limb ischemia. Eur J Vasc Endovasc Surg. 2006;32(6):668–674.
30.
AdamDJBeardJDClevelandT. BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366(9501):1925–1934.
31.
BradburyAWAdamDJBellJ. BASIL trial Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(5 suppl):5S–17S.
32.
BradburyAWAdamDJBellJ. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: analysis of amputation free and overall survival by treatment received. J Vasc Surg. 2010;51(5 suppl):18S–31S.
33.
NolanBWDe MartinoRRStoneDH. Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass. J Vasc Surg. 2011;54(3):730–735.
34.
RomitiMAlbersMBrochado-NetoFCDurazzoAEPereiraCADe LucciaN. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008;47(5):975–981.
35.
FernandezNMcEnaneyRMaroneLK. Multilevel versus isolated endovascular tibial interventions for critical limb ischemia. J Vasc Surg. 2011;54(3):722–729.
36.
FernandezNMcEnaneyRMaroneLK. Predictors of failure and success of tibial interventions for critical limb ischemia. J Vasc Surg. 2010;52(4):834–842.
37.
SadekMEllozySHTurnbullICLooksteinRAMarinMLFariesPL. Improved outcomes are associated with multilevel endovascular intervention involving the tibial vessels compared with isolated tibial intervention. J Vasc Surg. 2009;49(3):638–643.
38.
JacqueminetSHartemann-HeurtierAIzzilloR. Percutaneous transluminal angioplasty in severe diabetic foot ischemia: outcomes and prognostic factors. Diabetes Metab. 2005;31(4 pt 1):370–375.
39.
HeringJAngelkortBKeckNWildeJAmannB. Long-term outcome of successful percutaneous transluminal angioplasty of the fibular artery in diabetic foot syndrome and single-vessel calf perfusion depends on doppler wave pattern at the forefoot. Vasa. 2010;39(1):67–75.
40.
PomposelliFBKansalNHamdanAD. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg. 2003;37(2):307–315.
41.
ZhuYQZhaoJGLiuF. Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia. J Endovasc Ther. 2009;16(5):604–612.
42.
SkoutasDPapanasNGeorgiadisGS. Risk factors for ipsilateral reamputation in patients with diabetic foot lesions. Int J Low Extrem Wounds. 2009;8(2):69–74.
43.
SchillingerMSabetiSDickP. Sustained benefit at 2 years of primary femoropopliteal stenting compared with balloon angioplasty with optional stenting. Circulation. 2007;115(21):2745–2749.
44.
KrankenbergHSchlüterMSteinkampHJ. Nitinol stent implantation versus percutaneous transluminal angioplasty in superficial femoral artery lesions up to 10 cm in length: the femoral artery stenting trial (FAST). Circulation. 2007;116(3):285–292.
45.
LairdJRKatzenBTScheinertD. RESILIENT Investigators. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the RESILIENT randomized trial. Circ Cardiovasc Interv. 2010;3(3):267–276.
46.
DudaSHBosiersMLammerJ. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial. J Endovasc Ther. 2006;13(6):701–710.
47.
DudaSHBosiersMLammerJ. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol. 2005;16(3):331–338.
48.
DonasKPTorselloGSchwindtASchönefeldEBoldtOPitouliasGA. Below knee bare nitinol stent placement in high-risk patients with critical limb ischemia is still durable after 24 months of follow-up. J Vasc Surg. 2010;52(2):356–361.
49.
DonasKPSchwindtASchönefeldTTessarekJTorselloG. Below-knee bare nitinol stent placement in high-risk patients with critical limb ischaemia and unlimited supragenicular inflow as treatment of choice. Eur J Vasc Endovasc Surg. 2009;37(6):688–693.
50.
FalkowskiAPoncyljuszWWilkGSzczerbo-TrojanowskaM. The evaluation of primary stenting of sirolimus-eluting versus bare-metal stents in the treatment of atherosclerotic lesions of crural arteries. Eur Radiol. 2009;19(4):966–974.
51.
KarnabatidisDSpiliopoulosSDiamantopoulosA. Primary everolimus-eluting stenting versus balloon angioplasty with bailout bare metal stenting of long infrapopliteal lesions for treatment of critical limb ischemia. J Endovasc Ther. 2011;18(1):1–12.
AlexandrescuVHubermontG. Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist?Diabetes Metab Syndr Obes. 2011;4:327–336.
55.
TaylorGIPalmerJH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113–141.
56.
TaylorGIPanWR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102(3):599–616.
57.
GeorgakarakosEKapoulasKKoukoumtzisDMantatzisMLazaridesMK. An uncommon clinical presentation of acute limb ischemia: underscoring the role of perigenicular collaterals. Vascular. 2012;20(3):174–177.
58.
AlexandrescuVAHubermontGPhilipsY. Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service. J Endovasc Ther. 2008;15(5):580–593.
59.
NevilleRFAttingerCEBulanEJDucicIThomassenMSidawyAN. Revascularization of a specific angiosome for limb salvage: does the target artery matter?Ann Vasc Surg. 2009;23(3):367–373.
60.
IidaONantoSUematsuM. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv. 2010;75(6):830–836.
61.
IidaOSogaYHiranoK. Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. Vasc Surg. 2012;55(2):363–370.
62.
AlexandrescuVHubermontGPhilipsY. Combined primary subintimal and endoluminal angioplasty for ischaemic inferior-limb ulcers in diabetic patients: 5-year practice in a multidisciplinary ‘diabetic-foot’ service. Eur J Vasc Endovasc Surg. 2009;37(4):448–456.
63.
AlexandrescuVVincentGAzdadK. A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty. J Endovasc Ther. 2011;18(3):376–387.
64.
SchneiderPACapsMTOgawaDYHaymanES. Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene. J Vasc Surg. 2001;33(5):955–962.
65.
ConteMS.Challenges of distal bypass surgery in patients with diabetes: patient selection, techniques, and outcomes. J Vasc Surg. 2010;52(3 suppl):96S–103S.
66.
PrompersLSchaperNApelqvistJ. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51(5):747–755.
67.
DeRubertisBGPierceMRyerEJTrocciolaSKentKCFariesPL. Reduced primary patency rate in diabetic patients after percutaneous intervention results from more frequent presentation with limb-threatening ischemia. J Vasc Surg. 2008;47(1):101–108.
68.
AwadSKarkosCDSerrachino-InglottF. The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia. Eur J Vasc Endovasc Surg. 2006;32(1):51–59.
69.
LazaridesMK. The impact of interventional management on healing of ischemic foot lesions. Int J Low Extrem Wounds. 2009;8(2):64–66.
70.
BradburyAWAdamDJBellJ. BASIL trial Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: a description of the severity and extent of disease using the Bollinger angiogram scoring method and the Trans Atlantic Inter-Society Consensus II classification. J Vasc Surg. 2010;51(5 suppl):32S–42S.
RogersLCAndrosGCaporussoJHarklessLBMillsJLSrArmstrongDG. Toe and flow: essential components and structure of the amputation prevention team. J Am Podiatr Med Assoc. 2010;100(5):342–348.
73.
JeffcoateWEdmondsMRaymanGShearmanCStuartLTurnerB; Putting Feet First Implementation Group. Putting feet first -- national guidance at last. Diabet Med. 2009;26(11):1081–1082.
74.
AzumaNUchidaHKokuboTKoyaAAkasakaNSasajimaT. Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?Eur J Vasc Endovasc Surg. 2012;43(3):322–328.
75.
PapanasNMaltezosEEdmondsM. St. Vincent declaration after 15 years or who cleft the devil's foot?Vasa. 2006;35(1):3–4.
76.
PapanasNMaltezosEEdmondsM. The diabetic foot: a plea for the elementary?Acta Diabetol. 2006;43(4):152–153.
77.
PapanasNMaltezosE. The diabetic foot: established and emerging treatments. Acta Clin Belg. 2007;62(4):230–238.
78.
NairDGSamsonR. Which diabetics are at risk for lower-extremity problems and what preventive measures can be taken?Semin Vasc Surg. 2008;21(3):154–159.
79.
ParaskevasKIBakerDMPompellaAMikhailidisDP. Does diabetes mellitus play a role in restenosis and patency rates following lower extremity peripheral arterial revascularization? A critical overview. Ann Vasc Surg. 2008;22(3):481–491.
80.
CheshireNJWolfeJHBarradasMAChamblerAWMikhailidisDP. Smoking and plasma fibrinogen, lipoprotein (a) and serotonin are markers for postoperative infrainguinal graft stenosis. Eur J Vasc Endovasc Surg. 1996;11(4):479–486.
81.
FatourouEMParaskevasKISeifalianAMHamiltonGMikhailidisDP. The role of established and emerging risk factors in peripheral vascular graft occlusion. Expert Opin Pharmacother. 2007;8(7):901–911.
82.
TiakaEKPapanasNManolakisACMaltezosE. The role of nerve growth factor in the prophylaxis and treatment of diabetic foot ulcers. Int J Burns Trauma. 2011;1(1):68–76.
83.
TiakaEKPapanasNManolakisACMaltezosE. The role of hyperbaric oxygen in the treatment of diabetic foot ulcers. Angiology. 2012;63(4):302–314.
84.
TiakaEKPapanasNManolakisACGeorgiadisGS. Epidermal growth factor in the treatment of diabetic foot ulcers: an update. Perspect Vasc Surg Endovasc Ther. 2012;24(1):37–44.
85.
ParaskevasKIWierzbickiASMikhailidisDP. Statins and noncardiac vascular disease. Curr Opin Cardiol. 2012;27(4):392–397.
86.
RoblessPMikhailidisDPStansbyGP.Cilostazol for peripheral arterial disease. Cochrane Database Syst Rev. 2008;(1):CD003748.
