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A common complication of diabetes mellitus is the development of foot lesions due to ischemia (insufficient blood supply to the area). A common pattern in these patients is blood vessel occlusion in the leg below the knee, while the vessels in the foot are spared. Surgical treatment can be performed, usually by placing a bypass graft to the distal tibial or pedal arteries (arteries in the lower leg and foot, respectively). These bypasses may be constructed in various ways, obtaining inflowing blood from different types of grafts and various arterial sources (such as the common or superficial femoral in the thigh, or popliteal in the knee area). The graft vein may be in situ (anatomically left in place with the upper and lower ends of the vein segment joined to the arterial system); reversed vein technique (the vein is removed and reversed to disable the venous valves); or a non-reversed vein graft (the vein is removed, the valves cut, and the vein used as a nonreversed graft). There is no consensus regarding the best technique, and the best source of inflow has also been questioned. A review was undertaken of 146 patients (156 operations) to determine if the various techniques result in different outcomes. All patients had bypass to the dorsalis pedis artery in an effort to avoid leg amputation and 95 percent of the patients were diabetic. Source of inflow of arterial blood was the common femoral (58 legs), distal superficial femoral or popliteal (88 legs), tibia artery (3 legs), and previous bypass graft (7 legs). The most commonly used bypasses were in situ vein grafts (75 legs), and reversed or nonreversed grafts (62 legs). There were four deaths (2.7 percent), and within 30 days, seven grafts failed (4.5 percent). Follow-up averaged 18 months; actuarial patency was 87.1 percent, and limb salvage 91.6 percent. No significant difference was found between in situ and other types of grafts. No significant difference was found in inflow source, suggesting the practicality of using the more distant source because of its shorter length and lower risk of complications. It is suggested that no one technique be rigidly adhered to, but that the best procedure be selected for each situation. (Consumer Summary produced by Reliance Medical Information, Inc.)

Diabetic patients with ischemic disease of the lower leg (decreased blood supply to the leg, often characterized by pain) are not often considered to be candidates for vascular reconstruction surgery. Digital subtraction angiography (DSA) is a vascular imaging technique that has been used by the authors to improve visualization of the distal arteries of the feet and legs of such patients. As a result of this testing, a group of patients likely to benefit from vascular surgery can be identified. The results of a review of the medical records of 96 patients are presented. These patients had extensive disease of the tibial arteries of the lower leg, but the dorsal pedal artery (in the foot) was found to be open. Of this group, 94 percent had diabetes and underwent 97 bypass grafts, which were placed to the dorsal pedal artery. (In a bypass graft, a vein or prosthetic vascular material is grafted to an artery, so that blood flow bypasses a segment of a diseased artery.) All procedures were performed in order to save the limb from amputation. The most common indications for surgery were ischemic ulcer of the foot, secondary infection, pain at rest, and gangrene (death of tissue, usually due to ischemia, followed by bacterial invasion and subsequent decay). The patients (44) with secondary infection were treated with antibiotics prior to surgery. In 92 cases (88.5 percent of total cases) the dorsal pedal artery was visualized with DSA; 91 bypasses were performed. Of 12 cases in which the dorsal pedal artery could not be seen on DSA, but blood flow was audible on continuous wave Doppler (ultrasound) examination, bypass was successful in six cases. Two patients died within 30 days of surgery. However, at the time of hospital discharge, the feet of 89 patients were considered to have been saved. Eighteen months later, actuarial studies revealed graft patency (remaining open) to be 81.8 percent, limb salvage 86.9 percent, and patient survival 80 percent. To avoid overlooking the potential option of vascular reconstruction, especially for diabetic patients, it is recommended that an attempt always be made to visualize the blood vessels of the foot by means of angiography. (Consumer Summary produced by Reliance Medical Information, Inc.)

• In recent years, our operative approach to ulceration and gangrene in the diabetic foot has changed markedly. We now investigate all such patients for ischemia, even in the presence of neuropathy and localized infection. This strategy is based on a rejection of the concept of a microvascular occlusive lesion, an improved understanding of the pattern of atherosclerotic occlusion, an emphasis on arteriographic delineation of the foot arteries, and increasing success with extreme distal arterial reconstruction, especially vein bypass grafts to the dorsalis pedis artery. From 1984 through 1990, 2883 procedures were performed at our institution on patients with diabetes mellitus. There was a statistically significant decrease in every category of amputation, which correlated precisely with the increasing rate of dorsalis pedis artery bypass. Our indications for surgery, in-hospital mortality, and the bypass-associated amputation rate did not change.(Arch Surg. 1992;127:617-621)

• Ischemic foot ulceration in the diabetic patient is a source of great physical and emotional strain for the patient and represents a significant financial burden for the health care system responsible for the cost of such care. Limb salvage remains the primary therapeutic goal; yet, fiscal constraints imposed by diagnosis related group—based reimbursement systems require maximal cost efficiency in the care process. Between 1984 and 1990, the changes in our team management approach to this problem, emphasizing aggressive surgical revascularization of threatened limbs, have improved the quality of care and dramatically reduced the major and minor amputation rate. In the process, we have reduced the length of hospital stay and the overall cost of care. Despite this improvement in outcome and efficiency, Medicare reimbursement remains insufficient, with an average loss of $7480 per admission.(Arch Surg. 1993;128:576-581)

• We have previously shown that intraoperative angioscopy is a safe, useful, and effective method for monitoring infrainguinal bypass grafts. The videotaped recordings of the intraoperative angioscopy studies of 25 failed infrainguinal bypass grafts inserted between May 1987 and July 1989 and 3 failing grafts that were angioscoped during the subsequent graft salvage procedure were reviewed in a systematic fashion according to a fixed protocol, to identify any endovascular findings either initially missed or in which the relevance to graft failure had been unappreciated at the time of bypass grafting. We were able to identify new venous pathologic characteristics and highlight endoluminal features, of both a technical and nontechnical nature, which have a probable causal relationship to graft failure. However, the significance of some of the endovascular findings that were seen during infrainguinal bypass grafting has yet to be fully defined.(Arch Surg. 1990;125:749-755)

• The inability to see through blood remains the main obstacle to the widespread and routine use of angioscopy. Local irrigation with a balanced salt solution is presently the most widely used method to clear the blood. By applying basic principles of irrigation and using a unique, dedicated, irrigation pump, we found that routine angioscopy during lower extremity revascularization that yields consistent high-quality studies is feasible, clinically useful, and safe. Between May 1, 1987, and July 31, 1988, 136 intraoperative angioscopies were performed during 112 peripheral bypass procedures, 15 thrombectomies, 2 embolectomies, and 7 miscellaneous revascularization procedures. Mean total irrigation fluid used in the peripheral bypasses was 398 mL (range, 0 to 1400 mL). Good visual quality was obtained in more than 80% of angioscopies and the failure rate was only 1.8%. On the basis of the findings in 71 of the 136 angioscopies, 78 clinical or surgical decisions were made. No complications were directly attributable to the insertion of the angioscope or use of the pump.(Arch Surg. 1989;124:604-608)