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Diabetic and ischemic foot ulcers are difficult to heal, and the mastering of numerous treatment methods is imperative to achieve healing. One of these methods is the fillet toe flap used to cover specific diabetic wounds of the forefoot associated with toe osteomyelitis. Instead of amputating the infected toe, phalanges are removed while keeping the viable surrounding soft tissue.A systematic review was performed searching electronic databases up to October 2019 to identify relevant articles reporting the outcomes of the fillet flap in forefoot ulcers of patients with diabetes or peripheral artery disease. All study designs were included. The healing rate was the primary outcome. Secondary outcomes were the time to heal, ulcer recurrence, and complication rates of such infection, partial necrosis, and total necrosis.The 8 studies that met the inclusion criteria were all case series or case reports, with a total of 28 patients including 29 flaps. The mean healing rate was 92.8% (2/29); in both cases, total necrosis was due to infection (7.2%). No ulcer recurrence or partial necrosis was noted.Though having limited indications, the fillet flap illustrates the full optimization of the available resources for wound coverage. The consistent presence of an axial vessel makes the fillet flap a reliable local flap to be used in specific circumstances where the loss of a toe is unavoidable. Further research is needed with large prospective controlled trials to support the findings of the review.Les ulcères diabétiques et ischémiques du pied sont difficiles à guérir. Il est impératif de maîtriser de multiples méthodes thérapeutiques pour qu’ils cicatrisent. Le lambeau en filet de l’orteil, utilisé pour couvrir des plaies diabétiques précises de l’avant-pied associées à l’ostéomyélite de l’orteil, fait partie de ces méthodes. Au lieu d’amputer l’orteil infecté, les phalanges sont retirées, mais les tissus mous viables avoisinants sont conservés.Les chercheurs ont effectué une analyse systématique des bases de données électroniques jusqu’en octobre 2019 pour extraire les articles appropriés sur les résultats des lambeaux en filet pour les ulcères de l’avant-pied des patients atteints du diabète ou d’une maladie artérielle périphérique. Toutes les méthodologies d’étude étaient incluses. Le taux de guérison était le résultat clinique primaire, et le temps de guérison, la récurrence des ulcères, le taux de complications de cette infection et, la nécrose partielle et totale, les résultats cliniques secondaires.Les huit études qui respectaient les critères d’inclusion étaient toutes des séries ou des rapports de cas, pour un total de 28 patients qui avaient reçu 29 lambeaux. Le taux de guérison moyen s’élevait à 92,8 % (deux sur 29). Dans les deux cas, la nécrose totale était causée par l’infection (7,2 %). Aucune récurrence d’ulcère ni nécrose partielle n’a été observée.Même si les indications sont limitées, le lambeau en filet fait appel à l’optimisation totale des ressources disponibles pour couvrir les plaies. Grâce à la présence continue d’un vaisseau axial, le lambeau en filet est un lambeau local fiable à utiliser dans des situations particulières, lorsqu’il est impossible d’éviter de perdre un orteil. Il faudra réaliser la présence d’importants essais prospectifs contrôlés pour soutenir les observations de l’analyse.

This article is a technical review of the common techniques used in the treatment of lower-limb occlusive arterial disease associated with diabetes. The techniques described here reflect the author’s own practice and are methods that the author finds helpful in avoiding complications and in making the technical aspects of the procedures easier. Keywords: Diabetes, Foot ulcer, Ischemia, Endovascular treatment, Angioplasty, Stenting, Retrograde access, Subintimal, Intraluminal, Pedal arch, Perfusion

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Цель. Определение морфологических особенностей кожных ран стопы пациентов с нейроишемической формой синдрома диабетической стопы (СДС) с целью оптимизации тактики и методов хирургического лечения. Материал и методы. Произведено морфологическое исследование мягких тканей стопы 12 пациентов с гнойно-некротическими осложнениями нейроишемической формы СДС с использованием гистологических, гистохимических и морфометрических методик. Пациенты были разделены на 2 клинические группы. Первую группу составили 6 пациентов, у которых согласно клиническим, анамнестическим и инструментальным методам исследования преобладали ишемические изменения. Вторая группа 6 пациентов, у которых преобладали нейропатические изменения в тканях. Результаты. Выявлена неоднородность клинических, инструментальных и морфологических данных у пациентов с гнойно-некротическими осложнениями нейроишемической формы СДС. В наблюдениях первой группы трофические нарушения в стопе клинически представлены сухой гангреной. Морфологически выражены тяжелые циркуляторные расстройства, утолщение стенок артериол и капилляров с сужением их просвета. Изменения периферических нервных стволиков характеризовались либо слабо выраженной демиелинизацией, либо отсутствием признаков разрушения миелина. Во второй группе трофические нарушения в стопе клинически представлены инфицированными ранами, остеомиелитом, флегмоной мягких тканей. Гистологически определялся обширный некроз с наложениями фибрина и гнойного экссудата. Выявлено также уменьшение количества сосудов, утолщение их стенки и сужение просвета. Изменения периферических нервных стволиков характеризовались разрушением миелина вплоть до тотальной демиелинизации и полной дегенерации осевых цилиндров, местами наблюдалось полное выпадение нервных волокон. Заключение. Проведенное исследование позволило при схожести сосудистых нарушений (макрои микроангиопатия) в обеих клинических группах убедительно показать морфологические различия при преобладании ишемического или нейропатического компонента в нейроишемической форме СДС. Выявленные клинико-морфологические особенности проявлений нейроишемической формы СДС доказывают необходимость индивидуального похода к лечению пациентов с учетом преобладания тех или иных морфологических изменений.

A patient with ischemic ulcer in the foot underwent femoral to peroneal in situ bypass with severe calcific occlusive disease using tourniquet occlusion. Postoperative arteriogram showed patent bypass with small residual arteriovenous fistula with faint filling of the deep vein. Management of residual arteriovenous fistula is described.

Background and Aims: Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. Material and Methods: This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V–VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days–183 months). Results: Limb salvage was at 30 days—92%, at 1 year—91%, and at 5 and 10 years—86%. Survival and amputation-free survival were at 30 days—93% and 86%, at 1 year—80% and 76%, at 5 years—51% and 48%, and at 10 years—21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days—97%, at 1 year—88%, at 5 years—72%, and at 10 years—66%. Conclusion: Hybrid outflow revascularization is an important tool in the vascular surgeon’s armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

RESUMEN: Exposición de un caso clínico de un varón de 69 años que presentaba una dehiscencia de unos 5 cm tras una amputación transmetatarsiana debido a rechazo de un injerto cutáneo al sufrir una quemadura de tercer grado. Se realizó desbridamiento cortante de tejido desvitalizado y curas en ambiente húmedo con apósitos de hidrofibra con iones de plata; posteriormente, se realiza implantación de terapia de presión negativa hasta conseguir el tejido de granulación a nivel de piel. Finalmente, se utilizaron apósitos liofilizados de colágeno (Epiona®) para una completa cicatrización y epitelización. Se prescribe zapato ortopédico, ortesis con relleno de la zona amputada e hidratación. DEHISCENCE IN DIABETIC FOOT AFTER TRANSMETATARSAL AMPUTATION ABSTRACT:Exposure of a clinical case of a 69-year-old man who presented a dehiscence of about 5 cm after a transmetatarian amputation due to rejection of a skin graft when suffering a third degree burn. Cutting debridement of devitalized tissue and cures in humid environment were performed with hydrofiber dressings with silver ions; subsequently, negative pressure therapy is im-planted until the granulation tissue is obtained at the skin level. Finally, lyophilized collagen dressings (Epiona®) were used for complete healing and epithelization. Prescribed orthopedic shoe, orthosis with filling of the amputated area and hydration.

Objective A multidisciplinary approach is required to treat critical limb ischemia. We determined the poor prognostic factors of ischemic ulcer healing after optimal arterial revascularization, and assessed the efficacy of the medication therapy using cilostazol, which is a selective inhibitor of phosphodiesterase 3. Methods In this retrospective, single-center, cohort study, 129 limbs that underwent infrainguinal arterial revascularization for Rutherford class 5 critical limb ischemia were reviewed. The primary end point was the ulcer healing time after arterial revascularization. The secondary end point was the amputation-free survival rate. Results Of the 129 limbs, endovascular therapy was performed in 69 limbs, and surgical reconstructive procedures were performed in 60 limbs for initial therapy. Complete ulcer healing was achieved in 95 limbs (74%). The median ulcer healing time was 90 days. In multivariate analysis, no cilostazol use significantly inhibited ulcer healing ( p = 0.0114). A white blood cell count >10,000 ( p = 0.0185), a major defect after debridement ( p = 0.0215), and endovascular therapy ( p = 0.0308) were significant poor prognostic factors for ulcer healing. Additionally, ischemic heart disease ( p Conclusions Ulcer healing within 90 days after arterial revascularization is impaired by no cilostazol use, a white blood cell count >10,000, a major defect after debridement, and endovascular therapy. Furthermore, cilostazol improves amputation-free survival rate in patients with critical limb ischemia.

Chronic wound is associated with many health comorbidities. It is essential for the clinicians to understand factors that contribute to its development and the delayed healing. Effective healing requires wound bed preparation, wound debridement, use of appropriate dressing materials, and, for some, the use of various modalities such as ultrasound, negative pressure wound therapy, and electrical stimulation.

Objective: This study aimed to assess risk factors for developing marginal ulcer (MU) after gastric bypass (GBP) surgery for obesity. Background: MU is a common and potentially serious complication of GBP surgery, little is known about its etiology. Methods: This population-based cohort study of GBP in 2006-2011 evaluated MU in relation to diabetes, hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD), ulcer history, use of proton pump inhibitors (PPIs), aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs). Multivariable Cox proportional hazard regression models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for confounding. Results: Among 20,294 GBP patients, diabetes and peptic ulcer history entailed statistically significantly increased risk of MU (HR = 1.26, 95% CI 1.03-1.55 and HR = 2.70, 95% CI 1.81-4.03), although hyperlipidemia, hypertension, and COPD did not. PPI users had an increased HR of MU (HR = 1.37, 95% CI 1.17-1.60). Aspirin and NSAID consumption less than or equal to median entailed decreased HRs of MU (HR = 0.56, 95% CI 0.37-0.86 and HR = 0.30, 95% CI 0.24-0.38), although aspirin and NSAID users more than median had an increased risk and no association with MU, respectively (HR = 1.90, 95% CI 1.41-2.58 and HR = 0.90, 95% CI 0.76-1.87). The use of SSRI less than or equal to median had a decreased risk of MU (HR = 0.50, 95% CI 0.37-0.67), although use more than median entailed increased HR (HR = 1.26, 95% CI 1.01-1.56). Conclusions: Diabetes and peptic ulcer history seem to be risk factors for MU, but not hyperlipidemia, hypertension, or COPD. Limited doses of aspirin, NSAIDs, and SSRIs might not increase the risk, although higher doses of aspirin do. The association with PPI could be due to confounding by indication.

2010年8月、洛和会音羽病院に創傷治癒センターが設立された。本センターにおける下肢慢性創傷の診断、治療、予防に対する基本的な考え方を概説する。人口の高齢化、メタボリックシンドロームの増加に伴い、難治性の下肢創傷患者が増加している。足病医のいない日本ではこれらに単一の診療科が対応するのは困難であり、チーム医療の核となる慢性創傷治療専門のセンターが期待されている。下肢慢性創傷の多くは以下の3疾患に分類される。即ち、1)虚血性潰瘍、2)糖尿病性潰瘍、3)静脈性潰瘍、である。それぞれが異なる病態であり、いずれも再発率は高い。治療効果を上げるためには正確な診断と適切な予防プログラムが必要である。(著者抄録)

Objectives: Analyze the influence of the collateral distal vessels on ischemic ulcer healing and limb salvage after successful distal procedures, according to an angiosome model. Methods: Retrospective analysis of 76 ischemic ulcers revascularized by surgical (n = 41) and endovascular (n = 35) distal procedures. All interventions were primary procedures with single outflow vessel that remained patent during follow-up. Ulcers were classified according to an angiography angiosome study as ‘‘direct revascularization’’ ([DR] n = 45), ‘‘indirect revascularization’’ ([IR] n = 31), and IR ‘‘through collaterals’’ ([IRc] n = 18). Healing rates and limb salvage were compared according to the type of revascularization. Results: Ulcer healing rate at 12 months was higher in DR than in IR (92% vs 73%, P = .008) but similar to IRc (92% vs 85%). Limb salvage at 24 months was higher in DR than in IR (93% vs 72%, P = .02) but similar to IRc (93% vs 88%). Conclusion: Ulcer blood flow restoration through collateral vessels may give similar results to those obtained through its specific source artery.

Objective: We investigated the effect of immersion of feet in CO2-enriched water for preventing expansion and formation of ischemic ulcer in critical limb ischemia of diabetic patients after surgical revascularization. Materials and methods: Eligible patients were allocated CO2 group (CO2 immersion plus standard care) or control group (standard care alone) and were followed up for 3 months after surgical revascularization. The end point is defined as an expansion of a target ulcer (more than 101% of original size) or the formation of new ulcers during the follow-up period. Results: Fifty-nine patients out of originally enrolled 66 patients with type II diabetes were included in intention-to-treat population. The cumulative prevention rate for ischemic ulcer after 3 months was 97.1% in the CO2 group, while, in the control group, it was 77.8%, i.e., significantly lower than the CO2 group (P = 0.012, log-rank test). The transcutaneous oxygen pressure increased significantly only in the CO2 group, from 56 ± 14 to 63 ± 15 mmHg (P < 0.01, Wilcoxon signed rank test), in 3 months. Conclusion: These results suggest that addition of CO2 immersion to standard care of critical limb ischemia in diabetic patients improves early postoperative outcome after vascular surgery.

Studies have shown that exogenous platelet-derived growth factor-BB (PDGF-BB) could accelerate the ulcer healing, but the lack of efficient growth factor delivery system limits its clinical application. Our previous work has demonstrated that the native human PDGF-BB was added a collagen-binding domain (CBD), TKKTLRT, to develop a collagen-based PDGF targeting delivery system. Here, we showed that this CBD-fused PDGF-BB (CBD-PDGF) could bind to collagen membrane efficiently. We used the rabbit dermal ischemic ulcer model to study the effects of CBD-PDGF loaded on collagen membranes. Results revealed that this system maintained a higher concentration and stronger bioactivity of PDGF-BB on the collagen membranes and promoted the re-epithelialization of dermal ulcer wounds, the collagen deposition, and the formation of capillary lumens within the newly formed tissue area. It demonstrated that collagen membranes loaded with collagen-targeting human PDGF-BB could effectively promote ulcer healing.

A úlcera hipertensiva de Martorell é úlcera isquêmica dolorosa de membro inferior, mais comum em mulheres, com dor desproporcional a seu tamanho e associada à hipertensão arterial sistêmica grave. É descrito um caso de homem negro, 56 anos, com hipertensão mal controlada de longa duração e lesão ulcerada extensa na panturrilha direita, cuja dor só foi aliviada com morfina, bloqueios peridurais e simpatectomia lombar. O diagnóstico baseou-se em hipertensão arterial, pulsos arteriais palpáveis, ausência de distúrbios venosos e dor intensa. O exame histopatológico de pele revelou alterações características, como espessamento da camada íntima da arteríola e estreitamento da luz. Martorell's hypertensive ulcer is a painful lower extremity ischemic ulcer, with female-to-male predominance and associated to severe systemic arterial hypertension. We describe a case of a 56 years-old black man with long standing and poorly controlled arterial hypertension who presented a large ulcer on the right calf, whose pain was improved with morphine, peridural blockages and lumbar sympathectomy. The diagnosis was based on systemic arterial hypertension, palpable arterial pulses of lower extremities, absence of venous insufficiency and presence of intense pain. Cutaneous histopathology revealed characteristic lesions in the arterioles, such as thickening of intimal layer and narrowing of the lumen.

Coiling of the artery is a rare morphologic entity, most frequently found in the internal carotid arteries. Coiling of other arteries is rarely reported because it is usually asymptomatic. We report a case of 360 degrees coiling of the right external iliac artery found by color duplex scan and arteriography. The patient was a 72-year-old man who presented with a 2-month history of an ischemic ulcer on his right toe and a right ankle-brachial-pressure index (ABPI) of 0.0 and 0.4 on admission. We resected 7 cm of the affected artery and performed end-to-end reconstruction. After 2 months of follow-up, his ischemic ulcer had healed and the ABPI of the right foot was 0.0 and 0.8.

Between 1991 and 1995 the authors performed the arteriovenous fistula (AVF) procedure, which forms the first stage of staged arteriovenous reversal (AVR), in 6 patients (4 with Buerger's disease, 2 with atherosclerosis obliterans) with lower extremity arterial occlusive disease. The patients were all men with a mean age of forty-one years. The clinical indications for revascularization included rest pain and nonhealing ischemic ulcer. The results were disappointing: 4 patients with patent fistulas underwent major amputation, and 2 with occluded fistulas underwent toe amputation.

Persistent sciatic artery is a very uncommon embryologic vascular variant, with a prevalence of 0.05% based on angiographic studies. Two different types of this anomaly can occur, complete or incomplete, on the basis of the relationship between sciatic artery and femoral artery. Although many of these patients are asymptomatic, it may represent a threat to the viability of the lower extremity because of atherosclerotic degeneration resulting in aneurysmal dilatation, occlusive thrombosis, or embolic phenomena with distal complication. We present a case of a 64-year-old man with combined, complete and incomplete, type of persistent sciatic artery causing ischemic ulcer of the first toe.

This case report describes the use of a new medical device that utilizes vacuum-compression therapy (VCT) in the management of a 30-year-old female patient with severe arteriosclerosis and an associated nonhealing fasciotomy wound. Attempts were made to treat the patient with local care consisting of debridement and saline-moistened gauze dressings. Following a poor response to nonsurgical management, a skin graft was performed in an attempt to encourage more rapid healing. Infection and poor healing followed the graph, and only 40% of the graft remained viable after 12 days. Outpatient physical therapy management consisted of hydrotherapy and hydrocolloid dressings. This treatment resulted in minimal success until combined with VCT. The patient received hydrotherapy, VCT, and hydrocolloid dressings three times per week for 11 weeks. Wound healing occurred at an average rate of 0.64 cm2 per day, and the wound completely reepithelialized by the end of the eighth week of VCT therapy. Increased capillary filling is proposed as a primary factor in the improved healing.

A case of arteriosclerosis obliterans with ischemic ulcer treated by totally implanted arterial access system is described. The patient was a 96-year-old man with ischemic ulcer (Grade 4 of Fontaine's classification) in the right 2, 3, and 4th toes. Angiography revealed an obstruction of the popliteal artery and poor run off to the peripheral artery. Reconstruction by bypass grafting was not indicated and intravenous injection of LipoPGE1 was not effective. So a totally implanted arterial access system was used and LipoPGE1 was injected through the system repeatedly. Though the minimum amputation of the toe was required, perioperative peripheral circulation was sufficient and wound healing was satisfactory.

Limb-threatening ischemia (rest pain, ischemic ulcer, gangrene), in the presence of native autogenous vein.

Arterial pathology of the lower extremity is common in the elderly. It has been the author's experience that most arterial pathology affecting the foot is caused by peripheral arterial occlusive disease, emboli, or infection. One of the most important factors determining whether healing will take place is the adequacy of the arterial blood supply. It is essential that health care providers be able to recognize whether the patient's blood flow is sufficient to maintain tissue nutrition or heal an ischemic ulcer, whether signs or symptoms presented by the patient are a result of an arterial system disorder, and, if arterial blood flow is compromised, whether the patient should be referred to a specialist.

The management of the chronically ischemic leg with ulcer formation that is not suitable for either surgical or interventional treatment is still a matter of controversy. We describe three cases of ischemic ulcer treated with basic fibroblast growth factor spray. Ulcer healing was accelerated and complete epithelialization was achieved in all cases. Basic fibroblast growth factor spray is useful in the treatment of the ischemic ulcer in patients with arteriosclerosis obliterans, especially in high-risk surgical patients.