Infrainguinal Reconstruction in Diabetes

Dramatic changes have occurred in the efficacy of infrainguinal reconstruction in diabetic patients. Enhanced limb salvage resulted from comprehensive understanding of patterns of macrovascular involvement, better perioperative control of sepsis and hyperglycemia, and advances in techniques for limb salvage. This report summarizes the applicability of recently evolving surgical techniques. Advances in pattern recognition have eliminated the misconception that microvascular involvement of the foot precludes successful reconstruction. A decreasing incidence of amputation in diabetic patients is currently seen. Interventions applicable to the usual patterns of diabetic macroangiopathy include femorodistal bypass to ankle or foot and popliteal distal bypass using autogenous vein usually in situ. In the absence of usable vein (a rare occurrence), the authors have observed intermediate patency using polytetrafluoroethylene to a vein cuff and anticoagulation. Initially, successful bypasses in diabetic and nondiabetic patients exhibit comparable long-term patency. Local toe or foot amputations are used more frequently to maintain bipedal gait. With careful management, a high rate of limb salvage is practical for nonsmoking, nonuremic diabetic patients.