Bypass Grafts Still Preferred For Foot Revascularization

By Mark S. Lesney

CHICAGO -- Bypass grafts are still the most commonly used approaches for revascularization of the diabetic foot, and are considered by most specialists to be the preferred method. However, open surgery is part of a treatment algorithm that grows in complexity as more and more considerations come into play, Gary Gibbons, M.D., said at the Vascular Annual Meeting.

Dr. Gibbons

"To achieve the most rapid and durable healing, what you want to do is restore a pulse to the foot by whatever means you can," he explained. Typically, this is still through an open bypass, according to Dr. Gibbons, professor of surgery at Boston University and executive director, Foot Care Specialists of Boston Medical Center.

But the open bypass procedures--which are dictated by the status of the patient's vascular anatomy and wound morphology--can be quite complex. In order to be prepared for the almost inevitable surprises upon exploring the foot,

"I tell my residents every time they're with me that I want three approaches to do this operation, because it is the nature of diabetic vascular disease [that] oftentimes approach No. 1 isn't going to work," he said.

The most critical consideration, outside of the surgery itself, is the overall control of sepsis before and after the operation. "We used to think, just get the blood sugar down to maybe 200 [mg/dL], but now we really, really like to have very low blood sugars in the postoperative course. It's the greatest way to determine how well you drain sepsis, because the blood sugar will not fall until you have adequately debrided and controlled sepsis," Dr. Gibbons said.

After surgery, the effects of revascularization on infection can become quickly evident. "Don't be surprised if you have to take the patient immediately back into the operating room 24 hours later to further control sepsis because you have awakened the bacteria," he said.

Although these bypasses are durable, limb salvage is ultimately more important than patency, he added. "The thing to remember is that a third of these patients are going to be dead in 5 years. But the thing is, they want to die intact."

Additionally, Dr. Gibbons said, "I am on a mission for protecting the other leg and foot. Anywhere from 24% to 48% [of these patients] will have a contralateral extremity problem within the next 3 years," and therefore they must be monitored carefully long after surgery on the currently affected foot.

Dr. Gibbons said that his center is doing more and more endovascular treatment of diabetic foot patients. For many of the more complex wounds with damaged vasculature, a bypass can salvage a foot in the only way possible. He stressed, though, that the needs of the individual patient must be taken into consideration, and that individual cases are quite variable in determining appropriate treatment. "The most important thing to remember is that, with the right approach, we can heal diabetic wounds and prevent amputation."