3. The most important principle in treating foot ischemia in patients with diabetes is recognition that the etiology of this ischemia is macrovascular occlusion of the leg arteries due to atherosclerosis

4. Ischemia in Diabetic patientsIschemia in Diabetic patients Diabetic patients typically have tibial and peroneal arterial occlusive disease with relative sparing of the foot arteries. Ischemia in diabetes results from atherosclerotic macrovascular disease as well as from microcirculatory dysfunction LoGerfo FW, Coffman JD. N Eng J Med 1984;311:1615-9.

5. Arterial disease in DiabetesArterial disease in Diabetes  In 10% of patients, a foot artery, usually the dorsalis pedis artery, is the only suitable outflow vessel.  an additional 15%, the dorsalis pedis artery will appear to be the best target vessel compared with other patent but diseased tibial vessels Pomposelli FB et al. J Vasc Surg 1990;11: 745- 51.

6. Mangement of CLI in DMMangement of CLI in DM  Medical therapy.  Endovascular  Surgery  Combination of endovascular and surgery  Primary amputation

7. Determinants in Selecting Primary Approach  Assessment of the patient’s:  ambulatory function.  quality of life.  CLI severity.  long-term survival.  and periprocedural risks. Vascular anatomy plays a final critical role in decision- making, particularly in regard to the selection of endovascular vs surgical revascularization Michael S. Conte, JVS 2012

8. Effect of initial treatmentEffect of initial treatment *patients who initially received a vein bypass graft fared significantly better than those who had received a prosthetic. *Patients who underwent bypass after failed angioplasty fared considerably worse than those who received a bypass graft initially. *patients who initially received a vein bypass graft fared significantly better than those who had received a prosthetic. *Patients who underwent bypass after failed angioplasty fared considerably worse than those who received a bypass graft initially. Bradbury et al, JVS 2010

9. Even in this era of “endovascular first,” it could be argued that in the setting of extensive tibial artery occlusive disease, the most appropriate revascularization involves bypass to the distal tibial arteries Nevile and Sidawy, Seminars in vascular surgery, 2012

10.  Failed endovascular therapy might make a successful bypass more difficult and unlikely, it is important to identify those patients best treated with initial surgical bypass.

11. Endovascular interventions in DM  Endovascular interventions may be associated with worse patency rates in diabetic patients (53% vs 71% at 12 months, 49% vs 58% at 18 months; P.05) due to their higher prevalence of limb-threatening ischemia as the presenting symptom DeRubertis BG. J Vasc Surg 2008;47:101-8.

12. Selection of approach: Endo vs Open  Selection of a revascularization strategy between catheter-based and open surgical approaches is often considered as a trade-off between short-term risk and longer-term efficacy.

13. Result of bypass in DMResult of bypass in DM 5 years10 years Primary patency56.8%37.7% Secondary patency 62.7%41.7% Limb salvage78.2%57.7% Patient survival was 48.6% at 5 years and 23.8% at 10 years. perioperative mortality was only 0.9%. The popliteal artery was the source of inflow in 53.2% of patients. Pomposelli FB et al. J Vasc Surg 2003;37:307-15.

14. Prediction of amputation free survival following bypass Diabetes is not one of them Schanzer A et al. J Vasc Surg 2008;48:1464-71. Schanzer A,. J Vasc Surg 2009;50:769-75; Schanzer A et al. J Vasc Surg 2008;48:1464-71. Schanzer A,. J Vasc Surg 2009;50:769-75;

15. Effect of Diabetes on vein Bypass  Diabetes is not a risk factor for vein bypass failure.  In some studies graft failure was lower in diabetes: shorter bypass?  In diabetes: long tem survival and limb salvage is reduced but not graft patency Monahan & Owens CD. Semin Vasc Surg 2009;22:216-26.

16. Bypass: DM vs no DMBypass: DM vs no DM PREVENT III trial, JVS 2006

17. Endo vs open in DMEndo vs open in DM  Limb salvage rates and wound healing trend comparable.  There was a trend toward faster WHT for OPEN.  There were no significant differences between groups regarding amputation-free survival rate, major adverse limb events, and major adverse cardiac events. Zhang et al JVS, 2012, 581,

18. Healing after interventionHealing after intervention  In patient with wounds > 2 cm  142 bypasses and 148 endovascular procedures with 58% diabetic patients Neville RF, et al: J Vasc Surg 516:11S-12S, 2010

19. Wound sizeWound size Neville RF, et al: J Vasc Surg 516:11S-12S, 2010 Larger wounds (more than 2 cm) heal better than smaller wounds

20. Rate of healingRate of healing  Faster healing rates. Neville RF, et al: J Vasc Surg 516:11S-12S, 2010

21. Bypass to angiosomesBypass to angiosomes Percentage of complete healing after revascularization of the artery feeding the angiosome in which the wound was located (Direct) versus an artery that did not supply the wound’s angiosome and relied on arterial-arterial connections for perfusion (Indirect). Neville RF, et al: Ann Vasc Surg 2009.

22. Long Term resultsLong Term results  BASIL (The only prospective study) long term results: For those patients who survived to 2 years or longer, which comprised 70% of the study population, open bypass was associated with improved survival and a trend of improved amputation-free survival. Bradbury et al, JVS, 2010

23. Bypass vs Endovascular Intervention (BASIL)  Two-year post hoc analysis revealed that surgery was associated with a reduced risk of future amputation, or death, or both Adam DJ et al; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005;366:1925-34.

24. Bypass vs tibial angioplastyBypass vs tibial angioplasty  Meta analysis of 30 studies.  Compared popliteal–tibial bypass vs. tibial angioplasty.  primary patency was better with bypass (72% v 49% at 3 years).  Limb salvage was about the same (82%)in both groups at 3 years. Romiti M,et al. J Vasc Surg 47: 975-981, 2008

25. Do stents make a differnce?Do stents make a differnce?  Meta analysis of 18 studies.  Primary patency 79% and salvage 96% at 1 year.  Stents mostly fro inadequate study.  Sirolimus performed better than paxcil eluting stents. Both better than bare metal Biondi-Zoccai et laJ Endovasc Ther 16:251-260, 2009

26. Stent vs no stentStent vs no stent  A nonrandomized trial of 79 patients with angioplasty versus 300 patients with angioplasty and stenting.  1-year patency rates were 69% for PTA and 76% for stenting ( P NS)  Limb salvage rates were 97%, and 99% ( P NS) Bosiers Hart et al, Vascular 14:63- 69, 2006

28. Treatment in DMTreatment in DM Each operation must be individualized according to the patient’s available venous conduit and arterial anatomy

29. Factors determining Choice of Approach  Vein Bypass first if:  Acceptable risk factors.  Expected long term survival  Adequate autogenous Vein conduit is available.  No infection or tissue problems at sites of bypass

30. Factors determining Choice of Approach  Endovascular Approach first:  High risk patients  Autogenous vein not present or inadequate.  In adequate tissue coverage for the bypass.

31. Factors determining Choice of Approach  Primary amputation first:  Major tissue loss.  Nonfunctional limbs with tissue loss

32. “Endo First”“Endo First”  Not supported by the only prospective study.  Might complicate proper surgical approach.  Short term mentality is a disservice to patients who are candidates for long term solution.  Unnecessary procedure with additional cost out of the system and patient but into the pockets for operators.

33. Endo firstEndo first May violate the simplest surgical principle of doing no harm to the only available target vessel for bypass It is popularized by operators who never inside a vessel but looked at in black and white. Is the procedure of choice in patients who are not candidates for surgery. May violate the simplest surgical principle of doing no harm to the only available target vessel for bypass It is popularized by operators who never inside a vessel but looked at in black and white. Is the procedure of choice in patients who are not candidates for surgery.

34. Fernando Gallardo Pedrajas, et al, Sem Vasc Surg, 2012

35. Open FirstOpen First  Faster healing.  More healing  Better long term results  Less re intervention on patients who getting older.  No increased mortality or morbidity compared to endo Surgery is not a death sentence