When Should Foot Surgery Take Place After Revascularization?

Three vascular surgeons collaborated on a dynamic panel discussion at Great Debates and Updates in Diabetic Foot, looking at key cases, current evidence, and their experience to discuss various outlooks on the ideal timing of diabetic foot surgery in proximity to revascularization. Matthew Sideman, MD, Professor of Surgery and Interim Chief of Vascular and Endovascular Surgery University of Texas Health San Antonio, listed several options teams may have when planning such timing:

·       Foot surgery prior to revascularization

·       Revascularization in the same surgical session as foot surgery

·       Revascularization with early foot surgery

·       Revascularization with delayed foot surgery

He shared that there is no one right answer, and that the consideration should be patient-specific. Dr. Sideman went on to say that there isn’t much published providing guidance, but reviewed several available studies. 

In 2005 Sheahan and team looked at cases over a 10-year period, and found that revascularization after amputation, transmetatarsal amputation as the initial amputation and end-stage renal disease were all poor prognostic indicators.¹ In 2020, Doyle and colleagues noted that minor lower extremity amputations within 15-60 days of endovascular intervention may allow for improved healing.2 They additionally found that postop infection, wound dehiscence, male sex, diabetes, and absence of in-line flow were significant contributors to failure in these cases.² Another study from 2023 presented findings that Dr. Sideman noted are different from many think. These authors looked at 151 patients with Rutherford 5-level disease, and found a higher risk of amputation if foot surgery took place in the first 14 days after revascularization.³

Melissa Kirkwood, MD, Associate Professor in the Division of Internal Medicine and Chief of Surgery’s Division of Vascular Surgery at University of Texas Southwestern Medical Center, then presented some considerations from the BEST-CLI study.⁴ This prospective, randomized, multicenter, multispecialty, pragmatic clinical trial had two cohorts with chronic limb-threatening ischemia. The first had an adequate single-segment greater saphenous vein for bypass, and the second did not. The hypothesis was that the first cohort with the appropriate vein would see bypass outperforming endovascular intervention, and vice versa for the second cohort, said Dr. Kirkwood. However, patients studied that did have the adequate greater saphenous vein had a significantly lower rate of major adverse limb events or death when they underwent surgical revascularization versus endovascular.⁴ Interestingly, in the second cohort without the usable vein, the two groups saw similar outcomes to each other.⁴

Dr. Kirkwood concluded her portion of the discussion by pointing out that the timing of foot surgery versus revascularization is important based on the type of intervention performed. She noted that early endovascular failure must be considered when timing the needed foot surgery, as there may not be as much time to successfully operate on these patients while flow is adequate. Infection can also play a role, she said, and one must also considering that open procedures are as a whole less likely to require reintervention. 

Michael Siah, MD, then took the podium to address the impact of multidisciplinary management of the “no option” patient, sharing several relevant cases. Dr. Siah, an Assistant Professor in the Department of Surgery and the Director of Limb Salvage at the University of Texas Southwestern Medical Center, discussed deep vein arterialization as a potential option under the right circumstances. He added that typically one will need to wait 4-6 weeks following the procedure before undertaking foot surgery to allow for maturation of the pedal venous circuit.⁵ Early debridement is then limited to removal of infection only, he said, with no closure. He shared additional cases, and concluded by sharing that deep vein arterialization can be safe and feasible for a unique group of patients. 

References

1.     Sheahan MG, Hamdan AD, Veraldi JR, et al. Lower extremity minor amputations: the roles of diabetes mellitus and timing of revascularization. J Vasc Surg. 2005;42(3):476-480. 

2.     Doyle MD, Hastings G, Dontsi M, Dionisopoulos SB, Kane LA, Pollard JD. The effects of endovascular timing and in-line flow on the success of pedal amputations. J Foot Ankle Surg. 2020;59(5):964-968. 

3.     Tanda E, Ruiu G, Casula M, et al. Minor amputation after revascularization in chronic limb-threatening ischemia: What is the optimal timing? Vascular. 2023:17085381231214819.

4.     Farber A, Menard MT, Conte MS, et al. Surgery or endovascular therapy for chronic limb-threatening ischemia. N Engl J Med. 2022;387(25):2305-2316.

5.     Montero-Baker M, Lepow B. After deep vein arterialization: best practices. Endovascular Today. 2021. Available at: https://evtoday.com/articles/2021-may/limflow-percutaneous-deep-venous-arterialization.