Limb salvage in diabetics: challenges and solutions.
Our current understanding of wound healing in the diabetic suggests that proper management of the blood glucose level is a necessary but not sufficient condition for containment of infection and optimal wound healing. The pathologic changes observed in the peripheral capillary bed of diabetics are somewhat variable and have no consistent relationship to the wound healing process. Occlusive disease of the arterioles is probably quite similar in significance and distribution to normoglycemic patients with peripheral vascular disease and suggests that proximal arterial occlusion is the major determinant of poor distal perfusion. These observations offer strong evidence that sufficient runoff vessels are present to support attempts at reconstruction of obstructing lesions of the aortoiliac and infrainguinal arterial segments. Noninvasive vascular laboratory data and arteriograms must be carefully interpreted in order to assess fully the degree of arterial occlusive disease that exists as well as the potential for vascular reconstruction. Clinical experience is especially helpful in proper patient selection. Aggressive attempts at distal revascularization can achieve functional limb salvage in the great majority of patients, provided that meticulous technical standards are observed. Conservative surgical debridement and minor amputations are often successful in managing problems of soft-tissue necrosis once pulsatile flow has been restored.