Prevention of ulceration in the foot is the most important aspect in the treatment of diabetics. Preventive foot care is often neglected and the patient develops serious foot ulcers and infections. The surgical management is of different varieties, says Prof G Sivakumar. They are:
- Minor surgical procedures like drainage of puss from abscess cavities, removal of dead tissues, removal of bursa and excision of corns.
- Major amputation procedures in limb-threatening and life-threatening situations.
- Vascular reconstructive procedures to restore blood supply to the feet.
- Management of Charcot’s joints.
Neuropathy is responsible for about 80% of the foot ulcers. When the blood supply to the foot is impaired due to atherosclerosis the patient may require a vascular re-constructive procedure. Major amputations are averted and many limbs re salvaged by judicious and timely vascular procedures.
Vascular surgery is one of the recent specializations and essentially, vascular surgery involves the removal of blocks and by-passing obstructions. Early vascular surgical procedures were directed in correcting blood vessel aneurysms (balloon-like dilatation of arteries)
John Hunter pioneered in ligation of popliteal aneurysms and Alexis Carrel designed the method of joining cut blood vessels. This fetched him a Nobel prize. Visualising blood vessels (Angiography)was made possible due to the efforts of Moniz, Dos Santos and Seldinger. The problem of clotting of blood in crucial vessels was overcome with the invention of Heparin by McLean. With more need of blood vessel substitutes arose, grafts were designed. Michael Debackey of Texas contributed to the advances in the management of abdominal aortic aneurysms.
Managing war victims and road transport accident victims necessitated rapid advances in vascular reconstruction. Short segment blocks are treated with endovascular procedures and long segment blocks are treated with by-pass grafts using synthetic or vein grafts. Acute blocks are dissolved using intra-arterial drugs and big clots are removed using balloon catheters. When the blood supply is reduced to a level that threatens the very survival of the limb, the patient needs emergency management (critical ischaemia).
Endo-vascular Management: This is similar to all the intervention described for managing coronary arteries of the heart. A balloon catheter is used to dilate blood vessels and a stent is used to keep it open. Gruntzig and Dotter C T were the first to design these catheters. Last five years witnessed phenomenal advances in endovascular surgeries. Now even long synthetic grafts can be kept using endovascular techniques.
By-pass surgery: The common sites of blocks in blood vessels are in aorta and thigh. Inserting grafts between the aorta and iliac arteries and femoral and popliteal arteries are done using synthetic blood vessel substitutes made up of PTFE and Dacron. These operations are called Aorto Iliac bypass and ‘Fem-Pop” procedures. These are regularly performed in many centres in India.
Embolectomy: Acute clot obstruction of blood vessels produces blue cyanotic limbs and are managed by removal of clots using balloon catheters (Fogarty’s catheter). The catheter with a balloon in the tip is inserted through a small hole in the artery. Major open surgeries are avoided.
Vein grafts: The saphenous vein is often used as a substitute for bypassing blocks in thigh arteries.
The timing of vascular surgery is very important. Diabetics fare equally well as non-diabetics. Reperfusion of the foot makes ulcers heal and reduces pain in the foot. An ischaemic foot is so endangered that minimal sepsis is enough to produce infective gangrene. In diabetes when the foot is insensate the patient is oblivious to symptoms of ischaemia and delays surgical treatment.
Pic courtesy: readers digest