Revascularization for foot wounds: working with vascular specialists

Why a wound needs blood flow to heal

Peripheral artery disease (PAD) is present in about half of people with diabetes and a foot ulcer, and it is a major risk factor for a wound that won’t heal.⁠^[1,6]

Vascular specialists restore flow in three ways: from inside the artery (endovascular treatment, such as angioplasty), with open surgery (a bypass, or cleaning out the artery), or with a hybrid of both.⁠^[2] Restoring blood flow is only part of the treatment. The international diabetic foot guideline places it inside a full plan that also treats infection, clears dead tissue, takes pressure off the wound, controls blood sugar and improves nutrition.⁠^[1]

When it is considered

With diabetes, PAD and a foot ulcer, a procedure should be considered when there are signs of poor blood flow: missing foot pulses, flattened (monophasic) or absent Doppler signals, an ankle pressure under 100 mmHg or a toe pressure under 60 mmHg.⁠^[1] We check your pulses and do noninvasive circulation testing at our practice; more detailed imaging, such as arterial duplex ultrasound or angiography, is arranged with a vascular specialist.

When testing shows severely reduced blood flow, the diabetic foot guideline advises an urgent vascular referral. In observational studies, a delay of more than two weeks was linked with more leg loss, and treatment within 8 weeks with better healing and a better chance of keeping the leg.⁠^[1] If a wound gets worse, or hasn’t shrunk by about half after 4 weeks of good care, circulation should be rechecked and a vascular specialist consulted.⁠^[1] Infection or gangrene (such as a toe turning black) on a foot with poor circulation calls for a vascular specialist right away, to decide when to drain and when to restore flow.⁠^[1]

How the procedures are done

Angioplasty and stents. Through a tiny needle in the groin, with numbing medicine and a sedative, the specialist uses dye and live X-ray to guide a thin wire and catheter to the blockage. A small balloon opens it, and a metal mesh tube (stent) may be left to hold it open. Many people go home within 2 days, some the same day.⁠^[7]

Bypass surgery. The surgeon builds a new channel around the blockage with one of your own veins or a synthetic tube, usually under general or spinal anesthesia. Most people stay in the hospital 4 to 7 days.⁠^[8] For a bypass to the artery behind the knee or to arteries below it, the US guideline recommends your own vein when one is available.⁠^[2]

The angiosome idea

The foot and ankle can be mapped into six angiosomes, blocks of tissue each fed by one artery. Direct revascularization opens the artery feeding the wound’s area; indirect revascularization opens another artery and may rely on connecting vessels (collaterals).⁠^[1]

For endovascular treatment, the guideline suggests aiming at the wound’s own artery when practical, based on very low certainty evidence.⁠^[1] A review found direct treatment and indirect flow through collaterals about equally effective at restoring blood flow.⁠^[6]

Bypass or angioplasty: what the trials show

In BEST-CLI, a trial of 1,830 people with limb-threatening ischemia, those with a usable great saphenous vein had fewer amputations above the ankle, major repeat procedures or deaths with bypass first than with endovascular treatment first: 42.6% versus 57.4% over a median of 2.7 years. Without a good vein, results were similar.⁠^[4] In BASIL-2, in 345 people needing treatment below the knee, major amputation or death occurred in 53% with endovascular treatment first and 63% with vein bypass first, mainly because fewer endovascular patients died.⁠^[5]

Which first step suits you depends on where the blockages are, whether a vein is available, your other health problems and what you prefer.⁠^[2]

What studies report

An international review summarized 64 studies, mostly case series, of more than 13,000 people with diabetes, foot ulcers and PAD. Results were broadly similar after endovascular treatment and open surgery: about 80% and 85%, respectively, kept their leg at one year. A median of 60% had a healed wound by then.⁠^[6]

How we time foot surgery around it

When a deep abscess must be drained or wet gangrene removed, surgery comes first, with antibiotics started at once.⁠^[9,1] Once the infection is controlled, the diabetic foot guideline advises considering a procedure to restore flow within a few days if circulation is poor.⁠^[1]

Otherwise, blood flow usually comes first; once it has improved, most people with gangrene are assessed for a toe or partial foot amputation.⁠^[2] In one hospital’s 920 toe, ray and transmetatarsal amputations, about 90% of legs were saved at one year, but the odds of losing the leg were about twice as high when the artery procedure came afterward.⁠^[3]

Here is how we fit in. Dr. Efe Ozturk, a Foot and Ankle Surgeon, is board certified in wound care (FAPWH). We refer you to a vascular specialist and keep them updated; we don’t perform angioplasty or bypass. Dr. Ozturk performs the foot surgery: he drains infection, clears dead tissue, removes infected bone and, when a foot needs it, performs the smallest toe, ray, transmetatarsal or midfoot amputation likely to heal.

Recovery and follow-up

We keep seeing you for wound care visits every week or two to measure progress, trim dead tissue and protect the wound from pressure. Circulation should be rechecked, since arteries below the knee treated with angioplasty often don’t stay open long term.⁠^[1]

If a diabetic foot ulcer still isn’t healing after blood flow is restored, we may refer you for hyperbaric oxygen therapy, which may help it heal but doesn’t replace restoring blood flow.⁠^[2,9]

Antiplatelet and statin medicines are advised long term after revascularization.⁠^[9] Smoking can slow healing and raise the risk of blood clots;⁠^[8] our sister practice explains how smoking and diabetes slow healing (external site).

Risks and limits

Angioplasty can cause bleeding or a clot where the catheter went in, damage to the artery that sometimes needs urgent surgery, a reaction to the dye, kidney failure (more likely with existing kidney problems), a heart attack or, rarely, a stroke. Sometimes the artery can’t be opened, and the leg can still be lost.⁠^[7] Bypass risks include wound infection, a heart attack and a graft that stops working; some people need another bypass or an amputation.⁠^[8] In the international review, about 2% died within 30 days of either procedure.⁠^[6]

A procedure isn’t advised when healing is unrealistic, a major amputation is unavoidable, a working foot is unlikely or life expectancy is short.⁠^[1] The diabetic foot guideline rates the evidence on how much these procedures improve healing and amputation risk as low certainty.⁠^[1] When arteries can’t be opened, for some people venous arterialization, a newer procedure that sends arterial blood to the foot through its veins, may be considered.⁠^[2]

A below-knee amputation, if ever needed, is performed by a vascular or orthopedic surgeon. Told you need an amputation? Consider a limb salvage second opinion.

Questions to ask your vascular specialist

• Can flow be restored all the way into my foot?
• Is angioplasty or bypass the better first step for me, and do I have a usable vein?
• When can my foot surgery be done?

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. With diabetes or PAD, signs of infection around a wound (see a red, hot, swollen foot) or new foot pain at night or at rest need a same-day call to us.