Hyperbaric Oxygen for the Treatment of Diabetic Foot Ulcers: A Systematic Review

What can I do with a patient with diabetes and critically impaired limb perfusion who cannot be revascularized?

A patient with limb-threatening diabetic foot syndrome in whom relevant peripheral arterial occlusive disease is proven should receive arterial revascularization as soon as possible to avoid major amputation. However, 3 conditions may make it impossible to effectively restore limb perfusion: the patient will not profit from arterial revascularization owing to excessive tissue loss or sepsis ("too late"), the patient cannot be revascularized due to severe comorbidities ("too sick"), and arterial reconstruction is impossible because of technical and anatomical shortcomings in a patient who is otherwise fit for operation ("nonreconstructible limb perfusion"). This review outlines the therapeutic options specifically in the third group of patients in whom no technical option for surgical or endovascular revascularization exists.

An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system

OBJECTIVE

The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing.

METHODS

Between 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion.

RESULTS

Of the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel.

CONCLUSIONS

The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.