title: Combined primary subintimal and endoluminal angioplasty for ischaemic inferior-limb ulcers in diabetic patients: 5-year practice in a multidisciplinary 'diabetic-foot' service.
abstract: BACKGROUND
  This study aims to assess the patency, the clinical success and the limb-salvage rates of combined subintimal (SA) coupled to endoluminal angioplasty (EA) as the initial treatment of ischaemic inferior-limb ulcers in diabetic patients and to study the influence of other concurrent factors in the tissue-healing process.
  
  
  METHODS
  Since September 2002 until December 2007, a consecutive series of 176 limbs with manifold ischaemic wounds in 161 diabetic patients were treated by associated multilevel angioplasties in a multidisciplinary 'diabetic-foot team' (a third-line diabetic-care institution integrating two departmental hospitals). There were 98 associated SA with EA procedures, 26 re-vascularisations by single SA technique and 52 others including selective multilevel EAs that were retrospectively reviewed. The mean follow-up period was 22.1 months (in the range of 1-50 months) by clinical and duplex evaluation (every 6 months).
  
  
  RESULTS
  The initial technical success was noted in 149 limbs (84%). For the single or associated SA procedures, 102 of 124 procedures were successful (82%) and 145 of 150 of the miscellaneous EAs (96%) evinced an equally favourable outcome. The 27 initially failed endovascular procedures (22 SA and five EA) required 16 surgical re-vascularisation, eight adjuvant endovascular procedures besides three amputations. A total of 21 secondary and five tertiary angioplasties were equally necessary during the entire follow-up period of these patients. The 30-day survival rate was 99% (one patient died from myocardial infarction). In a intention-to-treat analysis, the cumulative primary and secondary patencies at 12, 24, 36 and 48 months were 62%, 45%, 41% and 38%, together with 80%, 69%, 66% and 66%, respectively. The aggregate clinical success rates at the same intervals were 86%, 77%, 70% and 69%, while the corresponding limb-salvage proportions showed 89%, 83%, 80% and 80%, respectively. The primary patency was negatively affected at 1 and 4 years by the length of the occluded segment (>10 cm) and the end-stage renal disease (ESRD) (p<0.0001). The limb-salvage rates were unfavourably influenced at the same periods by the extent of tissue defects (>3 cm), the ESRD and the presence of osteomyelitis. In addition, at 4 years, the age (>70 years), the accompanying peripheral neuropathy, the bedridden status and the presence of cardiac failure (left ventricular ejection fraction (LVEF)<30%) appeared equally as negative predictors (p<0.0001) for wound healing and limb rescue.
  
  
  CONCLUSIONS
  Primary angioplasty represents a low aggressive and efficacious method to improve the healing process in diabetic ischaemic ulcers. However, beyond appropriate re-vascularisation, even repetitive if necessary, achieving satisfactory limb-salvage rates probably implies a multidisciplinary control of the presenting risk factors for wound healing as well.
authors.affiliation: Department of Surgery, Princesse Paola Hospital, Marche-en-Famenne, Belgium. v.alex@skynet.be
authors.forename: V
authors.initials: V
authors.lastname: Alexandrescu
authors.forename: G
authors.initials: G
authors.lastname: Hubermont
authors.forename: Y
authors.initials: Y
authors.lastname: Philips
authors.forename: B
authors.initials: B
authors.lastname: Guillaumie
authors.forename: Ch
authors.initials: Ch
authors.lastname: Ngongang
authors.forename: V
authors.initials: V
authors.lastname: Coessens
authors.forename: P
authors.initials: P
authors.lastname: Vandenbossche
authors.forename: M
authors.initials: M
authors.lastname: Coulon
authors.forename: G
authors.initials: G
authors.lastname: Ledent
authors.forename: J-C
authors.initials: JC
authors.lastname: Donnay
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000379:methods*; D017719:Diabetic Foot / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D005528:Foot / Q000098:blood supply; D006333:Heart Failure / Q000150:complications; D006801:Humans; D007511:Ischemia / Q000628:therapy*; D023821:Limb Salvage / Q000379:methods; D008297:Male; D008875:Middle Aged; D051346:Mobility Limitation; D010348:Patient Care Team; D010523:Peripheral Nervous System Diseases / Q000150:complications; D012008:Recurrence; D012189:Retrospective Studies; D015607:Stents; D014654:Vascular Patency; D014945:Wound Healing