The role of the angiosomaly-oriented endovascular revascularization method in the complex treatment of diabetic foot syndrome

Objective: analyze the effectiveness of the angiosomal oriented endovascular revascularization method in the complex treatment of diabetic foot syndrome (DFS).
Materials and methods. One of the most serious complications of diabetes mellitus is damage to the vessels of the lower extremities. In diabetic macroangiopathy, an extended lesion of medium-sized arteries occurs, which, coupled with an atherosclerotic lesion, often leads to the formation of arterial stenosis and occlusion. The leading method for correcting the patency of the great vessels today is endovascular balloon angioplasty. The study examined the feasibility of selective angiosomal revascularization of the lower extremities. The advantages of angiosomaly-oriented endovascular revascularization are a reduction in the duration of the intervention, a decrease in the volume of the injected contrast drug, and targeted restoration of blood flow in the arteries that feed the affected segment of the limb. The study included 49 patients with a neuroischemic form of DFS with hemodynamically significant stenosis and occlusion of the lower extremities arteries. Patients were divided into 2 groups. Patients of both groups underwent complex conservative treatment and performed operations on the lower extremities (from surgical debridement to below the knee amputation). Patients of the first group underwent angiosomaly oriented revascularization of the lower extremities. Patients from the second group underwent traditional endovascular revascularization.
Results. After angiosomaly oriented revascularization, a complete restoration of the initial diameter of the vessel was achieved in 80.0 % of cases, the absence of residual stenosis – in 82.5 %, the absence of intimal dissection – in 95.0 % of cases. It was possible to achieve laminar blood flow in 90.0 % of cases. A reduction in the revascularization procedure by an average of 30 minutes and a decrease in the consumption of contrasting pharmaceuticals by an average of 100.0 ml are shown.
Conclusion. When evaluating the results of complex treatment of patients after angiosomaly oriented revascularization, a decrease in the average hospital stay (11 and 13 days, respectively), a decrease in the average healing time of a wound defect by 1.25 times, a decrease in the average duration of ulcerative epithelization (9 and 13 days, respectively) and a decrease in the volume of surgical intervention and the number of high amputations during the year after angioplasty compared with patients who underwent endovascular revascularization according to the traditional method.

1. IDF Diabetes Atlas. 7th ed. International Diabetes Federation; 2015.

2. Fox C. S., Pencina M. J., Meigs J. B., et al. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation. 2006; 113 (25): 2914-8.

3. Алгоритмы специализированной медицинской помощи больным сахарным диабетом / под ред. И. И. Дедова, М. В. Шестаковой. М., 2013. 120 с. [Algorithms of specialized medical care for patients with diabetes mellitus / ed. I. I. Dedova, M. V. Shestakova = Algoritmy spetsializirovannoy meditsinskoy pomoshchi bol'nym sakharnym diabetom / pod red. I. I. Dedova, M. V. Shestakovoy. M., 2013. 120 s. (In Russ.)]

4. Галстян Г. Р., Токмакова А. Ю., Егорова Д. Н. и др. Клинические рекомендации по диагностике и лечению синдрома диабетической стопы. Раны и раневые инфекции. Журнал им. проф. Б. М. Костючёнка 2015; 2 (3): 63–83. [Galstyan G. R., Tokmakova A. Yu., Egorova D. N., et al. Clinical guidelines for the diagnosis and treatment of diabetic foot syndrome. Wounds and wound infections = Galstyan G. R., Tokmakova A. Yu., Yegorova D. N. i dr. Klinicheskiye rekomendatsii po diagnostike i lecheniyu sindroma diabeticheskoy stopy. Rany i ranevyye infektsii. Zhurnal im. prof. B. M. Kostyuchenka 2015; 2 (3): 63–83. (In Russ.)]

5. Дедов И. И. Результаты реализации подпрограммы «сахарный диабет» федеральной целевой программы «Предупреждение и борьба с социально значимыми заболеваниями 2007–2012 годы» / под ред. И. И. Дедова, М. В. Шестаковой. М., 2012. 144 с. [Dedov I. I. Results of the implementation of the subprogram “diabetes” of the federal target program “Prevention and control of socially significant diseases 2007–2012” = Dedov I. I. Rezul'taty realizatsii podprogrammy “sakharnyy diabet” federal'noy tselevoy programmy “Preduprezhdeniye i bor'ba s sotsial'no znachimymi zabolevaniyami 2007–2012 gody” / pod red. I. I. Dedova, M. V. Shestakovoy. M., 2012. 144 s. (In Russ.)]

6. Piga R., Naito Y., Kokura S., et al. Shortterm high glucose exposure induces monocyte-endothelial cells adhesion and transmigration by increasing VCAM-1 and MCP-1 expression in human aortic endothelial cells. Atherosclerosis. 2007; 193 (2): 328–334.

7. Otsuka A., Azuma K., lesaki Т., Watada H. Temporary hyper-glycaemia provokes monocyte adhesion to endothelial cells in rat thoracic aorta. Diabetologia. 2006; 48 (12): 2667–2674.

8. Quagliaro L., Piconi L., Assaloni R., et al. Intermittent high glucose enhances ICAM-1, VCAM-1 and E-selectin expression in human umbilical vein endothelial cells in culture: the distinct role of protein kinase С and mitochondrial superoxide production. Atherosclerosis. 2005; 183 (2): 259–267.

9. Kilhovd B. K., Berg T. J., Birkeland K. I., et al. Serum levels of advanced glycation end products are increased in patients with type 2 diabetes and coronary heart disease. Diabetes Care. 1999; 22 (9): 1543–8134.

10. Guzzardi M. A., Hodson L., Guiducci L., et al. Independent effects of circulating glucose, insulin and NEFA on cardiac triacylglycerol accumulation and myocardial insulin resistance in a swine model. Diabetologia. 2014; 57 (9): 1937–1946.

11. Shoelson S. E., Lee J., Yuan M. Inflammation and the IKKP/IkB/NF-kB axis in obesity- and diet-induced insulin resistance. Int J Obes. 2003; 27 (Suppl. 3): S49–S52.

12. Shah B., Sha D., Xie D., et al. The relationship between diabetes, metabolic syndrome, and platelet activity as measured by mean platelet volume: the National Health and Nutrition Examination Survey 1999–2004. Diabetes Care. 2012; 35 (5): 1074–1078.

13. Vinik A. I., Erbas T., Park T. S., et L. Platelet dysfunction in type 2 diabetes. Diabetes Care. 2001: 24 (8): 1476–1485.

14. Su X., Han X., Mancuso D. J., et al. Accumulation of long-chain acylcarnitine and 3-hydroxy acyl-carnitine molecular species in diabetic myocardium: identification of alterations in mitochondrial fatty acid processing in diabetic myocardium by shotgun lipidomics. Biochemistry. 2005; 44 (13): 5234–5245.

15. Harris I. S., Treskov I., Rowley M. W., et al. G-protein signaling participates in the development of diabetic cardiomyopathy. Diabetes. 2004; 53 (12): 3082–3090.

16. Асмоловская М. Б., Доросевич А. Е. Пато- и морфогенетические особенности диабетических ангиопатий. Здравоохранение Беларуси. 1992; 7: 53–59. [Asmolovskaya M. B., Dorosevich A. E. Patho- and morphogenetic features of diabetic angiopathies = Asmolovskaya M. B., Dorosevich A. E. Pato- i morfogeneticheskiye osobennosti diabeticheskikh angiopatiy. Zdravookhraneniye Belarusi. 1992; 7: 53–59. (In Russ.)]

17. Балаболкин М. И., Клебанова Е. М., Креминская В. М. Патогенез ангиопатий при сахарном диабете. Сахарный диабет. 1999; 1: 2–8. [Balabolkin M. I., Klebanova E. M., Kreminskaya V. M. Pathogenesis of angiopathies in diabetes mellitus = Balabolkin M. I., Klebanova E. M., Kreminskaya V. M. Patogenez angiopatiy pri sakharnom diabete. Sakharnyy diabet. 1999; 1: 2–8. (In Russ.)]

18. Диагностика и лечение больных с заболеваниями периферических артерий: рекомендации Российского общества ангиологов и сосудистых хирургов. М., 2007. 112 с. [Diagnostics and treatment of patients with peripheral arterial diseases: recommendations of the Russian Society of Angiologists and Vascular Surgeons = Diagnostika i lecheniye bol'nykh s zabolevaniyami perifericheskikh arteriy: rekomendatsii Rossiyskogo obshchestva angiologov i sosudistykh khirurgov. M., 2007. 112 s. (In Russ.)]

19. Национальные рекомендации по ведению пациентов с сосудистой артериальной патологией (Российский согласительный документ). Часть 1. Периферические артерии. М.: Изд-во НЦССХ им. А. Н. Бакулева, РАМН, 2010. 176 с. [National guidelines for the management of patients with vascular arterial pathology (Russian conciliatory document). Part 1. Peripheral arteries = Natsional'nyye rekomendatsii po vedeniyu patsiyentov s sosudistoy arterial'noy patologiyey (Rossiyskiy soglasitel'nyy dokument). Chast' 1. Perifericheskiye arterii. M.: Izd-vo NTSSSKH im. A. N. Bakuleva, RAMN, 2010. 176 s. (In Russ.)]