Vascular management of the diabetic foot--a British view

Approximately 50% of diabetic hospital admissions in the United Kingdom are for foot problems. These relate primarily to neuropathic and vascular disease, often presenting as separate entities. Added to these problems is an impairment of the inflammatory response to intercurrent infection. Arterial lesions are those of arteriosclerosis, occurring at a young age. The lesions are more prominent in the calf vessels and distal profunda artery than across the adductor canal or the aorta-iliac segment. Surprisingly, microangiopathy does not present a major problem in digital vessels. Classification of foot problems is based on foot deformity and the degree of ulceration, infection and gangrene. Management is most effectively directed at educating doctors, nurses, patients and their carers, on foot care. Established foot lesions are best managed by a team, including chiropodists, orthotists, physicians and surgeons. This combined approach ensures optimal treatment of the diabetes and associated risk factors, such as hypertension. Patients usually have sufficient autonomic neuropathy to negate any advantages of sympathectomy, but temporary improvement of severe ulceration and pain may be obtained by prostaglandin E2 infusions, allowing time for angiographic assessment. Angioplasty provides the first line of vascular reconstruction. Surgical reconstruction may involve bypass to the level of the shin and ankle. Such revascularisations may reduce foot surgery to local amputation and debridement. Major amputation should not be delayed if it provides the most effective means of rehabilitation and return to community life.