Lower Extremity Arterial Reconstruction in Patients with Diabetes Mellitus: Principles of Treatment

A successful revascularization strategy must be individualized to each individual patient’s presentation. Peripheral arterial disease (PAD) should be appropriately staged and foot infection treated to obtain source control. Diagnostic angiography provides the most detailed anatomic information and is essential to determining the best revascularization strategy. Revascularization aims to restore inline pulsatile flow to the foot. Balloon angioplasty is the standard modality of treatment in the infrapopliteal arteries, the most common site of occlusive disease in diabetes. Stents and drug-coated technology are not well studied nor widely used in the tibial arteries. Surgical bypass is preferred for extensive, multi-level occlusive disease. Ipsilateral greater saphenous vein is the optimal autogenous conduit. Non-autogenous conduits have poor patency and are suboptimal for longer healing time. Selection of the optimal revascularization strategy for limb salvage in diabetic patients must be individualized based on each patient’s surgical risk, limb severity, and anatomic pattern of disease.