Surgical Bypass: When Is It Best and Do Angiosomes Play A Role?

The etiology of foot lesions in diabetics is multifactorial. Arterial insufficiency, neuropathy, and susceptibility to infection are major factors contributing to the formation of nonhealing diabetic foot lesions. These factors lead to a 15% ulceration rate in diabetics with 20% resulting in amputation. This amputation rate, 4.1 per 1,000 per year, represents a risk 40 times greater for diabetics, with a subsequent second amputation in 60% by 5 years. Conversely, more than half of all lower-extremity amputations are performed in diabetic patients. Therefore, the primary goal in diabetic lower-extremity care is to heal foot ulcerations and prevent amputations and major disabilities. Lower-extremity revascularization is a major facet of achieving the goal of healing and amputation prevention. Due to the severity, distribution, and complexity of diabetic vascular disease, surgical bypass continues to play a role in attaining this goal. Surgical bypass might be the best option for diabetic patients with significant tissue loss or to revascularize the appropriate angiosome of the foot and maximize healing potential. In order to offer surgical bypass to these patients, innovative techniques might need to be considered, including venous patches and cuffs, heparin-bonded grafts, and adjunctive distal arteriovenous fistulas.