Salvage of ischemic diabetic feet: Role of transcutaneous oxygen mapping and multiple configurations of in situ bypass

Salvage of ischemic diabetic feet with advanced infrapopliteal and pedal arch atherosclerosis requires distal revascularization to heal skin envelope injuries. A series of 60 consecutive diabetic extremities with 41 nonhealing skin envelopes requiring distal tibial or pedal bypass in 83 percent has been reported. Four configurations of in situ bypass, including femoropopliteal, femorotibial, femoral sequential popliteal-tibial, and popliteal-tibial [3,9,11,17] were utilized with reversed and nonvein bypass to achieve a 93 percent hospital survival rate and 90 percent limb salvage with 80 percent graft patency at 36 months. Transcutaneous oxygen mapping was used to predict the healing of skin envelope injuries and late amputations after bypass. Postoperatively, limbs with transcutaneous oxygen values at the midfoot and surrounding skin injuries of more than 30 mm Hg rapidly healed, whereas those with midfoot values of more than 30 mm Hg but transcutaneous values surrounding skin injuries of less than 30 mm Hg had wound complications (p < 0.001). Optimal limb salvage can be achieved with in situ bypass, sequential grafting, and high forefoot amputations if necessary. Transcutaneous mapping accurately predicts tissue healing and allows planning of the site and timing of late amputations.