ISSN: 2329-910X
Clinical Research on Foot & Ankle
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on Medical, Pharma, Engineering, Science, Technology and Business

Short Communication Open Access

Limb Salvage in Diabetic Patients: The Italian Experience

Luigi Uccioli*, Marco Meloni and Valentina Izzo
Department of Internal Medicine, University of Tor Vergata, Rome, Italy
Corresponding Author : Luigi Uccioli
Department of Internal Medicine, University of Tor Vergata
Viale Oxford 81,00133 Rome, Italy
Tel: +390620902784
Fax: +390620902804
E-mail: luccioli@yahoo.com
Received March 18, 2014; Accepted March 20, 2014; Published March 25, 2014
Citation: Uccioli L, Meloni M, Izzo V (2014) Limb Salvage in Diabetic Patients: The Italian Experience. Clin Res Foot Ankle S3:007. doi:10.4172/2329-910X.S3-007
Copyright: © 2014 Uccioli L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Related article at
DownloadPubmed DownloadScholar Google

Visit for more related articles at Clinical Research on Foot & Ankle

View PDF Download PDF

Abstract

Diabetes is rapidly increasing worldwide and diabetic foot is the main cause of non-traumatic lower limbs amputation. However epidemiological data report a reduction of amputee’s rate in different European countries and in USA. Also in Italy there were excellent results related to the improvement of treatment strategies. The aim of this commentary is to describe the Italian model analyzing the reasons that have contributed to this success.

Abstract
Diabetes is rapidly increasing worldwide and diabetic foot is the main cause of non-traumatic lower limbs amputation. However epidemiological data report a reduction of amputee’s rate in different European countries and in USA. Also in Italy there were excellent results related to the improvement of treatment strategies. The aim of this commentary is to describe the Italian model analyzing the reasons that have contributed to this success.
Keywords
Diabetes; Diabetic foot; Non-traumatic; Amputation
Commentary
Diabetes can be considered a fast-growing epidemic disease that currently affects 346 million people with a prevalence of 6% in the general population [1]. It is well know that diabetic foot (DF) is a typical and common complication of diabetes. The most recent epidemiological data report that a lesion appears in 15% of cases during the life of a diabetic patient [2-4]. Furthermore DF is the main cause of hospitalization and non-traumatic lower extremity amputation [3-5]. If we considered that the prevalence of major lower limb amputation affects more than 1 million of people between diabetic patients (4,8%), it is obvious the strong impact of this disease on the society in terms of quality of life and economic costs [6,7].
Currently the worldwide incidence of lower limbs loss is high with significant differences reported by various studies. In 1989, the Saint Vincent Declaration marked an important step with the aim to reduce the incidence of lower extremity amputations improving the healthcare measures for DF complications [8]. From this date several studies revealed significant improvements in the incidence of major amputation of lower limbs [9-14]. Amputees rate among the different countries are extremely variable and this odds could be explained by the heterogeneity of the population analyzed and the not standardized strategy to treat DF [15-21]. Also social, geographical and economics factors may influence the possibility of certain patients to access to necessary treatment for their disease, restricting the possibility of care for these group of people [22]. Overall in the European context there is a trend of reduction of major amputation that can be related to the reinforcement of multidisciplinary approach and the implementation of podiatry service [19-21].
In this scenary, Italy has a prominent role for the significant results obtained in terms of limb salvage in diabetic patients affected by peripheral arterial disease (PAD) complicated by diabetic foot ulcers (DFU) and critical limb ischemia (CLI).
Also in Italy the prevalence of diabetes is progressively increasing. According to the epidemiological analysis of the year 2012, 3.000.000 persons are affected by diabetes with a prevalence of 5.5% in the general population (www.epicentro.iss.it/igea/en/FactSheet.asp)
Italian data were reported in a recent study where the period 2001-2010 was analyzed. In these years, a mean annual of 11,639 subjects were amputees and 58,6% of whom had diabetes. The risk of major and minor amputation in patient with diabetes was respectively 6,4 and 11 times higher compared to patients without diabetes. In 2010, 2,47 for 1,000 people with diabetes had an amputation of the lower limbs. Overall it is documented a progressive reduction of amputations rate for major amputations among persons with diabetes (-30.7%), while the rate of minor amputations was stable (-4.6%) [23]. Therefore this recent Italian analysis reflects the framework of some European countries and USA characterized by a significant reduction in the rate of major amputations [11,20,24-30]. In this regard Italian model can be considered as a reference for the approach to DF disease. The main reasons of Italian success may be found both in the improvement of diabetes therapy and in the knowledge and approach to DF,especially in the treatment of lower limbs arterial disease with the implementation of endovascular approach that now guarantees a treatment for almost all patients affected by CLI [31-35]. It is well known that infection and ischemia show a rapid evolution and these conditions are the main risk factor for major lower limb amputation [36,37]. In relation to the necessity for identifying and treating a DFU with a high risk to be amputee, recent Italian papers implemented the role of the multidisciplinary approach and the need to establish a protocol of diagnosis and treatment for critical diabetic foot (CDF). Caravaggi et al. designed a new system of Diabetic Foot Triage to identify a diagnostic flow chart to stratify the severity of infectious process and to establish a surgical integrated protocol in case of emergency [38]. In our recent paper we defined the conditions of CDF and we have consolidated the main four point that must be treated in condition of emergency: 1) extensive surgical debridement to remove infected tissues, 2) aggressive antibiotic therapy, 3) immediate revascularization in case of ischemia, 4) careful management of general conditions [39].
In the Italian way of approaching to limb salvage, the management of vascular disease plays certainly a key role. In our country, the endovascular treatment of lower extremity disease is a steady approach and our results have validated this strategy to treat diabetic ischemic foot. In this regard, Italy has a prevalence of amputations among the lowest in Europe [40] and the Eurodiale study, where 14 European tertiary reference centers for the treatment of DF were included, reported that Italian centers had the best outcomes in terms of wound healing and amputation [41,42]. According to this concept, in 2013, the Italian Society of Diabetes (SID, AMD), Radiology (SIRM) and Vascular and Endovascular Surgery (SICVE) published the Italian guidelines for the treatment of PAD in diabetic patients. In this consensus document the role of angioplasty is emphasized. Several studies showed the effectiveness, the feasibility, the high rate of limb salvage and low operative risk of endovascular treatment [43-49]. Even if in certain conditions surgical revascularization allows a higher long-term patency if compared to angioplasty [50,51], several reasons justify the widespread use of percutaneous transluminal angioplasty (PTA) to treat PAD in diabetic patients. Usually a large part of diabetic patients affected by CLI are elderly with several comorbidity. Therefore they can’t tolerate a surgical procedure for the high operative risk and secondly it is often no possible to pack a by-pass because of the absence of a suitable vein and due to the presence of a local infection that may not guarantee an adequate anastomosis site [43,45,46,52-55]. In these fragile patients the endovascular approach can be considered the only option for its minimally invasiveness because it does not require general anesthesia and has few contraindications in patients with existing heart or kidney disease [32,43,46]. Moreover the lower limbs angioplasty can be divided in different times, performing a second procedure only after appropriate clinical and instrumental assessment which shows the need for other treatment. In this way it is possible reduce the surgical stress and the amount of contrast medium that can determine a contrast induced nephropathy or worsen the condition of renal failure in patients with already compromised renal function. Angioplasty can be easily repeated and it must be underlined that in the last years there was a significant growth of instrumental and alternative techniques which also allow the treatment of distal and aggressive lower limbs vascular disease [56]. Farther, a close collaboration between physicians who manage the clinical foot problem and interventional radiologist has now established. This cooperation allowed to design the road map for diagnosis of CLI and the best endovascular approach. Particularly, it is currently stronger the concept of “wound related artery”, defined as the target revascularization addressed to the artery that perfuses the wound area [57,58]. Moreover, the treatment of the angiosome involved by the lesion seems to show best results in terms of limb salvage and wound healing if compared to not target revascularization [59,60]. All these considerations have consolidated the concept of angioplasty first approach to treat the PAD in diabetic patients with CLI andDFU [61]. In relation to the incidence of major amputation, a separate discussion should be done about the dialyzed diabetic patient. In fact, in diabetic patients under dialysis treatment affected by ischemic foot lesion, the rate of amputation reaches the 44% as documented in several studies [62]. In our recent paper, we found that dialysed patient showed worse results if compared to the other classes. Therefore our analysis confirmed that renal replacement therapy implies a high risk of amputation. However, we found a higher limb salvage rate and a reduced major amputation and death if compared to literature data; furthermore our patients were unselected. We retain that the explanation of these results could be related to endovascular approach. In fact the angioplasty is much less invasive than traditional by-pass and therefore more feasible in these patients with poor clinical conditions. Even more we did not find significant differences between the different chronic kidney disease classes and the positive outcomes for all groups despite the worse conditions could be justified by our less invasive approach and the strict follow-up [63].
Conclusion
In conclusion, even if the data collection of several studies can sometimes be affected by many variables, overall there is a reduction of the incidence of amputations in USA and in some European countries. In this special ranking Italy has a considerable position and we retain that Italian approach to DF and limb salvage can be considered as a reference model.
The reasons for this success achieved in recent years can be attributed to the improvement of diabetes therapy, the definition of a systematic approach in case of CDF with a high risk of limb threatening, the consolidation of the endovascular treatment in case of CLI, the implementation of multidisciplinary approach particularly in the collaboration between diabetic foot specialist and interventional radiologists.
References

References

  1. value="1" id="Reference_Titile_Link">Centers for Disease Control (2000) Diabetes, A serious health problem. At-A-Glance 2000. Centers for Disease Control and Prevention, Atlanta, GA.

  2. value="2" id="Reference_Titile_Link">Palumbo PJ, Melton LJ (1985) Peripheral vascular disease and diabetes. In Diabetes in America. Data Compiled 1984, p. 1. US Government Printing Office, Washington, DC.

  3. value="3" id="Reference_Titile_Link">Reiber GE, Boyko EJ, Smith DG (1995) Lower extremity foot ulcers and amputations in diabetes. In Diabetes in America. (2ndedn), edited by MI Harris, C Cowie, and MP Stern, US Government Printing Office, Washington, DC.

  4. value="4" id="Reference_Titile_Link">Frykberg RG, Haabershaw GM, Chrzan JS (1998) Epidemiology of the diabetic foot: ulcerations and amputations. In Contemporary Endocrinology: Clinical Management of Diabetic Neuropathy, edited by A Veves, Humana Press, Totowa, NJ.

  5. value="5" id="Reference_Titile_Link">Pecoraro RE, Reiber GE, Burgess EM (1990) Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13: 513-521.

  6. value="6" id="Reference_Titile_Link">Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J (2005) The global burden of diabetic foot disease. Lancet 366: 1719-1724.

  7. value="7" id="Reference_Titile_Link">Johannesson A, Larsson GU, Ramstrand N, Turkiewicz A, Wiréhn AB, et al. (2009) Incidence of lower-limb amputation in the diabetic and nondiabetic general population: a 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations. Diabetes Care: 275-280.

  8. value="8" id="Reference_Titile_Link">Ebskov B, Ebskov L (1996) Major lower limb amputation in diabetic patients: development during 1982 to 1993. Diabetologia 39: 1607-1610.

  9. value="9" id="Reference_Titile_Link">Canavan RJ, Unwin NC, Kelly WF, Connolly VM (2008) Diabetes- and non diabetes-related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care: continuous longitudinal monitoring using a standard method. Diabetes Care 31: 459-463.

  10. value="10" id="Reference_Titile_Link">Henke PK (2009) Contemporary management of acute limb ischemia: factors associated with amputation and in-hospital mortality. Semin Vasc Surg 22: 34-40.

  11. value="11" id="Reference_Titile_Link">Krishnan S, Nash F, Baker N, Fowler D, Rayman G (2008) Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 31: 99-101.

  12. value="12" id="Reference_Titile_Link">Karakoc A, Ersoy RU, Arslan M, Toruner FB, Yetkin I (2004) Change in amputation rate in a Turkish diabetic foot population. J Diabetes Complications 18: 169-172.

  13. value="13" id="Reference_Titile_Link">Aksoy DY, Gürlek A, Cetinkaya Y, Oznur A, Yazici M, et al. (2004) Change in the amputation profile in diabetic foot in a tertiary reference center: efficacy of team working. Exp Clin Endocrinol Diabetes 112: 526-530.

  14. value="14" id="Reference_Titile_Link">Jeffcoate WJ, van Houtum WH (2004)Amputation as a marker of the quality of foot care in diabetes. Diabetologia 47: 2051.

  15. value="15" id="Reference_Titile_Link">Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, et al. (2011) Lower extremity amputations--a review of global variability in incidence. Diabet Med 28: 1144-1153.

  16. value="16" id="Reference_Titile_Link">Trautner C, Haastert B, Mauckner P, Gätcke LM, Giani G (2007) Reduced incidence of lower-limb amputations in the diabetic population of a German city, 1990-2005: results of the Leverkusen Amputation Reduction Study (LARS). Diabetes Care 30: 2633-2637.

  17. value="17" id="Reference_Titile_Link">López-de-Andrés A, Martínez-Huedo MA, Carrasco-Garrido P, Hernández-Barrera V, Gil-de-Miguel A, et al. (2011) Trends in lower-extremity amputations in people with and without diabetes in Spain, 2001-2008. Diabetes Care 34: 1570-1576.

  18. value="18" id="Reference_Titile_Link">Fosse S, Hartemann-Heurtier A, Jacqueminet S, Ha Van G, Grimaldi A, et al. (2009) Incidence and characteristics of lower limb amputations in people with diabetes. Diabet Med 26: 391-396.

  19. value="19" id="Reference_Titile_Link">Larsson J, Apelqvist J, Agardh CD, Stenström A (1995) Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach? Diabet Med 12: 770-776.

  20. value="20" id="Reference_Titile_Link">Anichini R, Zecchini F, Cerretini I, Meucci G, Fusilli D, et al. (2007) Improvement of diabetic foot care after the Implementation of the International Consensus on the Diabetic Foot (ICDF): results of a 5-year prospective study. Diabetes Res Clin Pract 75: 153-158.

  21. value="21" id="Reference_Titile_Link">van Houtum WH, Rauwerda JA, Ruwaard D, Schaper NC, Bakker K (2004) Reduction in diabetes-related lower-extremity amputations in The Netherlands: 1991-2000. Diabetes Care 27: 1042-1046.

  22. value="22" id="Reference_Titile_Link">Lavery LA, van Houtum WH, Armstrong DG, Harkless LB, Ashry HR, et al. (1997) Mortality following lower extremity amputation in minorities with diabetes mellitus. Diabetes Res Clin Pract 37: 41-47.

  23. value="23" id="Reference_Titile_Link">Lombardo FL, Maggini M, De Bellis A, Seghieri G, Anichini R (2014) Lower extremity amputations in persons with and without diabetes in Italy: 2001-2010. PLoS One 9: e86405.

  24. value="24" id="Reference_Titile_Link">Ikonen TS, Sund R, Venermo M, Winell K (2010) Fewer major amputations among individuals with diabetes in Finland in 1997-2007: a population-based study. Diabetes Care 33: 2598-2603.

  25. value="25" id="Reference_Titile_Link">Li Y, Burrows NR, Gregg EW, Albright A, Geiss LS (2012) Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988–2008. Diabetes Care 35: 273-277.

  26. value="26" id="Reference_Titile_Link">Holstein P, Ellitsgaard N, Olsen BB, Ellitsgaard V (2000) Decreasing incidence of major amputations in people with diabetes. Diabetologia 43: 844-847.

  27. value="27" id="Reference_Titile_Link">Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, et al. (2010) Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 97: 1348-1353.

  28. value="28" id="Reference_Titile_Link">Icks A, Haastert B, Trautner C, Giani G, Glaeske G, et al. (2009) Incidence of lower-limb amputations in the diabetic compared to the non-diabetic population. findings from nationwide insurance data, Germany, 2005-2007. Exp Clin Endocrinol Diabetes 117: 500-504.

  29. value="29" id="Reference_Titile_Link">Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, et al. (2010) Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care 33: 2592-2597.

  30. value="30" id="Reference_Titile_Link">Schofield CJ, Yu N, Jain AS, Leese GP (2009) Decreasing amputation rates in patients with diabetes-a population-based study. Diabet Med 26: 773-777.

  31. value="31" id="Reference_Titile_Link">Layden J, Michaels J, Bermingham S, Higgins B; Guideline Development Group (2012) Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ 345: e4947.

  32. value="32" id="Reference_Titile_Link">Werneck CC, Lindsay TF (2009) Tibial angioplasty for limb salvage in high-risk patients and cost analysis. Ann Vasc Surg 23: 554-559.

  33. value="33" id="Reference_Titile_Link">Faglia E, Mantero M, Caminiti M, Caravaggi C, De Giglio R, et al. (2002)Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med: 232.

  34. value="34" id="Reference_Titile_Link">Lupattelli T, Tannouri F, Garaci FG, Papa G, Pangos M, et al. (2010) Efficacy and safety of antegrade common femoral artery access closure using the Angio-Seal device: experience with 1889 interventions for critical limb ischemia in diabetic patients. J Endovasc Ther 17: 366-375.

  35. value="35" id="Reference_Titile_Link">Manzi M, Palena LM, Brocco E (2012) Clinical results using the direct stent puncture technique to treat SFA in-stent occlusion. J Endovasc Ther 19: 461-462.

  36. value="36" id="Reference_Titile_Link">Shah BR, Hux JE (2003) Quantifying the risk of infectious diseases for people with diabetes. Diabetes Care 26: 510-513.

  37. value="37" id="Reference_Titile_Link">Armstrong DG, Lavery LA, Harkless LB (1998) Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21: 855-859.

  38. value="38" id="Reference_Titile_Link">Caravaggi C, Sganzaroli A, Galenda P, Bassetti M, Ferraresi R, et al. (2013) The management of the infected diabetic foot. Curr Diabetes Rev 9: 7-24.

  39. value="39" id="Reference_Titile_Link">Uccioli L, Meloni M, Giurato L, Ruotolo V, Izzo V (2013) Emergency in Diabetic Foot. Emergency Med:160.

  40. value="40" id="Reference_Titile_Link">Anichini R, Lombardo F, Maggini M. Ricoveri per diabete, piede diabetico e amputazioni in Italia. In Il diabete in Italia, Graziella Bruno Editor. Edizioni Minerva L.

  41. value="41" id="Reference_Titile_Link">PrompersL, Schaper N, Huijberts M (2008)Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study Diabetologia 747-755.

  42. value="42" id="Reference_Titile_Link">Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, et al. (2008) Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study.DiabetMed 2008:700-707.

  43. value="43" id="Reference_Titile_Link">Faglia E, Caravaggi C, Marchetti R, Mingardi R, Morabito A, et al. (2005) Screening for peripheral arterial disease by means of the ankle-brachial index in newly diagnosed Type 2 diabetic patients. Diabet Med 22: 1310-1314.

  44. value="44" id="Reference_Titile_Link">Ferraresi R, Centola M, Ferlini M, Da Ros R, Caravaggi C, et al. (2009) Long-term outcomes after angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia. Eur J Vasc Endovasc Surg 37: 336-342.

  45. value="45" id="Reference_Titile_Link">Uccioli L, Gandini R, Giurato L, Fabiano S, Pampana E, et al. (2010) Long-term outcomes of diabetic patients with critical limb ischemia followed in a tertiary referral diabetic foot clinic. Diabetes Care 33: 977-982.

  46. value="46" id="Reference_Titile_Link">Faglia E, Mantero M, Caminiti M, Caravaggi C, De Giglio R, et al. (2002) Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med: 225-232.

  47. value="47" id="Reference_Titile_Link">Gargiulo M, Maioli F, Ceccacci T, Morselli-Labate AM, Faggioli G, et al. (2008) What’s next after optimal infrapopliteal angioplasty? Clinical and ultrasono- graphic results of a prospective single- center study. J Endovasc Ther 15:363-369.

  48. value="48" id="Reference_Titile_Link">Jämsén T, Manninen H, Tulla H, Matsi P (2002) The final outcome of primary infrainguinal percutaneous transluminal angioplasty in 100 consecutive patients with chronic critical limb ischemia. J Vasc Interv Radiol 455-463.

  49. value="49" id="Reference_Titile_Link">Hering J, Angelkort B, Keck N, Wilde J,Amann B (2010) Long-term outcome of successful percutaneous transluminal angioplasty of the fibular artery in diabetic foot syndrome and single-vessel calf perfusion depends on doppler wave pattern at the forefoot. Vasa.

  50. value="50" id="Reference_Titile_Link">Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, et al. (2003) A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg 37: 307-315.

  51. value="51" id="Reference_Titile_Link">Romiti M, Albers M, Brochado-Neto FC, Durazzo AE, Pereira CA, et al. (2008) Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 47: 975-981.

  52. value="52" id="Reference_Titile_Link">Boodhwani M, Sodha NR, Mieno S, Xu SH, Feng J, et al. (2007) Functional, cellular, and molecular characterization of the angiogenic response to chronic myocardial ischemia in diabetes. Circulation 116: I31-37.

  53. value="53" id="Reference_Titile_Link">Weis-Müller BT, Römmler V, Lippelt I, Porath M, Godehardt E, et al. (2011) Critical chronic peripheral arterial disease: does outcome justify crural or pedal bypass surgery in patients with advanced age or with comorbidities? Ann Vasc Surg 25: 783-795.

  54. value="54" id="Reference_Titile_Link">Werneck CC, Lindsay TF (2009) Tibial angioplasty for limb salvage in high-risk patients and cost analysis. Ann Vasc Surg :554.

  55. value="55" id="Reference_Titile_Link">Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, et al. (2006) Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg 32: 484-490.

  56. value="56" id="Reference_Titile_Link">Gandini R, Uccioli L, Spinelli A, Del Giudice C, Da Ros V, et al. (2013) Alternative techniques for treatment of complex below-the knee arterial occlusions in diabetic patients with critical limb ischemia. Cardiovasc Intervent Radiol 36: 75-83.

  57. value="57" id="Reference_Titile_Link">Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 40: 113-141.

  58. value="58" id="Reference_Titile_Link">Attinger CE, Evans KK, Bulan E, Blume P, Cooper P (2006) Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 117: 261S-293S.

  59. value="59" id="Reference_Titile_Link">Iida O, Nanto S, Uematsu M, Ikeoka K, Okamoto S, et al. (2010) Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv 75: 830-836.

  60. value="60" id="Reference_Titile_Link">Alexandrescu V, Vincent G, Azdad K, Hubermont G, Ledent G, et al. (2011) A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty. J Endovasc Ther 18: 376-387.

  61. value="61" id="Reference_Titile_Link">Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, et al. (2013)Treatment of peripheral arterial disease in diabetes a consensus of the Italian Societies of Diabetes (SID, AMD), radiology (SIRM) and vascular endovascular surgery (SICVE). Nutr Metab Cardiovasc Dis.

  62. value="62" id="Reference_Titile_Link">Albers M, Romiti M, Bragança Pereira CA, Fonseca RL, da Silva Júnior M (2001) A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. Eur J Vasc Endovasc Surg 22: 294-300.

  63. value="63" id="Reference_Titile_Link">Giurato, L, Gandini R, Meloni M., Pampana E, Ruotolo V, et al. (2013) Percutaneous Angioplasty in Diabetic Patients with Critical Limb Ischemia and Chronic Kidney Disease. Open Journal of Endocrine and Metabolic Diseases 3:208-212.

--
Limb Salvage in Diabetic Patients: The Italian Experience
Post your comment

Share This Article

Relevant Topics

Recommended Journals

View More

Article Tools

Article Usage

  • Total views: 14589
  • [From(publication date):
    specialissue-2014 - Sep 20, 2024]
  • Breakdown by view type
  • HTML page views : 10095
  • PDF downloads : 4494

Post your comment

captcha   Reload  Can't read the image? click here to refresh
Peer Reviewed Journals

Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals

Journals by Subject

Agri and Aquaculture Biochemistry Bioinformatics & Systems Biology Biomedical Sciences Business & Management Chemical Engineering Chemistry Clinical Sciences Computer Science Economics & Accounting Engineering Environmental Sciences Food & Nutrition General Science Genetics & Molecular Biology
Geology & Earth Science Immunology & Microbiology Informatics Materials Science Mathematics Medical Sciences Nanotechnology Neuroscience & Psychology Nursing & Health Care Pharmaceutical Sciences Physics Plant Sciences Social & Political Sciences Veterinary Sciences

Clinical & Medical Journals

Anesthesiology Cardiology Clinical Research Dentistry Dermatology Diabetes & Endocrinology Gasteroenterology Genetics Haematology Healthcare Immunology Infectious Diseases Medicine Microbiology
Molecular Biology Nephrology Neurology Nursing Nutrition Oncology Ophthalmology Orthopaedics Pathology Pediatrics Physicaltherapy & Rehabilitation
Psychiatry Pulmonology Radiology Reproductive Medicine Surgery Toxicology
International Conferences 2024-25
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Conferences by Country

USA Australia Italy Germany UK Japan Brazil South Korea Netherlands
Spain Canada China France India Singapore South Africa New Zealand Philippines
Poland Austria Finland Denmark Mexico Norway Romania

Medical & Clinical Conferences

Microbiology Diabetes & Endocrinology Nursing Healthcare Management Neuroscience Immunology Gastroenterology Genetics & MolecularBiology Pathology Alternative Healthcare Pediatrics Ophthalmology
Oncology & Cancer Cardiology Dentistry Physical Therapy Rehabilitation Psychiatry Infectious Diseases Medical Ethics & Health Policies Palliativecare Reproductive Medicine & Women Healthcare Surgery Radiology

Conferences By Subject

Pharmaceutical Sciences Pharma Marketing & Industry Agri, Food & Aqua Nutrition Physics & Materials Science Environmental Science EEE & Engineering Veterinary Chemical Engineering Business Management Massmedia Geology & Earth science
Top