Endovascular Vs Surgery in Diabetic Foot Patients Dr. Ravul Jindal MS FRCS FAMS FIVS Director Vascular Surgery (President Venous Association of India) Fortis Hospital Mohali, India

1. Dr Ravul jindal MS FRCS FAMS FIVS
Director vascular surgery
President Venous Association of India
Fortis Hospital
Mohali
India
www.indianvascularsurgery.com
Endovascular vs Surgery in
diabetic foot patients

2. Correct choice of treatment
at the right time
saves life and limbs
avoids unnecessary costs

3. Current scenario
The choice of Endovascular therapy (EVT) first vs surgical bypass for
patients with tissue loss, PAD, and diabetes is currently much debated
A recent comprehensive evidence-based review could find no clear
evidence favouring EVT vs open bypass
No randomized trials have been performed in patients with diabetes
between these two techniques

4. • Advantages
– Durable
– Effective (limb salvage / symptom relief)
• Disadvantages
– Morbidity & Mortality (5%)
– Poor long term patency BK
– Surveillance
– Potentially morbid
Surgical Bypass

5. Catheter based interventions
• Advantages
– Effective (limb salvage / symptom relief)
– Non-invasive
– Low Morbidity & Mortality
– Can be repeated
• Disadvantages
– Poor long term patency
– May have to be repeated
– Expensive!

6. Anatomical Factors
Location
Morphology of the lesion (TASC)
Guidelines
 Iliac: A,B,C – Catheter
 Femoro-popliteal: A, B – Catheter
 Tibial – Catheter if possible

7. `

8. TASC -Femoral-Popliteal Lesions

9. Long SFA occlusion

10. Bilateral SFA occlusions
TASC D right side

11. TASC D Aortoiliac occlusion
Patient condition

18. COST

22. Distal reconstructions

24. Left CLI with previous CABG
Poor conduit on other side

25. What u want to do here ?

26. PAD: Endovascular Intervention, Surgery &
Amputation Trends: 1996-2006
100
200
300
400
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Numberofprocedures/100,000Medicarebeneficiaries
Years
J Vascular Surgery 2009; 50:54-60
Total endovascular interventions
RR=3.3; 95% CI 2.9-3.8
Major LE amputation
RR=0.71; 95% CI 0.7-0.8
LE bypass surgery
RR=0.58; 95% CI 0.5-0.7
3x growth in endovascular interventions

27. A clinical practice guideline by the SVS in collaboration with the
American Podiatric Medical Association and the SVM JVS 2016
In functional patients with long-segment occlusive
disease and a good autologous conduit, bypass is likely to
be preferable
In the setting of tissue loss and diabetes, prosthetic
bypass is inferior to bypass with vein conduit

28. Conclusion
A balanced view would acknowledge that both EVT and open
surgery are important means of revascularization as part of a
comprehensive approach to functional limb salvage in
patients with diabetes
The choice of intervention likely depends on the degree of
ischemia, the extent of arterial disease, the extent of the
wound, the presence or absence of infection, and the
expertise of the practitioner