Shining a light on an underexplored area

It’s a joy for me to see a topic examined which, clinically, I have long suspected to be true. This paper examines the long-term effectiveness of open vascular surgery compared to endovascular interventions in patients with diabetic heel ulceration and peripheral arterial disease (PAD). It was undertaken at Skåne University Hospital, Sweden. This study retrospective comparative study examined patients undergoing vascular interventions between 1983 and 2013 with follow-up until 2018. The aim of this study was to evaluate the difference in amputation-free survival (AFS) between open and endovascular revascularisation in patients with diabetes, PAD, and heel ulcers. Severe peripheral vascular disease (SPVD) was defined as toe pressure <45 mm Hg or ankle pressure <80 mm Hg, however, there was no definition of non-severe PAD. Retrospective data were collected from the endocrinology, vascular and orthopaedic surgery databases from the two centres within the study region that had a population of 700,000 people. The two centres in this area are the only facilities that provide vascular interventions. Overall, 127 limbs with heel ulcers diabetes and PAD were included in the study, of which 121 underwent endovascular intervention and 30 by-pass surgery. There were no significant differences in demographic or comorbidities between the two groups. The mean age was 71 years (60–79) with 41% (n=53) being female. The median follow-up period was 40 months (interquartile range was 14–90 months. Patients in the by-pass group were more often current smokers (P=0.015), and more often had ischaemic heart disease (P=0.002) and SVPD (P=0.001) compared to the group not undergoing vascular surgery. Previous ulcer was more common in the endovascular group (P=0.001), compared with by-pass group, whereas patients treated with open vascular surgery more often had foot oedema (P=0.006) and local foot pain (P=0.038), compared to the endovascularly treated group. AFS was higher in patients undergoing by-pass group compared to the endovascular group (P=0.009). The obvious confounding/biases in this study are clear; it is retrospective, small group numbers, advanced changes in diagnostic imaging over the study period, no definition of PAD, only SPVD, and the improvements in pharmacological agents (e.g. statins, platelet aggregation inhibitors) in the latter years of the study period.
That said, heel ulcers are notoriously difficult to heal and this study clearly suggests that for heel ulceration and AFS rates, open by-pass surgery appears to have much better outcomes than endovascular interventions. This is an area that should be looked at more closely and perhaps hybrid approaches using endovascular and open surgery may yield better long-term AFS in all foot ulcers.