The effectiveness of direct revascularization (DR) versus indirect revascularization (IR) and open versus endovascular revascularization for people with diabetes, peripheral artery disease (PAD), and tissue loss is inconclusive in terms of wound healing, prevention of minor and major amputations, and adverse events, according to a study published in Diabetes Metabolism Research and Reviews.
To determine whether DR was superior to IR in people with diabetes and tissue loss for wound healing or preventing minor and major amputation and adverse events, researchers performed a systematic review of title and abstract searches conducted from 1980 to November 30, 2022. The study also aimed to determine whether endovascular revascularization was superior to open revascularization for wound healing or preventing minor and major amputation and adverse events. A total of 26 studies with 5190 participants compared DR and IR, while 11 studies with 28,182 participants who received an endovascular procedure and 9515 participants who received an open procedure were included in the review.
When comparing DR and IR, all studies reported a greater proportion of participants healed with a DR (66.9%-96.4%) than IR (54.6%-85.7%). For minor and major amputations, DR seemed to reduce the number of participants requiring amputations. For example, 3 of 4 studies reported fewer major amputations in those receiving DR (2.9%-13.4%) compared with those who received IR (9.2% to 27.2%).
However, IR with collaterals may reduce major adverse limb events similar to DR. IR with collaterals may also improve amputation-free survival at higher rates than IR and DR. Of the 4 studies that reported the outcome of mortality, 2 studies reported lower mortality in those receiving DR. The 2 other studies reported a nonsignificant difference between DR and IR in lowering mortality rates. The certainty of evidence was rated as very low in people with diabetes, PAD, and a foot ulcer on whether DR is superior to IR in healing, preventing amputations, preventing mortality, or increasing survival.
The certainty of evidence was moderate for open revascularization surgery being more effective than endovascular revascularization in preventing major adverse limb events or death. However, evidence is low to support whether endovascular revascularization is more effective to open or hybrid revascularization to heal a foot ulcer or prevent minor or major amputations in people with diabetes, PAD, and tissue loss.
Study limitations include the evidence not being captured during the search, the researchers not being contacted for unpublished studies, and the data lacking suitability for meta-analysis, which limits the interpretation of the study.
“The findings of this review highlight the limited evidence comparing outcomes for DR and IR and endovascular and open revascularisation for diabetes‐related foot disease, including healing and amputation,” the researchers wrote.
Chuter V, Schaper N, Mills J, et al. Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev. Published online August 4, 2023. doi:10.1002/dmrr.3700