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Antiphospholipid syndrome is an autoimmune disease characterized by vascular thrombosis involving both the arterial and venous systems that can lead to tissue ischemia or end-organ damage. Much of the literature describes various symptoms at initial presentation, but isolated tissue ischemia manifesting as a solitary blue toe is unusual. We discuss a case of a 23-year-old man who presented to the emergency department with a solitary blue fourth digit with minimal erythema and edema, who was suffering from exquisite pain. Following an extensive workup, the patient was diagnosed with antiphospholipid syndrome with thrombi of the vasculature in their lower extremity. With therapeutic anticoagulation, the patient's symptoms subsided and amputation of the digit was prevented.

Background: The treatment of diabetic foot ulcers in this case is complex and multidisciplinary, and an interdisciplinary team is extremely beneficial., Case Presentation: We performed the intervention on an old type 2 diabetes patient with poor health, whose left toes were severely necrotic. Surgery, including debridement and patella truncation, had positive effects on lower extremity circulation, infection control, cavity treatment, bone destruction, surgical debridement, recovery of foot function, and nursing. After 5 months, the patient's foot ulcer had healed, and walking function was preserved., Conclusions: Scheduling interventional surgery and debridement are the key point in a complicated diabetic foot ulcers case, and multidisciplinary collaboration in treatment of diabetic foot is significantly important.

Objectives: Among symptomatic dancers, sonographic abnormalities are common. Whether asymptomatic dancers have any abnormalities remains unknown. Some dancers became cyanosis over distal feet after ballet training. The hemodynamic changes at the feet in ballet are not clearly understood., Design: Cross-sectional study., Methods: In 25 dancers and 14 non-dancers, B-mode ultrasonography was used to measure cross-sectional areas (CSA) of tendons of deep posterior compartment muscles. Doppler ultrasonography was used to measure peak velocity (V peak ) of posterior tibial artery in three ankle postures: the neutral position, passively and forced actively plantar flexion (en pointe). The big toe oxygen saturation was recorded in neutral position and during 1-min en pointe. Single-leg standing heel rise test was performed to represent the muscle function., Results: The CSA of FHL was larger in dancers (0.26cm 2 [0.20, 0.30] vs 0.21cm 2 [0.17, 0.24], p<0.01), while other tendons were not different (all p>0.05). Higher V peak was recorded in passively plantar flexion than in neutral position (p<0.01, in both groups). The blood flow was undetectable during en pointe, more frequently in dancers (54.9% vs 14.3%, p<0.01). Oxygen saturation decreased during en pointe more prominently in dancers (85% [80, 90] vs 94% [84, 97], p<0.01). There was no significant difference in muscle function., Conclusions: US showed the FHL tendon thickening and en pointe-related vascular compromise in pre-professional dancers, even when they are asymptomatic., (Copyright © 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: To evaluate foot perfusion in patients with critical limb ischemia (CLI) using quantitative perfusion multi-detector-row CT and estimate perfusion parameter changes before and after percutaneous transluminal angioplasty (PTA)., Materials and Methods: This prospective study investigated 13 patients (10 men; median age, 72 y; range, 51-84 y) with CLI who underwent CT foot perfusion examinations with a 128-slice dual-energy CT scanner 1 day before and 1 week after PTA. Key parameters such as permeability surface (PS), blood volume (BV), and blood flow (BF) were analyzed and compared statistically. The studies were also examined by a second observer to determine interobserver reproducibility., Results: Revascularization was technically successful in all patients, and mean ankle-brachial index increased from 0.36 ± 0.16 to 0.75 ± 0.22. After revascularization, mean BV increased from 1.55 mL/100 g ± 0.83 to 4.51 mL/100 g ± 1.53, BF increased from 16.28 mL/100 g/min ± 4.97 to 31.49 mL/100 g/min ± 6.86, and PS increased from 3.1 mL/min/100 g ± 1.95 to 8.67 mL/min/100 g ± 3.85 (P < .05). Patients with poor response to revascularization who finally underwent amputation presented lower post-PTA perfusion parameters values than patients with significant clinical improvement (P < .05). All measurements demonstrated very good interobserver reproducibility, and intraclass correlation coefficients were 0.91 for BV, 0.94 for BF, and 0.95 for PS. The mean effective dose of the examination was estimated at 0.29 mSv., Conclusions: CT foot perfusion is a reproducible technique that may be a useful modality for the estimation of PTA outcome. Significant restitution of perfusion parameters was observed after successful revascularization., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Pseudoaneurysms of the dorsalis pedis artery are rare complications following arthroscopic surgery. This manuscript reports a case of an intra-articular pseudoaneurysm presenting nearly 5 months following an arthroscopic Broström procedure. The rarity of this complication and the patient's unusual clinical presentation prompted the use of imaging to diagnose the problem and guide management. Although imaging artifacts are often a nuisance, recognition of clinically relevant artifacts can help make a diagnosis. This case illustrates such a situation.

The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature., (Copyright © 2019 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

We present a method of imaging angiographic structures in human extremities, including hands, arms, legs, and feet, using a newly developed photoacoustic computed tomography (PACT) system. The system features deep penetration (1.8 cm in muscular tissues) with high spatial and temporal resolutions. A volumetric image is acquired within 5 to 15 s while each cross sectional image is acquired within 100  μs. Therefore, we see no blurring from motion in the imaging plane. Longitudinal and latitudinal cross-sectional images of a healthy volunteer clearly show the vascular network of each appendage and highlight the system's ability to image major and minor vasculatures, without the use of an external contrast or ionizing radiation. We also track heartbeat-induced arterial movement at a two-dimensional frame rate of 10 Hz. This work substantiates the idea that PACT could be used as a noninvasive method for imaging human vasculatures.

Purpose: To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches., Materials and Methods: Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A "tension-free" surgical approach was used to treat foot lesions., Results: At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction., Conclusion: HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.

More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was effective in survival and functional recovery (salvage) of the extremity together with regular wound care, antibiotherapy and surgical repair., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright © Undersea and Hyperbaric Medical Society.)

Objectives: To assess the efficacy of indigo carmine angiography for wound healing after successful below-the-knee intervention in patients with critical limb ischemia (CLI)., Methods: A multi-center prospective intervention study was conducted. Fifty-four limbs of 53 patients in Rutherford categories 5 and 6 underwent endovascular therapy (EVT). After successful EVT, 5 mL of indigo carmine was injected through a catheter at the distal popliteal artery and color changes in the foot were evaluated. The results of indigo carmine angiography were divided into three groups: In type I, the color change of the wound was deeper than the surrounding tissue; in type II, the change in wound color was similar to the surrounding tissue; and in type III, no discoloration of the wound was observed by the indigo carmine., Results: The wound healing rates at 3 months were 78% (25/32) for type I, 70% (7/10) for type II, and 42% (5/12) for type III (P for trend = 0.025). Indigo carmine angiography-related complications were not seen., Conclusion: Indigo carmine angiography was found to be a safe and useful procedure to provide visual information on foot perfusion. This dye coloring method demonstrated that after successful angioplasty, the perfused area was made visible at the microcirculation level. Indigo carmine angiography can thus be considered an important predictor for wound healing by EVT in patients with CLI., (© 2018 Wiley Periodicals, Inc.)

Aneurysms of the dorsalis pedis artery are rare, and they are not commonly examined histologically. In general, pseudoaneurysms are thought to be more common than true aneurysms of the dorsalis pedis artery. We present a patient with a true aneurysm of the dorsalis pedis artery, which was initially diagnosed as a pseudoaneurysm that had developed because of a blunt trauma of the ankle. However, the intraoperative appearance and histological examination both confirmed a true aneurysm. Our experiences seem to confirm that postoperative histological examination is needed to distinguish pseudoaneurysms from true aneurysms of the dorsalis pedis artery. The treatment of aneurysms of the dorsalis pedis artery is simple and includes resection, which completely relieves the symptoms; few patients need vascular reconstructions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Over 30 million people in the United States (over 9%) have been diagnosed with diabetes. About 25% of people with diabetes will experience a diabetic foot ulcer (DFU) in their lifetime. Unresolved DFUs may lead to sepsis and are the leading cause of lower-limb amputations. DFU rates can be reduced by screening patients with diabetes to enable risk-based interventions. Skin temperature assessment has been shown to reduce the risk of foot ulceration. While several tools have been developed to measure plantar temperatures, they only measure temperature once a day or are designed for clinic use only. In this report, wireless sensor-embedded socks designed for daily wear are introduced, which perform continuous temperature monitoring of the feet of persons with diabetes in the home environment. Combined with a mobile app, this wearable device informs the wearer about temperature increases in one foot relative to the other, to facilitate early detection of ulcers and timely intervention., Objective: A pilot study was conducted to assess the accuracy of sensors used in daily wear socks, obtain user feedback on how comfortable sensor-embedded socks were for home use, and examine whether observed temperatures correlated with clinical observations., Methods: Temperature accuracy of sensors was assessed both prior to incorporation in the socks, as well as in the completed design. The measured temperatures were compared to the reference standard, a high-precision thermostatic water bath in the range 20°C-40°C. A total of 35 patients, 18 years of age and older, with diabetic peripheral neuropathy were enrolled in a single-site study conducted under an Institutional Review Board-approved protocol. This study evaluated the usability of the sensor-embedded socks and correlated the observed temperatures with clinical findings., Results: The temperatures measured by the stand-alone sensors were within 0.2°C of the reference standard. In the sensor-embedded socks, across multiple measurements for each of the six sensors, a high agreement (R 2 =1) between temperatures measured and the reference standard was observed. Patients reported that the socks were easy to use and comfortable, ranking them at a median score of 9 or 10 for comfort and ease of use on a 10-point scale. Case studies are presented showing that the temperature differences observed between the feet were consistent with clinical observations., Conclusions: We report the first use of wireless continuous temperature monitoring for daily wear and home use in patients with diabetes and neuropathy. The wearers found the socks to be no different from standard socks. The temperature studies conducted show that the sensors used in the socks are reliable and accurate at detecting temperature and the findings matched clinical observations. Continuous temperature monitoring is a promising approach as an early warning system for foot ulcers, Charcot foot, and reulceration., (©Alexander M Reyzelman, Kristopher Koelewyn, Maryam Murphy, Xuening Shen, E Yu, Raji Pillai, Jie Fu, Henk Jan Scholten, Ran Ma. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 17.12.2018.)

Buffaloes represent a major source of milk production, especially in developing countries including Egypt. The buffalo foot is frequently involved in a large proportion of lameness cases. The relatively small size and complexity of its structures often render the radiographic evaluation of the foot challenging. Magnetic resonance imaging (MRI) is a noninvasive imaging technique that is regarded as both safe and accurate for assessment of the foot disorders in both man and animals. The purpose of the current investigation was to describe the MRI anatomy of buffalo foot using cadaveric hind feet. The feet were subjected to consecutive MRI scanning using a 0.3 Tesla scanner. Both T1-weighted (T1-W) and T2-weighted (T2-W) spin-echo pulse sequences were applied in dorsal, sagittal and transverse planes. The heterogeneity of signal intensities noted amongst foot components allowed for clear differentiation of bones, tendons, ligaments, adipose tissue and synovial fluid. The T1-W images provided an excellent overview of the foot. They were valuable for visualizing the bones and the alignment of tendons and ligaments. The T2-W images were particularly useful for the evaluation of synovial structures such as tendon sheaths and joint cavities. A communication between the two plantar sacs of the metatarsophalangeal (fetlock) joints was evident in T2-W images. MRI findings were further confirmed using relevant gross anatomical sections. The present study establishes a detailed MRI anatomic reference of buffalo foot that could help veterinary researchers, clinicians and surgeons for increasing the accuracy of interpretation of foot MRI scans of both healthy and diseased animals., (© 2018 Blackwell Verlag GmbH.)

Critical limb ischemia (CLI) is the most severe manifestation of peripheral artery disease, which is common but rarely diagnosed. Noninvasive biomarkers are urgently required to assist in the diagnosis of CLI. Accumulating evidence indicates that miRNAs play an important role in the development of various diseases. In this study, microarray profiling revealed 11 miRNAs with significantly altered expression in four T2DM patients with CLI compared with that in four sex- and age-matched T2DM patients without CLI. In independent cohorts, qRT-PCR validation confirmed the increased miRNA-4739 level in patients with CLI versus patients without CLI. miRNA-4739 levels increased with FPG and HbA1c (all P < 0.05). After adjusting for the risk factors, miRNA-4739 levels were found to be associated with an increased odds ratio (OR) of T2DM with CLI (OR =12.818, 95% confidence intervals (CI) 1.148 to 143.143, P = 0.038). ROC curve analysis revealed that the area under the curve (AUC) of miR-4739+confounding risk factors was 0.94 (95% CI 0.891 to 0.998, P < 0.001), which was higher than that of confounding risk factors (AUC 0.94 vs . 0.91, 95% CI -0.122 to 0.060, P > 0.05) and of miR-4739 (AUC 0.94 vs . 0.69, 95% CI -0.399 to -0.101, P < 0.001), respectively. We conclude that elevated plasma miRNA-4739 levels are independently associated with CLI in T2DM patients. miRNA-4739 is implicated as a novel diagnostic marker and a potential therapeutic target for CLI in diabetes.

Timely diagnostics of microcirculatory system abnormalities, which are the most severe diabetic complications, is one of the major problems facing modern health care. Functional abnormalities manifest themselves earlier than the structural ones, and therefore their assessment is the issue of primary importance. In this study Laser Doppler flowmetry, a noninvasive technique for the cutaneous blood flow monitoring, was utilized together with local temperature tests and wavelet analysis. The study of the blood flow in the microvascular bed of toes was carried out in the control group of 40 healthy subjects and in two groups of 17 type 1 and 23 type 2 diabetic patients. The local temperature tests demonstrated that the diabetic patients have impaired vasodilation in response to local heating. The tendency for impaired low frequency pulsations of the blood flow associated with endothelial and neurogenic activities in both diabetes groups was observed. Local thermal tests induced variations in perfusion and its spectral characteristics, which were different in the groups under study. In our opinion, the obtained preliminary results can be a basis for further research and provide a deeper understanding of pathological processes that drive microvascular abnormalities caused by diabetes mellitus., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Previous studies show conflicting results in wound healing outcomes based on angiosome direct perfusion (DP), but few have adjusted for wound characteristics in their analyses. We have previously shown that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing in diabetic foot ulcers (DFUs) treated by a multidisciplinary team. The aim of this study was to compare WIfI classification vs DP and pedal arch patency as predictors of wound healing in patients presenting with DFU and peripheral arterial disease., Methods: We performed a retrospective review of a prospectively maintained database of all patients with peripheral arterial disease presenting to our multidisciplinary DFU clinic who underwent angiography. An angiosome was considered directly perfused if the artery feeding the angiosome was revascularized or was completely patent. Wound healing time at 1 year was compared on the basis of DP vs indirect perfusion, Rutherford pedal arch grade, and WIfI classification using univariable statistics and Cox proportional hazards models., Results: Angiography was performed on 225 wounds in 99 patients (mean age, 63.3 ± 1.2 years; 62.6% male; 53.5% black) during the entire study period. There were 33 WIfI stage 1, 33 stage 2, 51 stage 3, and 108 stage 4 wounds. DP was achieved in 154 wounds (68.4%) and indirect perfusion in 71 wounds (31.6%). On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2% for WIfI 3/4 vs 77.3% for WIfI 1/2; P = .02), whereas DP and pedal arch patency were not (both, P ≥ .08). After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing (WIfI 3/4: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.88), whereas DP (HR, 0.82; 95% CI, 0.55-1.21) and pedal arch grade (HR, 0.85; 95% CI, 0.70-1.03) were not., Conclusions: In our population of patients treated by a multidisciplinary diabetic foot service, the Society for Vascular Surgery WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. Our results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome-directed perfusion results previously observed., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis represents the current gold standard in calcaneal fracture treatment, but it is associated with a wound complication rate of up to 30%. Literature suggests that micro-circulation is one of the key factors for sufficient wound healing. The aim of this study was to evaluate soft tissue micro-circulation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in non-trauma situations, with special attention to surgical approaches., Methods: Micro-circulation of the lateral hindfoot of 125 participants was non-invasively measured at 2 and 8 mm depths, utilizing a Micro-Lightguide O2C® spectrophotometer. Blood flow (BF [AU]) and oxygen saturation (SO2 [%]) of ten measurement points (MPs) were documented. Demographic factors (age, gender, body mass index [BMI], systolic/diastolic blood pressure, smoking, and pack-years) and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach, and a self-modified extended lateral approach) were analyzed., Results: The SO2 assessments at 2- and 8-mm depths revealed higher values in males (p = 0.043; p = 0.025). There was a correlation between higher age and lower 2 mm BF (p = 0.044). Smoking history and number of pack-years did not predict micro-circulation. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach (p < 0.001). The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters (SO2 (2 mm), p < 0.001; SO2 (8 mm), p = 0.001; BF (2 mm), p < 0.001; BF (8 mm), p < 0.001), compared to the surrounding area., Conclusions: In non-trauma situations, young males were associated with better micro-circulatory supply of the lateral hindfoot. There was a trend for higher blood flow in regions of the Palmer and Ollier approach. The distal calcaneal tuberosity was clearly superior in all micro-circulatory parameters when compared to the surrounding area.

Background: Destruction of digits from trauma results in a much more significant influence on patients' mental state and quality of life than do injuries to other parts. The purpose of this study was to describe a novel modification of medial plantar venous flap for soft tissue defects in the hands and digits., Methods: Nine patients received medial plantar venous flap to resurface soft tissue defects in the hands or digits between January 2015 and February 2017. This flap can be used either in a free-island pattern or in a flow-through pattern through the medial branch of the great saphenous vein. All patient data including preoperative statues and follow-up examinations (flap survival rates, complication rates, total active motion, static 2-point discrimination, and Semme-Weinstein test score) were analyzed., Results: We included 6 men and 3 women, with a mean age of 34.2 years. The medial plantar venous flaps were used for vascularization in 5 patients because of segmental defects of bilateral digit arteries. Eight flaps survived uneventfully in this study. One flap partially failed (20% of the flap area) because of venous congestion. The functional outcomes and sensory restoration were satisfied for all 9 flaps., Conclusions: Compared with the traditional medial plantar flap, the medial plantar venous flap involves a simpler surgical procedure and allows for revascularization of distal areas using the flow-through technique. Furthermore, the medial plantar area presents a sensitive, glabrous skin with proper bulkiness and allows for movement of the underlying structure.

Background:  Peroneus brevis muscle flap is a distinguished, distally based safe flap that can be manipulated to cover small defects in the leg and ankle. For large-sized defects, a more distal, larger flap is required either locally or distantly., Methods:  Forty-two distally based peroneus brevis muscle flaps were elevated in 42 patients (30 males and 12 females) with major lower leg, ankle, and proximal foot defects of 6 to 15 cm in length and 6 to 12 cm in width. Anatomical findings were recorded as number, size, and sources of blood supply, entry sites, the lowermost two arterial supplies, internal distribution of blood supply to the muscle, the relationship between external and internal distribution of the blood vessels, the length of the muscle, the entry site of the main artery, and the splitting of the proximal portion of the peroneus brevis muscle to increase its width to sufficiently cover large defects., Results:  The anatomical findings suggested that the muscle can be safely extended to cover a large defect in the leg, ankle, or proximal foot. In addition, the longitudinal splitting of the muscle increases its width by up to three times, making it an excellent long-surviving flap to cover a large defect., Conclusion:  A distally based peroneus brevis muscle flap has a rich blood supply and safely reaches the proximal foot, with a secure splitting to cover large defects in the leg, ankle, and proximal foot., Competing Interests: None. Disclosure The author has no financial or personal relationships with other people or organizations that could inappropriately influence my work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The pedicled medial plantar (MP) flap is an optimal solution for defects involving the weight-bearing areas of the foot. However, venous congestion is a frequently encountered complication, especially with the reverse-flow variants of the flap, and several strategies have been reported in literature both to prevent and to manage it. In this article, we present the use of a medial plantar flap based distally on the lateral plantar artery with the adjunct of an extra metatarsal perforator from the dorsalis pedis artery as a vascular enhancement to avoid the venous congestion and to improve the overall circulation. This bipedicled flap was successfully advanced to cover a 5 × 3 cm soft-tissue defect located at the level of the first and second metatarsal heads of the right foot resulting from the excision of a squamous cell carcinoma in an 80-year-old male patient with a history of cardiovascular disease. The postoperative course was uneventful. The patient was discharged 7 days after the operation and was able to walk after 6 weeks wearing normal shoes. We believe that preserving plantar metatarsal perforators during the harvesting of an MP flap based distally on the lateral plantar artery may be a precious adjunct as it increases blood supply, especially the venous drainage of the flap., (© 2018 Wiley Periodicals, Inc.)

Introduction: Routine noninvasive vascular study results can be affected by a multitude of factors and do not provide information specific to the location of the wound. Results must be extrapolated and may prompt a false sense of security that adequate perfusion for healing exists., Case Report: The case of an 80-year-old Caucasian man, who presented with chronic ulceration of the left lateral malleolus and fifth metatarsal base with concurrent metatarsal osteomyelitis, is presented. Initial routine noninvasive vascular studies were consistent with peripheral vascular disease and chronic lower extremity wounds. Baseline near-infrared imaging (NIRI) assessment with a handheld device provided site-specific rapid assessment of tissue oxygen saturation, which revealed local ischemia, chronic inflammation, and infection. Wound deterioration over the next 2 months prompted repeat noninvasive vascular studies consistent with increased perfusion while rearfoot transcutaneous oximetry pressure measurements were inconclusive. The patient underwent formal vascular evaluation and intervention. Repeat NIRI assessment 5 days postoperatively revealed transition from the chronic inflammatory to the proliferative phase of wound healing., Conclusions: Serial NIRI assessment in this case highlights its ability to detect factors that led to delayed would healing in the face of unreliable routine noninvasive vascular study results.

Background: Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot., Methods: A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet., Results: One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527)., Conclusions: No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

Background: Shared decision making is a consultative process designed to encourage patient participation in decision making by providing accurate information about the treatment options and supporting deliberation with the clinicians about treatment options. The process can be supported by resources such as decision aids and discussion guides designed to inform and facilitate often difficult conversations. As this process increases in use, there is opportunity to raise awareness of shared decision making and the international standards used to guide the development of quality resources for use in areas of prosthetic/orthotic care., Objectives: To describe the process used to develop shared decision-making resources, using an illustrative example focused on decisions about the level of dysvascular partial foot amputation or transtibial amputation. Development process: The International Patient Decision Aid Standards were used to guide the development of the decision aid and discussion guide focused on decisions about the level of dysvascular partial foot amputation or transtibial amputation. Examples from these shared decision-making resources help illuminate the stages of development including scoping and design, research synthesis, iterative development of a prototype, and preliminary testing with patients and clinicians not involved in the development process., Conclusion: Lessons learnt through the process, such as using the International Patient Decision Aid Standards checklist and development guidelines, may help inform others wanting to develop similar shared decision-making resources given the applicability of shared decision making to many areas of prosthetic-/orthotic-related practice. Clinical relevance Shared decision making is a process designed to guide conversations that help patients make an informed decision about their healthcare. Raising awareness of shared decision making and the international standards for development of high-quality decision aids and discussion guides is important as the approach is introduced in prosthetic-/orthotic-related practice.

Introduction: Foot offloading is the mainstay treatment for plantar diabetic foot ulcers (DFUs)., Objective: This multicenter, single-blinded, randomized controlled trial evaluates the efficacy of a total offloading foot brace for healing plantar DFUs., Materials and Methods: Seventeen patients were randomized to standard therapy (ie, reducing stress and pressure via mechanical offloading) or offloading foot brace. Comparison of plantar pressures was performed using digital pressure sensing films. The ulcers were assessed by physical inspection and digital planimetry of photographs., Results: Reductions in peak plantar pressures ranged from 67.3% to 89.4% (P = .09). Healing at weeks 12 to 15 had minimal differences (brace vs. control: 71.7% vs. 80.3%, respectively). Although not significant, earlier periods of the brace versus the control demonstrated faster wound healing in weeks 2 to 5 (36.0% vs. 6.8%, respectively) and weeks 6 to 9 (50.7% vs. 17.0%, respectively)., Conclusions: The total offloading foot brace minimizes plantar pressure, allowing for early healing of DFUs, and optimizations in brace design may enhance healing of plantar DFUs.

The improvement of peripheral circulation is crucial for the care of vasculopathic diabetic foot ulcer (DFU). Near-infrared spectroscopy (NIRS) was used to investigate the effects of Buerger's exercise on dorsal foot skin circulation with novel technique of measuring the absorption difference in wavelength of light between oxy-hemoglobin (HbO 2 ) and deoxy-hemoglobin (HbR). Patients with vasculopathic DFU who could tolerate Buerger's exercise three times a day at home for at least 8 weeks were enrolled (group A). They were divided into two subgroups: without previous percutaneous transluminal angioplasty (PTA) (group A1) vs. with previous PTA (group A2). Wireless NIRS were applied on patients' dorsal foot to assess the peripheral circulation in follow-up clinics. The patients' wound condition, follow-up time, and concentration of HbO 2 and total hemoglobin (HbT) before and after exercise rehabilitation program were documented. From May 2015 to February 2016, 14 patients with average age of 70.2 ± 11.2 were enrolled in this study (group A), including eight without previous PTA (group A1), and six with previous PTA (group A2). The concentration of HbO2 and HbT were significantly increased after exercise rehabilitation program training in group A (p = 0.024 in HbO 2 , p = 0.02 in HbT, n = 14) and group A2 (p = 0.021 in HbO 2 , p = 0.028 in HbT, n = 6), while the concentration in group A1 were improved with borderline significance after exercise (p = 0.055 in HbO 2 , p = 0.058 in HbT, n = 8). The majority of the ulcers were either completely healed (11/14 = 78.57%) or improving (3/14 = 21.43%). Buerger's exercise improved the peripheral circulation and wound condition in patients with vasculopathic DFU. The wireless apparatus is a novel and efficient tool to monitor rehabilitation program.

The aim of this study was to investigate the plantar blood flow response to the same accumulated pressure stimulus in diabetic patients with different peak plantar pressure (PPP), which is important for assessing the risk of diabetic foot ulcer. Eleven diabetic subjects with high PPP (PPP ≥ 207 kPa) and 8 diabetic subjects with low PPP (PPP < 207 kPa) were asked to walk naturally on a treadmill so as to induce an accumulated stimulus of 73,000 kPa·s on their first metatarsal head, which was monitored with a sensorized insole. Blood perfusion (BP) in the first metatarsal head was measured before and after walking. Results showed that blood flow after applying the same walking stimulus was significantly decreased in comparison to the basal BP before walking in both high PPP and low PPP groups (p < 0.05), but no significant differences were found between the two groups in terms of BP parameters and its percentage change (p > 0.05). Moreover, BP parameters were not significantly correlated to PPP and the pressure-time integral (PTI) of the subjects' gait (p > 0.05). This indicated that, besides PPP and PTI, the accumulated mechanical stimulus should be taken into consideration when assessing the risk of diabetic patients developing foot ulcers. Graphical abstract Plantar blood flow response to a walking stimulus.

Diabetes may cause different foot problems, which could easily lead to infection, ulcers, and increasing risk of amputation due to nerve or vascular injury. In order to reduce the risk of amputation, Buerger's exercise is frequently used for rehabilitation to improve the blood circulation in lower limbs. However, it is difficult to evaluate the rehabilitation efficiency with Buerger's exercise objectively. In this study, a novel non-invasively optical system is developed to non-invasively monitor the change of the foot blood circulation before and after long-term Buerger's exercise. Radial basis function neural network is also used for classifying the healthy and diabetic groups from the change of relative total hemoglobin (HbT) concentration and tissue oxygen saturation (StO2) and providing an index to evaluate the rehabilitation efficiency with Buerger's exercise. Finally, the experimental results show that the relative HbT concentration and StO2 in lower limbs corresponding to different groups are significantly different and could be used as the factors for the classification of healthy subjects and diabetic foot patients. Moreover, the tendency of the relative HbT concentration and StO2 rise after the long-term rehabilitation with Buerger's exercise.

Background: We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system., Methods: The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections., Results: Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity., Conclusions: The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.

Background: Spectral Doppler ultrasound examination of pedal arteries is one of the most frequently used noninvasive assessment methods by health-care professionals for the diagnosis and ongoing monitoring of people at risk for or living with peripheral arterial disease. The aim of this study was to determine the interrater reliability of the interpretation of spectral Doppler waveform analysis., Methods: An interrater reliability study was conducted among five experienced podiatric physicians at the University of Malta Research Laboratory (Msida, Malta). A researcher who was not a rater in this study randomly selected 229 printed spectral Doppler waveforms from a database held at the University of Malta. Each rater independently rated the qualitative spectral waveforms., Results: Interrater reliability of the spectral Doppler waveform interpretation was excellent among the five experienced podiatric physicians (α = 0.98). The intraclass correlation coefficient showed a high degree of correlation in waveform interpretation across raters ( P < .001)., Conclusions: This study demonstrates high interrater reliability in visual spectral Doppler interpretation among experienced clinicians. The current foot screening guidelines do not refer to spectral Doppler waveform analysis in their recommendations, which has been shown in studies to be an important modality for the diagnosis of peripheral arterial disease when ankle-brachial pressure indexes are falsely elevated in calcified arteries. If interpreted correctly, the information obtained can provide an indication of the presence of peripheral arterial disease and facilitate early management of this condition.

The rodent model has been largely used for understanding specific disease pathophysiology, with low cost and the large spectrum from genetic strains. Here, we present a diffuse speckle contrast analysis (DSCA) system to measure blood flow changes non-invasively in rat's thigh and paw during femoral arterial occlusion (FAO) surgery which is the procedure for inducing peripheral arterial disease. The blood flow index in rat's paw showed significant decrease according to arterial occlusion. Moreover, we analyzed cross-correlation between two measurement positions. The results showed the affinity with hemodynamic response. In conclusion, the DSCA system secured the intraoperative blood flow monitoring during FAO surgery in a rat model.

Objectives: The purpose of this prospective study was to evaluate the acute success and complication rates of combined transradial and transpedal access for femoral artery intervention., Background: Improved equipment and techniques have resulted in transition from transfemoral to transradial access for intervention of superficial femoral artery., Methods: Between 2014 and 2016, clinical and angiographic data from 145 consecutive patients with symptomatic superficial femoral stenosis, treated via primary radial access using the 6-F SheathLess Eaucath PV guiding catheter were evaluated in a pilot study. Secondary access was achieved through the pedal or popliteal artery. The primary endpoints were major adverse events, target lesion revascularization, and rates of major and minor access-site complications. Secondary endpoints included angiographic outcome, procedural factors, crossover rate to femoral access site, and duration of hospitalization., Results: Technical success was achieved in 138 patients (95.2%). Combined radial and pedal access was obtained in 22 patients (15.1%). The crossover rate to a femoral access site was 2%. Stent implantation was necessary in 23.4% of patients. Chronic total occlusion recanalization was performed in 63 patients, with a 90.4% technical success rate. The mean contrast consumption, radiation dose, and procedure time were 112.9 ml (101.8 to 123.9 ml), 21.84 Gy/cm 2 (9.95 to 33.72 Gy/cm 2 ), and 34.9 min (31.02 to 38.77 min), respectively. The cumulative rate of access-site complications was 4.8% (0% major, 4.8% minor). The cumulative incidence rates of major adverse events at 3 and 12 months follow-up was 8.3% and 19.2%. The cumulative incidence rates of death at 3- and 12-month follow-up were 2.8% and 5.6%., Conclusions: Femoral artery intervention can be safely and effectively performed using radial and pedal access with acceptable morbidity and a high technical success rate., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

The angiosome concept of foot perfusion was conceived based on anatomical studies of arterial circulation and used for planning surgical procedures, tissue reconstruction, and amputation. Its application is relevant in diabetic patients with critical limb ischemia and nonhealing foot ulcer or amputation. An understanding of foot angiosome anatomy is useful for predicting healing and planning arterial revascularization. A review of the literature, including the most recent systematic reviews and meta-analyses, indicates improved wound healing is achieved when the angiosome concept is followed. The greatest value of angiosome-based revascularization is in patients with lesion(s) limited to a single angiosome, or to achieve optimal healing of amputation sites. Future research should focus on proper identification of (imaging) modalities to determine the hemodynamic and functional changes before and after revascularization, thus identifying the "real" angiosome and directing optimal therapy., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

The history of the recognition and surgical treatment of lower limb ischemia dates back to the Middle Ages. The twin Saints Comas and Damian were ascribed to have saved a gangrenous limb in the 13 th century and became patrons of future surgeons. The physicians that followed developed the theories of blood flow, anatomy of the arterial circulation, and recognition that occlusive disease was the cause of limb ischemia and gangrene. Innovative physicians developed the techniques of arterial surgery and bypass grafting to restore limb blood flow and allow healing of lesions. In the 1960s, the era of endovascular intervention by the pioneering work of Charles Dotter, who developed techniques to image diseased arteries during a recanalization procedure. The development of guide wires, angioplasty balloons, and stents quickly followed. Management of lower limb ischemia and the diabetic foot will continue to evolve, building on the history and passion of preceding physicians and surgeons., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The pathophysiology of the diabetic foot ulcer and soft-tissue infection is due to neuropathy, trauma, and, in many patients, concomitant peripheral artery occlusive disease. Diabetic neuropathy results in foot deformity, leading to increased skin pressure with walking. Once a foot ulcer develops, the limb is at high risk for invasive infection and, when combined with peripheral artery occlusive disease, the patient should be considered to have critical limb ischemia. A multidisciplinary approach to care for the diabetic foot is recommended, which includes annual (3-month intervals in high-risk patients) assessments by a primary care physician and referral to a podiatrist and vascular surgeon for diabetics with a foot ulcer for evaluation of foot arterial perfusion and off-loading therapy to reduce plantar skin pressure with walking. When invasive foot infection develops and tissue beneath the fascia is involved, inpatient care is recommended for systemic antibiotic therapy, vascular laboratory testing of artery limb perfusion, and surgical debridement of infected tissue. The goals of treatment are to achieve a healed foot and keep the patient ambulatory., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The dorsalis pedis artery is responsible for blood supply to the dorsal aspect of the foot and is vital in the clinical assessment of the arterial supply thereof. Clinical assessment should consider anatomical variations of dorsalis pedis artery. Clearly, a thorough understanding of the potential variations of the vasculature in the area is important for a precise clinical assessment of arterial supply to the foot. The aim of this study was to investigate the different branching patterns of the dorsalis pedis artery that exist in a South African population., Methods: A Cadaveric study in which a total of 33 dissected lower limbs (27 adult cadavers and 6 partial wet lower limb specimens) of a South African population sample were studied. The course and branching pattern of the dorsalis pedis artery were photographed and documented., Results: Nine variations of the dorsalis pedis artery were recorded, with the standard branching pattern being the most common with an incidence of 36.36% and a completely absent dorsalis pedis artery variation was noted in 6.06% of the sample., Conclusion: Nine variations of the arterial anatomy of the dorsalis pedis artery were identified in this current study. Each of these may possibly alter the location or strength of the dorsalis pedis pulse affecting clinical assessment outcomes. Knowledge of dorsalis pedis variations may be useful to clinicians when making clinical decisions., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To determine agreement between invasive blood pressures measured in three peripheral arteries in anaesthetized horses undergoing elective surgery., Study Design: Prospective balanced incomplete block design., Animals: A total of 18 client-owned horses., Methods: Invasive blood pressure (IBP) was measured simultaneously in one of the following three combinations: 1) transverse facial and facial artery; 2) transverse facial and metatarsal artery; and 3) facial and metatarsal artery. The agreement in blood pressure measured for each combination was performed in six horses. At each sample time, systolic (SAP), mean (MAP) and diastolic (DAP) arterial pressures were measured concurrently in each artery, and the mean of three consecutive measurements was recorded. The position of horse, heart rate and use of dobutamine were also recorded. Bland-Altman analysis was used to assess agreement between sites., Results: A total of 54 paired measurements were obtained, with 18 paired measurements from each combination. All paired measurements showed poor and haphazard (nonsystematic) agreement. The widest limit of agreement was 51 mmHg for SAP measured in the facial artery and metatarsal artery, with a bias of -11 mmHg. The smallest limit of agreement was 16 mmHg for MAP measured in the transverse facial and metatarsal artery, with a bias of 1 mmHg., Conclusions and Clinical Relevance: There was poor and haphazard agreement for SAP, MAP and DAP measured in each pair of peripheral arteries in this study. These results show that blood pressure measured in different peripheral arteries cannot be used interchangeably. This has implications for studies that use IBP as an outcome variable and studies determining agreement between noninvasive blood pressure and IBP measurements in horses under general anaesthesia., (Copyright © 2018 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective To analyze the outcomes of 119 (188 feet) patients undergoing foot varicose vein phlebectomy with and without sclerotherapy between 2013 and 2015. Methods Legs and feet were treated in one single procedure. Clinical and ultrasound assessments were carried out at 7, 30, and 90 days for visualization of the sapheno-femoral and sapheno-popliteal junctions and the deep vein system. Results Mean age was 50 ± 12 years (25-79 years); 67 patients were female (56.3%). Median venous clinical severity score was 4 (range 2-5) before and 1 (range 0-2) at 90 days ( p < 0.001). Edema and transient paresthesia were the most frequent complications (13 (10.92%) and 11 (9.24%) patients, respectively). All complications were resolved at 90 days except one case of edema (resolved after 150 days with compression stockings and lymphatic drainage manual therapy). Conclusions Symptomatic foot varicose vein intervention was safe and effective. Further studies should focus on assessment of vein-specific quality of life questionnaires.

Aims: We conducted a nationwide educational initiative to determine the prevalence and risk factors of diagnosed and undiagnosed painful and painless distal sensory polyneuropathy (DSPN)., Methods: Among 1850 participants, 781 had no history of diabetes (ND), 126 had type 1 diabetes (T1D), and 943 had type 2 diabetes (T2D). Painful DSPN was defined as polyneuropathy detected by bedside tests with pain and/or burning in the feet, while painless DSPN was defined as polyneuropathy with paresthesias, numbness, or absence of symptoms., Results: DSPN was detected in 48.2% of ND, 44.3% of T1D, and 55.3% of T2D subjects. DSPN was painful, painless, or atypical in 62.1, 24.8, and 13.1% of the participants. Painful DSPN was more severe than painless DSPN. Painful and painless DSPN were previously undiagnosed in 61.5 and 81.1% of the participants, respectively. In T2D subjects, painful and painless DSPN were associated with a higher and lower BMI, respectively. Among ND participants 39.2% had HbA1c levels indicating prediabetes/diabetes., Conclusions: Around half of participants in an educational initiative had DSPN, 62% of whom had the painful entity that correlated with BMI in T2D. Since many cases of neuropathy and diabetes remain undiagnosed, effective strategies to timely detect both conditions should be implemented., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Patency of the pedal-plantar arch limits risk of amputation in peripheral artery disease (PAD). We examined patients without chronic kidney disease (CKD)/diabetes mellits (DM) [PAD-control], those with DM without CKD, and those with CKD without DM., Method: Uni- and multivariate logistic regression was used to assess association of CKD with loss of patency of the pedal-plantar arch and presence of tibial or peroneal vessel occlusion. Multivariate models adjusted for age, sex, hypertension, hyperlipidemia and smoking., Results: A total of 419 patients were included [age 75.2 ± 10.3 years, 288 (69%) male]. CKD nearly doubled the unadjusted odds ratio (OR) for loss of patency of the pedal-plantar arch. After adjustment, association remained significant for severe CKD [estimated glomerular filtration rate (eGFR) ≤ 29 ml/min compared with eGFR ≥ 60 ml/min, adjusted (adj.) OR 8.24 (95% confidence interval {CI} 0.99-68.36, p = 0.05)]. CKD was not related to risk of tibial or peroneal artery occlusion [PAD-control versus CKD, adj. OR 1.09 (95% CI 0.49-2.44, p = 0.83)] in contrast to DM [PAD-control versus DM, adj. OR 2.41 (95% CI 1.23-4.72, p = 0.01), CKD versus DM, adj. OR 2.21 (95% CI 0.93-5.22); p = 0.07)]., Conclusions: Below the knee (BTK) vascular pattern differs in patients with either DM or CKD alone. Severe CKD is a risk factor for loss of patency of the pedal-plantar arch.

Objective/background: To evaluate complete wound healing and limb salvage rates in patients with critical limb ischaemia (CLI) with concurrent foot ulceration/gangrene who underwent angiosome targeted infrapopliteal balloon angioplasty., Methods: This was a prospective observational study. In total, 212 patients who underwent successful infrapopliteal balloon angioplasty to assist wound healing and achieve limb salvage were included from June 2014 to March 2016. Propensity score matching was developed to compare complete wound healing, 1 year amputation free survival (AFS), and limb salvage rates between the two study groups (direct revascularisation [DR] and indirect revascularisation [IR])., Results: Direct flow to the foot wounds based on the angiosome principle was achieved in 117 legs (55.2%) versus 95 legs (44.8%) that represented the IR group. Seventy-three matched pairs were obtained to minimise intergroup differences in baseline characteristics. Twelve months after angioplasty, the complete wound healing rates were 80.8% and 63.0% (p = .02), AFS rates were 72.6% and 61.6% (p = .164), and limb salvage rates were 90.4% and 82.2% (p = .148) in the DR and IR groups, respectively., Conclusion: This study suggests that the complete wound healing rate is better when the target foot lesion receives direct perfusion following the angiosome concept, whereas limb salvage and AFS rates were not significantly different among the DR and IR groups., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

The aim of this multicenter, prospective, observer-blinded, parallel group, randomized controlled trial was to assess the safety and efficacy of EDX110, a nitric oxide generating medical device, in the treatment of diabetic foot ulcers in a patient group reflecting "real world" clinical practice compared against optimal standard care. Participants were recruited from ten hospital sites in multidisciplinary foot ulcer clinics. The ulcers were full thickness, with an area of 25-2,500 mm 2 and either a palpable pedal pulse or ankle brachial pressure index > 0.5. Infected ulcers were included. Treatment lasted 12 weeks, or until healed, with a 12-week follow-up period. Both arms were given optimal debridement, offloading and antimicrobial treatment, the only difference being the fixed used of EDX110 as the wound dressing in the EDX110 group. 135 participants were recruited with 148 ulcers (EDX110-75; Control-73), 30% of which were clinically infected at baseline. EDX110 achieved its primary endpoint by attaining a median Percentage Area Reduction of 88.6% compared to 46.9% for the control group (p = 0.016) at 12 weeks in the intention-to-treat population. There was no significant difference between wound size reduction achieved by EDX110 after 4 weeks and the wound size reduction achieved in the control group after 12 weeks. EDX110 was well tolerated. Thirty serious adverse events were reported (12 in the EDX110 group, of which 4 were related to the ulcer; 18 in the control group, of which 10 were related and 1 possibly related to the ulcer), with significant reduction in serious adverse events related to the ulcer in EDX group. There was no significant difference in adverse events. This study, in a real world clinical foot ulcer population, demonstrates the ability of EDX110 to improve healing, as measured by significantly reducing the ulcer area, compared to current best clinical practice., (© 2018 by the Wound Healing Society.)

Purpose: To determine if a new photoacoustic imaging (PAI) system successfully depicts (1) peripheral arteries and (2) microvascular circulatory changes in response to thermal stimuli., Methods: Following ethical permission, 8 consenting subjects underwent PAI of the dorsalis pedis (DP) artery, and 13 completed PAI of the index fingertip. Finger images were obtained after immersion in warm (30-35 °C) or cold (10-15 °C) water to promote vasodilation or vasoconstriction. The PAI instrument used a Fabry-Perot interferometeric ultrasound sensor and a 30-Hz 750-nm pulsed excitation laser. Volumetric images were acquired through a 14 × 14 × 14-mm volume over 90 s. Images were evaluated subjectively and quantitatively to determine if PAI could depict cold-induced vasoconstriction. The full width at half maximum (FWHM) of resolvable vessels was measured., Results: Fingertip vessels were visible in all participants, with mean FWHM of 125 μm. Two radiologists used PAI to correctly identify vasoconstricted fingertip capillary beds with 100% accuracy (95% CI 77.2-100.0%, p < 0.001). The number of voxels exhibiting vascular signal was significantly smaller after cold water immersion (cold: 5263 voxels; warm: 363,470 voxels, p < 0.001). The DP artery was visible in 7/8 participants (87.5%)., Conclusion: PAI achieves rapid, volumetric, high-resolution imaging of peripheral limb vessels and the microvasculature and is responsive to vasomotor changes induced by thermal stimuli., Key Points: • Fabry-Perot interferometer-based photoacoustic imaging (PAI) generates volumetric, high-resolution images of the peripheral vasculature. • The system reliably detects thermally induced peripheral vasoconstriction (100% correct identification rate, p < 0.001). • Vessels measuring less than 100 μm in diameter can be depicted in vivo.