Endo-enthusiasm or Endo-realism: Striking at the heart (or sole) of technology adoption and results in diabetic limb salvage.

A terrific article by our colleague Prof. Werner Lang with a “perspective” by our equally perceptive SALSAmigo Rich Neville in this month's Vascular Specialist regarding Open vs. Endovascular Surgery. My SALSA partner, Joe Mills might say that, while endovascular procedures might be considered for many limb salvage procedures initially, it is the distal demand (i.e. the complexity of the wound) that is just as important as the type of lesion.  Enjoy the article:

Elsevier Global Medical News (Mark S. Lesney)
NEW YORK – Endovascular therapy has increasingly become an 
initial option for the treatment of critical lower limb ischemia, but 
there are still indications for bypass surgery in some patients, 
according to Dr. Werner Lang. 
Despite data in favor of endovascular treatment, bypass 
surgery still offers the best therapy with respect to long-term 
patency. Even in patients for whom healing time may be short, 
pedal vein grafts may still be the treatment of choice, said Dr. 
Lang at the Veith symposium on vascular medicine sponsored by 
the Cleveland Clinic.
Diabetic patients in particular may benefit from the bypass 
surgery approach. There are no prospective randomized trials 
with diabetic patients that have shown, with sufficient evidence, 
an advantage in outcomes after endovascular therapy. However, 
outcomes for subgroups in some studies suggest that 
endovascular procedures are preferable in diabetic patients who 
have multifocal tibial artery stenosis or occlusions. 
In addition, there are trends indicating that limb salvage rates 
are similar for endovascular therapy and bypass surgery. This is 
possible because – even though its long-term patency rates are 
lower – endovascular therapy is actually sufficient for many 
patients: Their ischemic lesions will heal within the patency 
period of the endovascular therapy, and thus long-term patency 
is not needed in all cases. 
Dr. Lang, professor of surgery at the Friedrich-Alexander 
University Erlangen-Nuremberg (Germany) and chief of the 
vascular surgery department at University Hospital Erlangen, 
presented evidence showing that the selection of patients for 
either endovascular therapy or bypass surgery should depend on 
the ability to restore blood flow to the pedal arch with respect to 
the angiosomes of the ischemic lesion. Endovascular therapy 
must be considered inferior for any patients in whom this goal is 
not attainable, which can be the case for diabetic patients in 
“Another reason for a bypass-first strategy is the ability to 
combine vascular surgery with plastic reconstructive surgery – 
[for example,] free flaps with a microvascular anastomosis. For 
diabetic patients, a microvascular anastomosis will not usually be 
possible after endovascular therapy alone, as the quality of the 
vessel wall of the original artery is generally poor in diabetic 
patients even after such therapy,” Dr. Lang said in an interview
Finally, the decision between a bypass-first strategy and an 
angioplasty-first strategy should depend not only on angiographic 
findings alone, but also on clinical characteristics and the need to 
achieve direct revascularization of the pedal arteries, Dr. Lang 
PERSPECTIVE  (by Richard F. Neville, Professor and Director of Vascular Services, George Washington University Hospital)
I agree with Dr. Lang regarding the role of endovascular therapy 
and surgical bypass for lower extremity revascularization. I 
believe we are now beyond the rush of enthusiasm for the 
“endovascular first” approach for every patient and have moved 
into the era of subgroup analysis to determine which patients are 
best treated with which modality. Our own research, as 
presented at this years Society for Vascular Surgery meeting in 
Boston, identified at least one subgroup best treated with surgical 
bypass – those patients presenting with tissue loss greater than 
2 cms in largest diameter. Other important factors are arterial 
anatomy, patient comorbidity, and the experience and skill of the 

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