الفهرس 
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Abstract
This study was carried on sixty-four patients with ischemic diabetic foot with tibial artery disease.
All of the patients in the present study were subjected to the following:
• Full history taking.
• Clinical examination of both upper limbs and lower limbs
• Meticulous examination of arteries and veins of both Lower limbs for distal pulsations, pallor, coldness, paresthesia, weak motor power and trophic changes (hair loss, muscle wasting, ulcers or gangrene). In addition, ankle / brachial index (ABI) and TCPO2 (transcutaneous oximetry) measurements for all patients.
• Wound examination including (site, size, shape, number and extent).
• Color duplex ultrasound (CDU) examination of the arteries of the affected lower limb for screening pre-operatively including: diameter (in mm), velocity of blood flow (in cm/sec) and flow volume (in ml/min) of arteries of the selected lower limb was measured and tabulated.
• Multislice computed tomographic angiography (MCTA) of abdominal aorta and both lower limbs done for all cases.
• Laboratory investigations: Complete blood picture, blood chemistry (s. urea, s. creatinine, AST, ALT), coagulation profile (PT, PTT) and lipid profile.
• After decision, Endovascular revascularization (PTA) of infra-popliteal arteries was performed in all patients.
• Post procedure assessments of the patients were done at 1, 6, and 12 months by clinical examination, measurement of ABI, TcPO2, and ultrasound color Duplex examination regarding the following points:
Clinical improvement with absence of rest pain and ∕ or progressive tissue healing during the follow-up period.
Hemodynamic state (ABI, and TcPO2 percutaneous oximetry).
Limb salvage rate. (Absence of major amputation).
Short-term clinical success of PTA has evaluated based on ulcer size and appearance.
The finding can be summarized in:
1. The 64 patients were 52 males and 12 females, the age of those patients ranged between 42 and 74 years with a mean age of 64.28 ± 6.35 years.
2. In all patients, 62 were having type 2 diabetes mellitus and 2 having type 1 diabetes. The duration of diabetes since first time diagnosis ranged from 0 (accidentally discovered on admission) to 32 years duration with a mean of 17.9 ± 5.8 years. 28 patients were taking oral hypoglycemic drugs while 36 patients were using insulin.
3. Among all patients, history of cardiovascular problems was found in 34 patients, 39 patients had a history of Hypertension, 10 patients had a history of Neuropathy 13 patients had a history of Cerebro-vascular disease and 34 patients had a history of retinopathy.
4. All patients were having current wound, 27 patients have non-infected and 37 patients have infected wound. according to The University of Texas wound classification system 5 patients are grad I stage C, 8 patients are
grade II stage C, 14 patients are grad III stage C, 11 patients are grad I stage D, 8 patients are grad II stage D and 18 patients are grad III stage D.
5. Lesion severity was significantly related to patients’ age (P=0.03), with higher age (mean 64.3 years) in patients with type C lesions (lesions without infection) compared to (mean 60.9 years) in patients with type D lesions (with infectious component).
6. In regard to ABI (Ankle-brachial index) and TCPO2 measurements 24 patients have ischemia grade I, 29 patients have ischemia grade II and 11 patients have ischemia grade III.
7. At the pre-procedural angiograms, the 64 patients 117 infra-popliteal lesions, 45 involved the posterior tibial artery, 32 the anterior tibial artery, 24 the peroneal artery, 9 the Pedal artery and 7 the Plantar artery.
8. 66.7% of the infra-popliteal lesions were occlusions (74% of occlusions were longer than 10 cm) and 33.2% were stenosis. Occlusion of all infra-popliteal vessels were present in 29.7% of the patients.
9. According to the Joint Vascular Societies Council classification the mean calf score was 7.8±1.6 (median 8), while the mean foot score was 7.3±2.3 (median 8), at least two calf and foot obstructed arteries (score 2.5 or 3) were observed in 63% and in 65% of limbs, respectively. The pre-procedural calf and foot scores were statistically lower in III-D lesions compared with the remaining lesions (P < .002 and P < .03, respectively)
10. 66.7% of the blow knee lesions were occlusions (74% of occlusions were longer than 10 cm) and 33.2% were stenosis. Occlusion of all blow the knee vessels were present in 29.7% of the patients.
11. The revascularization procedure was technically successful in 57 patients (Revascularization of at least one tibial artery) and in 7 cases the
procedure was not effective due to the presence of heavily calcified chronic occlusions that could not be overcome with guide wires.
12. There were two minor complications (two groin hematomas that did not require any special treatment), and therefore the overall complication rate was 3.1%.
13. At immediate post-procedural angiographic examination, the mean calf score was 4.6 ± 2.3 (median, 4) with a mean reduction of 3.2 ± 1.9 (range, 0-8), whereas the mean foot score was 5.9 ± 2.6 (median, 6.5), with a mean reduction of 1.4 ± 1.6 (range, -2.5 to 8).
14. There was improvement in the hemodynamic markers included mean ABI improvement from 0.60 (pre-angioplasty) to 0.91 (day one post-angioplasty) and mean TcPO2 from 32.3 mmHg (pre-angioplasty) to 47.7 (day one post-angioplasty).
15. At 1 year we observed a limb salvage rate of 78.9%, 6 major amputations (9.4 %), 24 minor amputations (37.5 %) and 32 complete healing (56.1%), Also healing in non-infected wound group was 24 of 27 patients with patency rate (88.9%) while in the infected wound group was 28 of 37 patients with patency rate (75.7%).
16. At the Duplex evaluation, we found 21 restenosis (36.8 %). 15 were symptomatic, with recurrent and worsening ulcer, and the patients underwent further treatment, 5 cases with PTA, in 3 cases with major amputation.
17. Among the clinical and angiographic variables included in the analysis , the clinical outcome was significantly related to the foot scores with ulcer healing obtained in patients with lower pre-procedural (mean score, 6.8 in healed patients and 7.8 in non-healed patients; P < .047) and post-
procedural (mean score, 5.5 in healed patients and 6.3 in non-healed patients; P < .049) foot scores
18. 91 % of healed group have patent pedal artery before PTA while only 25 % of non-healed group have patent pedal artery before PTA and this means that Clinical PTA success was significantly associated with the presence of at least one patent pedal vessel (dorsal pedal and/or common plantar arteries) on arteriography before PTA
19. Our study demonstrated that PTA in diabetic patients with infra-popliteal disease is a safe and effective option.
20. The foot score represents the most significant angiographic parameter to evaluate chances for ulcer healing, and, consequently, to state the success of the revascularization procedure and with the presence of at least one patent pedal vessel (dorsal pedal and/or common plantar arteries) on arteriography before PTA.