Never amputate without consultation of a vascular surgeon

Lower limb ischaemia is one of the determinants in the development of diabe tic foot ulcers and the most important factor preventing their healing. The re are a number of misleading factors masking the presence of atherosclerot ic disease and tissue damage; these are reduced inflammatory response to in fection, autosympathectomy and mediasclerosis, which all diminish the clini cal suspicion of ischaemia. Therefore, adequate assessment of the lower lim b circulation should be routinely performed in complicated diabetic foot. T his evaluation can often be made with simple methods. In addition to clinic al examination ankle/brachial pressure index, systolic toe pressure, plethy smographic pulse volume recordings and simple hand-held Doppler auscultatio n are most often sufficient to make a decision as to whether angiography is needed or not. Duplex examination can give more profound information on th e severity and extent of arterial occlusive disease, but the method is stro ngly user-dependent. Early vascular consultation is mandatory in diabetic f oot work-up and should be undertaken within 2 weeks if a new skin lesion sh ows no tendency to heal. Long bypass grafting procedures and microvascular free flap techniques have been shown to achieve excellent results in reliev ing critical leg ischaemia, even in the presence of large foot lesions, and should be used to prevent major amputation. The timing of various procedur es is a controversial issue. Feet with small ulcers or restricted dry gangr ena can be revascularised first, with minor amputations and local surgery o f the ulcer being done thereafter. In the septic neuroischaemic foot, major amputation may be unavailable but if the infection is not immediately life -threatening the infected part of the foot should be drained and debrided p roperly and left wide open, sometimes with a guillotine amputation in order not to risk the bypass graft, which can be done a couple of days later. Co pyright (C) 2000 John Wiley & Sons, Ltd.