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Foot ulceration remains the leading diabetic complication requiring hospitalization (). Treatment of the diabetic foot ulcer is often a complex process that involves a multidisciplinary approach. Despite best efforts, failure to heal a diabetic foot ulcer can lead to amputation (). As the incidence of diabetes in the general population is expected to rise, the prevalence of ulcerations and amputations will follow. The resulting cost to society can be measured in direct costs attributed to treatment, as well as indirect costs in lost productivity. The total cost of diabetic foot ulcerations in the United States has been estimated to approach $4 billion annually, as extrapolated from the costs of ulcer care and amputations (). However the costs are measured, diabetic foot ulcerations represent a major public health challenge of growing proportions.

Foot problems remain the most common reason for hospitalization for patients with diabetes mellitus (,). Approximately 20% of the 12–15 million patients with diabetes in the United States can expect to be hospitalized for a foot problem at least once during their lifetime, and account for an annual health care cost for this problem alone in excess of one billion dollars (). The primary pathological mechanisms of neuropathy and ischemia set the stage for pressure necrosis, ulceration, and multimicrobial infection, which if improperly treated ultimately leads to gangrene and amputation (). Understanding how the factors of neuropathy, ischemia, and infection are impacting on an individual patient with a foot complication and simultaneously effecting proper treatment for all factors present is essential to foot salvage. Although this chapter focuses on the treatment of ischemia owing to arterial insufficiency, it is important to remember that ischemia is accompanied by infection in approx 50% of patients in our experience (), and that most, if not all, patients will have peripheral neuropathy present as well. Although focusing on correction of ischemia, often by operative reconstruction or percutaneous intervention, the vascular surgeon cannot ignore these other factors if foot salvage is ultimately to be successful.

The field of vascular surgery has undergone significant changes recently. Beginning with the development of less invasive techniques to manage general surgical pathology, such as laproscopic procedures, there has been a paradigm shift in the type of techniques that are available to treat patients. Historically, vascular surgery patients have been successfully treated with open surgical procedures in the majority of cases. Technology has allowed for the advent of change. In addition, the desire of patients to be treated with less invasive methods of management has pushed this technology as well as the clinical pattern of treatment.

In recent years, clinicians have begun to recognize the impact that educational, psychosocial, and behavioral factors have on treatment success for leg and foot wounds. Furthermore, many now consider quality of life as an important outcome of treatment for those suffering from neuropathy, foot ulcerations, and amputations. However, although interest is increasing, behavioral aspects of the diabetic foot remain fledging science. Researchers are only now beginning to investigate the psychological response to diabetic foot ulceration and amputation and the behavioral and psychological factors that influence self-care. Although cross-sectional studies have explored these areas, little longitudinal data currently exists.

Diabetes represents the primary cause of nontraumatic amputation in the Western World (). It is estimated that about 25% of subjects with diabetes will experience problems over the course of their lives with their feet and that one-third of these patients will undergo amputation (–). Although these data highlight the extent of this problem in the diabetic population, they do not necessarily predicate inevitability: on the contrary, they serve to demonstrate that simple and relatively inexpensive measures may be able to reduce even up to 85% the number of amputations (–). Some clinical conditions put the patient with diabetes “at risk of ulceration.”; An awareness of these conditions and the identification of subjects at risk may permit the introduction of suitable preventive strategies (–).