The need for arteriography in diabetic patients with gangrene and palpable foot pulses.

A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status.