Gangrene may be the first sign

of PAD in diabetic patients, and this may give rise to a false conviction that it is too late for revascularisation [84] and amputation is the only alternative. However, it should always be remembered that the local clinical picture may appear to be more compromised than it actually is because it may be greatly affected by an infection that can be cured with appropriate therapy, and so it may be possible to save a limb that at first sight seems definitely lost. PCI 32765 There are also situations in which the involvement is such that there is no possibility of saving the foot and major amputation is unavoidable. However, even in these cases (as in the case of partial amputation), it is essential to investigate the vascular tree because correcting underlying ischaemia may allow a more distal amputation Apitolisib and the more rapid healing of the amputated stump. Even if a lesion is so large that limb salvage seems impossible or so small that it seems hardly worthy of a thorough diagnosis, the local condition of the foot should never condition therapeutic choices in absolute terms, although various studies have shown that a large ulcer is a risk factor for healing failure and major amputation [3] and [13]. The apparently obvious observation that a large ulcer implies an increased risk of major amputation disguises an extremely important aspect of managing DF: foot lesions are never

large at the beginning but become so because of inadequate (and therefore ineffective) treatment or, even worse, the picture has been completely underestimated and inappropriate treatment has been continued for a long time. The concept of ‘time is tissue’ also applies to the foot, and so delayed or inadequate treatment leads to the irreversible loss of portions

of foot tissue [85]. In particular, it has been demonstrated that, if a patient with an acutely phlegmonous foot is immediately PAK6 referred to a tertiary centre [49], the outcome in terms of amputation is surely better than when he or she is first referred to a less suitable hospital because, in order to be effective, the necessary treatment (adequate surgical debridement and distal vascularisation) needs to be performed in a timely manner [86] and [87]. Another factor capable of significantly conditioning the choice and method of revascularisation is the involvement of the vascular tree. In order to define the type of intervention, it is important to assess the condition of the common iliac and femoral arteries, and equally important to evaluate distal run-off. There is no way that even optimal revascularisation will last over time without sufficient downstream blood flow: whether endoluminal or performed by means of bypass surgery, the revascularisation must allow the restoration of direct flow up to the dorsalis pedis or plantar arch [88]. One further aspect that needs to be considered is the patient’s general condition.