From the Lab to the Real World

Literal Breakthrough: Angioplasty Restores Circulation in Legs of Patients with Diabetes, Spares Amputation

A surgeon at Sunnybrook has applied angioplasty to restore blood flow in the legs of patients with advanced diabetes. This saves patients from amputation, and possible death, and saves health care dollars.

Some sobering facts: People with diabetes have a 25% lifetime risk of developing a foot ulcer. Non-healing diabetic foot ulcers accounting for 85% of diabetes-related limb amputations, according to the Public Health Agency of Canada (PHAC). People with diabetes are 23 times more likely to be hospitalized for a limb amputation than people without diabetes, according to the Canadian Diabetes Association (CDA).

What most people don’t know is that the post-amputation life expectancy is grim. The five-year mortality rate of amputees is 45%, according to the International Wound Journal. For those who survive, amputation leads to increased treatment. For the health care system, this means additional hospitalization costs. It is estimated that diabetic foot ulcers cost the Canadian health care system more than $150 million annually.

All of this led Dr. Giuseppe Papia, of Sunnybrook Health Sciences Centre, to conclude: “The day a patient with diabetes develops a foot ulcer is worse than the diagnosis of most cancers.”

This vascular surgeon sought to change things by employing angioplasty to restore the circulation of these patients with foot ulcers facing possible amputation.

Dr Giuseppe Papia
Dr. Giuseppe Papia, Sunnybrook Health Sciences Centre. Photograph courtesy of Sunnybrook.

Below-the-Knee Angioplasty Unites Technology and Know-How

Since the root cause of ulcers below the knee is a lack of circulation caused by peripheral arterial disease (a narrowing of blood vessels), Papia and his colleague Dr. Andrew Dueck switched gears in the approach to the problem and turned to angioplasty.

First used in 1977, angioplasty is a minimally invasive technique for mechanically reopening narrowed or blocked arteries in the heart (coronary arteries) without major surgery. A collapsed balloon on a balloon catheter is inserted into the narrowed arteries, then blown up or inflated to a fixed size using water pressure. The balloon forces expansion, opening up the blood vessel for improved flow. The balloon is then deflated and withdrawn.

“We realized why a third of these kinds of [below-the-knee] procedures were being done by cardiologists world-wide,” Papia told Sunnybrook magazine. “They had the right technology and know-how to do this. It just serendipitously fell together really well.”

Papia learned below-the-knee angioplasty at the Cleveland Clinic; Dueck, at the Arizona Heart Institute.


Patients Go Home Same Day

Having learned this new technique, what Papia and Dueck did was combine angioplasty techniques with plastic surgery concepts to restore blood flow to extremities below the knee – all without general anesthesia.

This is a huge improvement compared to bypassing a blocked artery, the common approach up until this point, which often meant lengthy recovery periods for patients, since the circulatory challenges of diabetes effectively slow down the healing process. It’s an even larger improvement compared to amputation.

With this new procedure, patients experience near-instant improvement. Once blood flow is restored, patients can go home the same day. Another plus is the fact that this procedure can be repeated, theoretically, as often as necessary – good, since peripheral arterial disease recurrence is high for those with diabetes.

“You have to evaluate what the bar is,” Papia told Sunnybrook. “If the bar is palliating the pain, healing the ulcer and giving patients a better quality of life, then what we’re doing is fantastic!”

Dr Papia BelowTheKnee_140130_033   Dr Papia BelowTheKnee_140130_073
Dr. Giuseppe Papia in surgery performing the below-the-knee angioplasty. Photograph courtesy of Sunnybrook Health Sciences Centre.

Patients’ Stories Speaks Volumes

Moisei (Michael) Korol, a 74-year-old repeat patient of Papia, makes a strong case for this new approach. He has undergone this new procedure three times since December 2012 – the first, to restore circulation to his left foot and help heal an ulcer; the second, to address pain in his right leg and clear arteries that were blocked below the knee; and the third, to help heal an ulcer on his right foot.

Another patient, 64-year-old Charles Hykawy, told Sunnybrook about his post-operative transformation. ”That ability to restore quality of life is what’s at the core of the work Dr. Papia is doing at [Sunnybrook’s] Schulich Heart Centre,” he said.

Papia and Dueck are now performing 200 procedures annually. Papia can’t remember the last time he did an amputation. “But I do remember the last two patients that I sent for an amputation. And I remember them because that doesn’t really happen anymore,” he told Sunnybrook.

To read an interview with the patient, Charles Hykawy, go here: For more information on this topic from the CDA: To read the CDA’s report on the cost of diabetes in Canada: For statistics quoted by Wound Care Canada from PHAC and the International Wound Journal (2007): To read the Sunnybrook article, written by Patrick Lynch for the Spring 2014 issue, go here: