the sequence of treatment for DM foot

I received a call today from our plastic surgeon. One of his inpatients was diagnosed to be a DM foot with foot ulcers. He had perated on the foot for several times to debride the necrotic tissue. According to his statement, the perfusion of those tissue were not so good. And the condition of the soft tissue got worsen after each debridement. He thus than arranged noninvasive study and image study which revealed that there is a total occlusion over the patient's femoral artery! No wonder that the lesion did not get better after debridement!
He had then call me for the possibility of revascularization.

Sure, revasclarization is a must for the tissue perfussion which is the fundamental element of wound healing. The problem is , the sequence (or priority) of treatment was obviously wrong!

From the viewpoint of a vascular surgeon, we should do as follows for a DM foot with ischemic compoment.

1. Infection control or minor debridment of the infected tissue
2. Revascularization , either PTA or bypass
3. Debridement or amputation to facilitate wound healing
4. Reconstruction, if needed

It's a pity that our physicion, let alone those patient, nearly always think about the vascular condition to late. They did not pay attention to their vascular condition. They may miss the chance of the optimal treatment.

My point is, vascular condition is the most fundamental. We have to keep in mind the diagnosis of ischemic leg.