Diabetes is a common disease, and its incidence is increasing every year. It is the seventh leading cause of death in the United States, with approximately 800,000 new cases each year. Diabetes can lead to peripheral neuropathy, fundus, nephropathy, and narrowing or occlusive lesions of the peripheral arteries (including the heart, brain, and peripheral arteries), with peripheral arterial disease (PAD) eventually occurring in 2-4 times more people with diabetes than normal. According to statistics, about 20% of diabetic patients in the United States may develop diabetic foot ulcers each year, and the number of amputations due to diabetic foot accounts for more than 50% of non-traumatic amputations, including 30% of those requiring amputation above the thigh, and 50% of those who already have one lower limb amputated will eventually lose the opposite limb. In particular, 50-70% of patients with combined lower extremity atherosclerotic occlusive disease who also have diabetic peripheral vascular disease will require surgical treatment; in contrast, only 20-40% of patients without diabetes will require surgical treatment. Therefore, the surgical treatment of diabetic foot has become a clinical challenge of wide interest to vascular surgeons. Diabetic patients have reduced sensation or even loss of sensation in the foot due to neuropathy, and may develop deformities; they are also prone to serious injuries, ulcers, gangrene and infections due to vascular lesions that cause ischemia in the foot and loss of vitality in the local tissues, and eventually some of them require amputation. These pathological changes in the foot are collectively referred to as diabetic foot. In short, a diabetic foot is a foot with loss of sensation due to neuropathy and loss of vitality due to ischemic tissues and co-infection. Although the pathological changes of the diabetic foot include neuropathy, vasculopathy, and foot ulceration and infection, most scholars still believe that tissue ischemia caused by peripheral arterial stenosis and occlusion is the main cause and danger of the diabetic foot. Therefore, the treatment of lower extremity ischemia has been the focus of diabetic foot treatment. At present, the surgical treatment for diabetic foot vascular lesions mainly includes three aspects, such as pharmacotherapy, surgical treatment and endovascular treatment: 1. Pharmacotherapy: The pharmacotherapy for diabetic foot, first of all, is to treat diabetes and actively control blood sugar. Diabetic patients often have hypertension, hyperlipidemia, atherosclerosis, etc., and should be actively treated and controlled for various related risk factors. The main pharmacological treatment for vascular lesions is the application of vasodilators and antiplatelet agents, of which antiplatelet agents have received widespread attention. A controlled study of more than 6,000 patients with peripheral vascular disease using poliovir and aspirin showed that poliovir was significantly better than aspirin in reducing heart attacks, ischemic strokes, and vascular-related deaths, and the U.S. FDA recommended poliovir as the drug of choice for reducing ischemic events in patients with PAD. Society Consensus (TASC) recommends Prednisone as an effective drug for the treatment of lower extremity ischemia. In addition, wound management mainly consists of wound debridement and dressing, local application of blood-vitalizing and vasodilating drugs, etc. However, if the blood flow to the wound site is not effectively improved, the local ulcer is difficult to heal, and it is even easy to combine with infection, aggravation of the ulcer or even gangrene, which requires amputation. Therefore, in addition to pharmacological treatment, local debridement and dressing exchange, the most critical treatment for diabetic foot is to rapidly improve and enhance the blood supply to the affected limb, increase tissue supply, improve the resistance to infection and healing ability of the tissue, and promote the healing of the ulcer and wound. Therefore, the treatment of diabetic vascular lesions should focus on the reconstruction of arterial blood flow to achieve the purpose of rapidly restoring blood flow to ischemic tissues. Surgical treatment is mainly suitable for patients with diabetes combined with lower extremity atherosclerosis-occlusive disease with large and medium vessels involvement and TASC grade C and D lesions. Because diabetes is closely related to atherosclerosis, patients with diabetic foot often have a combination of iliac and femoral artery stenosis or occlusion. Diabetic patients with lower extremity artery occlusion may have more ischemic symptoms in the affected foot, so it is important to re-establish arterial flow in the lower extremity. (1) Currently, the treatment of iliac artery lesions is mainly endovascular treatment, including iliac artery balloon dilation, stent implantation, and subintimal angioplasty, etc. Endovascular treatment can avoid open surgery, with less trauma and faster recovery, and the long-term patency rate is basically the same as that of surgical treatment. For the treatment of lesions in the femoral N artery (TASC grade C, D), autologous vein bypass or artificial vessel bypass is the main treatment. (2) Autologous saphenous vein bypass, including in situ vein bypass and to placed saphenous vein bypass. It is generally believed that as long as the saphenous vein is in good condition, it should be used as the first graft material. However, there is the problem of limited access to autologous veins and the possibility of complications such as poor wound healing due to the relative trauma of autologous vein access. Most authors now believe that the long-term patency rate of autologous saphenous vein bypass is better than that of artificial vessels. However, a prospective study by Ballotta showed no statistically significant difference in 1-, 3-, and 5-year patency rates between PTFE prosthetic vessels and autologous suprapatellar saphenous vein bypass. The Sala study also showed 4-year patency rates of 82.2% for autologous versus 80.6% for suprapopliteal bypass, with a statistically insignificant difference of 84.7% and 79.5% for 4-year second-stage patency, respectively. In our experience, regardless of the type of graft material selected, the main factors affecting the near-term (within 30 days) patency rate are the inflow and outflow tract conditions of the patient, perioperative anticoagulation measures, and the surgeon’s technique, while the main factors affecting the long-term (>90 days) patency rate are the progression of atherosclerosis, restenosis of the anastomosis and the progression of atherosclerotic lesions. (3) Artificial vessel bypass, mainly using PTFE material artificial vessel to perform femoral N artery bypass, is suitable for patients with poor autologous vein condition, presence of varicose veins or saphenous vein has been removed. It is generally believed that the 2-year patency rate of PTFE superior knee bypass can reach or approach 70%-80%, while the infrapopliteal patency rate is very low, only 30%-40%, but the composite bypass of the distal artificial vessel combined with the vein can increase the 2-year patency rate to more than 50%. In recent years, heparin-coated polyester vessels have been used in clinical practice, and their long-term patency rates are significantly better than those of PTFE artificial vessels. The author experiences that the softness of this heparin-coated vessel and suture stitch feel good, the needle hole is not easy to leak blood, the recent effect is satisfactory, but its long-term patency rate needs to be further confirmed. Endovascular treatment At present, the clinical endovascular treatment is mainly based on balloon dilation and stent implantation, although there are also reports of laser and rotary cutting techniques applied in clinical practice, but they are not yet commonly carried out. From the perspective of evidence-based medicine, there is a consensus that endoluminal balloon dilation and stent implantation are more effective than arterial bypass surgery for suprapopliteal lesions in TASC grades A and B, whereas endoluminal treatment is less effective for TASC grades C and D. Surowiec et al. reported patency rates of 86%, 80%, 75%, 66%, 60%, 58%, and 52% at 3, 6, 12, 24, 36, 48, and 60 months after stenting of the superficial femoral artery, respectively; Galied summarized data from a large number of luminal treatments for lower extremity arterial occlusions, including 923 balloon dilation and 473 stenting cases, in which balloon dilation was effective for 3-year patency of stenotic lesions. The 3-year patency rate for balloon dilation was 61% for stenotic lesions, 48% for occlusive lesions, 43% for severe stenotic lesions, and 30% for severe occlusive lesions, while the 3-year patency rate for stenting was 63% to 66%. The patency rate of lower extremity artery stenting is closely related to the lesion classification, and it is generally believed that stenting is mainly used for cases with post-dilatation entrapment, and those with post-dilatation patency without entrapment can undergo balloon dilation alone without stenting. However, the results of a recent well-designed prospective clinical study showed that the long-term patency rate of stenting for lower extremity arterial stenosis was significantly better than that of balloon dilation alone, with statistical differences. The treatment of infrapopliteal artery lesions has been a clinical challenge for vascular surgeons. In the past, inversion or in situ grafting of the infrapopliteal saphenous vein was the mainstay, but the long-term patency and limb salvage rates were not satisfactory and were more invasive. For example, a special long balloon (Amphirion Deep Balloon, Invatec.) produced by Invatec, Italy, has been used for the clinical treatment of subacromial artery stenosis in diabetic foot with good clinical results. A multicenter prospective clinical study by Faglia et al. on 221 patients with diabetic foot ulcers showed that PTA could promote foot artery reconstruction and the establishment of collateral circulation, reduce the amputation plane, and could be repeated with few complications, and recommended that PTA should be the treatment of choice for diabetic infrapopliteal artery stenosis. In 2005, the Department of Vascular Surgery of Peking Union Medical College Hospital conducted a clinical study on the endoluminal treatment of diabetic infrapopliteal vascular lesions, and the patients were grouped according to the TASC classification criteria for corresponding treatment. All of the selected cases were severe diabetic patients with severe resting pain and extremity ulcers. So far, more than 30 cases have been treated and the work is in progress. To date, the technical success rate is 93% and the limb salvage rate is 97%. Clinical follow-up revealed a high restenosis rate after balloon dilation of the infrapopliteal artery, with a restenosis rate of >50% at 6 months of nearly 30%, but the ulcer of the affected limb has healed and the clinical symptoms have disappeared. In our opinion, balloon dilation treatment of subacromial vascular lesions in diabetic feet can rapidly improve the blood supply to the limb and gain time for the healing of the affected foot ulcers and toe amputation wounds, and the restenosis after balloon dilation is a gradual process. This is the clinical significance and value of balloon dilation therapy, which is the key point that the limb salvage rate is much higher than the patency rate. In conclusion, the treatment of diabetic foot requires concerted efforts from various aspects, neither neglecting basic treatments such as controlling blood glucose, blood lipids, blood pressure, and smoking cessation, nor focusing only on interventional or surgical treatments. With the continuous advancement of technology, the treatment of diabetic lower extremity arteriopathy is becoming a hot spot for clinicians to focus on, and multicenter, randomized, and large sample clinical studies will likely better interpret its clinical treatment effects.