Preventing diabetic foot ulcers

Figure 1 We are impressed with the work done by Diabetes Africa. Last year they published a series of articles titled "Rethinking Podiatry Care in Africa." You can click on the image above to get to their site. We particularly like the quote by Smiso Ntuli, emphasizing that diabetes treatment is teamwork. image copyright: diabetesafrica.org

Are you aware that we can prevent most diabetic foot ulcers? To achieve this, we have to educate patients who have diabetes. At the same time, we as caregivers have to find the most likely patients to develop foot ulcers in the future. In many western countries, the guidelines state that when you have a patient who has, for example, callosities ( hard skin due to pressure) and at the same time sensory neuropathy ( diminished feeling in the feet), then this patient should be referred to a multidisciplinary team at specialist level. Let us restate this: in countries where the resources are available, diabetic patients without foot ulcers should be referred to a team of people dedicated to preventing diabetic foot ulcers. Obviously, in many regions of Africa, this is entirely unrealistic. There we are lucky if patients with already existing diabetic ulcers get referred to someone with a bit of experience at all. This doesn't mean that we can shrug our shoulders and resign. Just because you hear that they have excellent guidelines for preventing diabetic foot complications in Western countries, that doesn't mean that these guidelines are followed. For example, in these countries, it is recommended that the family doctor examines the feet of all of his diabetic patients at least once a year. What is the reality of this recommendation? This varies from country to country, but on average, only about 30% of the patients get their feet looked at when they go to the doctor's office. Wound unions/societies do their best to educate family doctors and patients about the importance of regular foot checks, but disappointingly, little has improved in the last two decades. So do not think that everything concerning diabetes foot is so rosy in western countries.

To succeed with the prevention of diabetic foot ulcers, we have to rely on all healthcare professionals like home care nurses, medical assistants, medical officers, assistant nurses, podiatrists, and doctors to find patients with a high risk of developing foot ulcers in the future. All healthcare workers should have a basic understanding of how important it is to prevent diabetic ulcers. If there is nowhere to refer the patients, we have to know how to educate them ourselves - about taking care of their feet and preventing mechanical injuries.

If we are to succeed in implementing good prevention guidelines in Africa, we have to focus on education. D- Foot International ( the "D" stands for diabetes) has organized workshops and other organizational activities on the continent for many years. They have developed a teaching program that seems to have the right pedagogic approach as they can show encouraging results in the areas they have focused on. Obviously, they cannot reach every municipality on the continent. We have to adopt their approach and adapt it to the places where we work.

Figure 1 With only very simple tools, we can perform a reliable risk assessment of the feet of diabetic patients. This requires some basic training and can be performed by healthcare professionals at all levels. image copyright: worlddiabetesfoundation.org

How do we check if a diabetic patient is at risk of developing a foot ulcer? The international consensus is that we have to perform three simple tests to screen for the risk of developing foot ulcers. The tests are so simple and low-tech that some of you may even be disappointed that we do not use more fancy tools. Keep in mind that the tests were developed to be carried out by anyone, regardless of where they work and their available resources. All you need are your eyes for inspection of the foot, your fingers for palpation of the arteries, and a monofilament to test whether the patient has sensory neuropathy. Ideally, you should use a standardized monofilament to do this. Do not despair if you do not possess a monofilament. There are a few workaround solutions to this- please also refer to our chapter dedicated to this test.

Remember: in this chapter, we are looking at preventing diabetic foot ulcers. In other words, these are patients who currently do not have a foot ulcer yet. Remember also always always to inspect both feet of the patient!

The simple three-step risk assessment

1. Inspection of the feet

Look for deformities in the foot: hammertoes, claw toes, hallux valgus, hollow feet ( pes cavus), flattened feet ( pes planus). Look for hard skin areas (callosities) that are tell-tale signs that this area is under mechanical stress. Deformities and hard, thickened skin are risk factors for developing a foot ulcer.

2. Testing the sensory nerves under the feet

Diabetes mellitus causes nerve damage over time. It is essential that we check whether the patient has sensory perception on the sole of their feet. All caregivers who provide wound care must be able to carry out a monofilament test. It is a very simple test, and all you need as a tool is a nylon monofilament. We have written a seperate chapter on this test- click on the image here to get to that chapter.

3. Checking the arterial circulation of the feet

For this test, we are simply using our fingers to palpate the pulse of the dorsal foot artery and the posterior tibial artery. If you can sense a pulsation in these arteries, the blood circulation is probably not catastrophic. If you cannot palpate a pulse, the patient should actually be referred to a vascular specialist. In most areas of Africa, this is not a realistic option. Remember, while a doppler probe is an excellent tool for checking arterial circulation, this is not a standard part of the international risk evaluation test. This makes sense because most caregivers worldwide do not have access to a doppler probe.

What do we do with the results of the simple, three-step risk assessment?

Once we have done the simple risk assessment, we go to a table to " plot" in the results. There are several different international algorithms for this purpose. In recent years the Tayside Foot Risk Assessment Protocol has gained wide acceptance. Tayside is a place in Scotland where a working group developed this risk assessment algorithm.

We have made a simplified version of the Tayside protocol ( table 1). In the table, we present you with the international recommendations for treating the patients according to their risk category. For example, patients with high-risk feet should, under optimal conditions, be referred to a multidisciplinary diabetic foot team. Suppose you work at an off-the-grid clinic where the nearest doctor is 300 km away, and an interdisciplinary team is non-existent. In that case, these recommendations are everything but realistic, and we are aware of that. In these circumstances, you have to improvise and do whatever you can to prevent the onset of diabetic ulcers. One step in the right direction is to read this chapter thoroughly and devise workaround solutions that fit your available resources.

Table 1 Modified version of the Tayside Risk Assessment Protocol. Once you have plotted in the results of the foot examination, the table tells you what risk category the patient is in and what consequences that has for further treatment. These are the international recommendations. For many parts of Africa, the recommendations must be adapted to the available local resources.

Note that you also have to know a few other facts about the patient to do a complete risk assessment. You should ask whether the patient has had previous foot ulcers, whether the patient has had an amputation of toes, or even major amputations. You should check their eyesight and check for other physical impairments. Poor vision is considered a risk factor because patients might not be able to see whether they have sustained an injury to the foot.

1. If the patient has no deformities, palpable pulses, and no loss of sensation, this is classified as a low risk for developing foot ulcers. The patients can clip their nails but should have a new foot examination within a year.

2. If the patient only has ONE risk factor- for example, hyperkeratosis or no palpable pulses then the patient is at moderate risk for developing a foot ulcer. Regular podiatrists can usually follow up on these patients, and preferably these patients should not cut their own nails.

3. If the patient has TWO OR MORE risk factors, this is a high-risk patient. Specialized podiatrists should follow these and preferably even a multidisciplinary team. Often these patients will need customized footwear.

4. The last category is beyond all risks - the patients who already have an ulcer. A multidisciplinary team should always follow these up.

Figure 1 No risk assessment tool is perfect. Sometimes, we have to use our clinical sense to assess the correct risk. If the patient in the image above has normal pulses, normal sensation, and no deformities, he/she may end up in the medium-risk category. Our only finding here was callus. We hope you will agree with us, however, that this is more than a simple callus. Here we see deep cracks in the skin, and we would definitely say that this patient is at high risk of developing foot ulcers.

Figure 1 The foot above has such a severe deformity that even if you found normal pulses and intact sensation of the foot, this would have to fall into the high-risk category. If you look carefully, though, you see callus over the PIP- joint of the second toe. Deformity + callus = two risk factors = high risk foot! This patient needs appropriate shoewear, preferably also a soft spacer between the first and second toe. Copyright: Molly Judge, St. Vincent Charity Hospital, Cleveland.

The Tayside Risk assessment protocol recommends referring medium to high-risk patients to podiatrists for regular follow-ups. These should ideally be certified podiatrists with special training for diabetic foot problems. These will be nowhere to be found in basically any rural area in Africa. Even in urban settings on the continent, there is a significant discrepancy regarding qualifications among podiatrists. The solution to this challenge is that other healthcare workers must acquire some basic podiatric skills to prevent diabetic ulcers. This involves learning how to offload a foot with pads or self-adhesive felt, deal with toenail issues, and give sensible advice on footwear.

Many caregivers do not realize how little it takes for a diabetic patient to be in the high-risk category. Suppose the patient, for example, has sensory neuropathy and, at the same time, deformities of, say, the toes. In that case, the patient falls into the high-risk category for developing foot ulcers. Also, the combination – of callosities ( hard skin due to mechanical irritation) and sensory neuropathy will put a patient into the high-risk group. Very many diabetic patients have callus and loss of sensation in the feet! This is not a rare condition. Ideally, patients in the high-risk category should be referred to interdisciplinary teams; in areas where such teams are not available, you either have to establish such a team yourself or improvise with what resources are available to you. Once you have found a high-risk patient, you should never lose them out of your sight again. It is of utmost importance that these patients receive clear information about preventive measures. They should have a low threshold for coming to the clinic if they sustain an injury to the foot or already have a foot ulcer. They must understand that no ulcer is too small to turn to the clinic for help. So even if you do not have the resources to establish a “ protection team,” there is no excuse for not establishing some educative system as a substitute.

Suppose you are lucky enough to work at a wound care center with more resources. In that case, you must be aware that the international guidelines recommend that you open your doors wide for diabetic patients who have not yet developed foot sores. Paradoxically, even in several western countries, some specialized wound care centers are unaware of this responsibility and turn away such referrals! If we are to take the prevention of diabetic foot ulcers seriously, we have to be accessible for high-risk patients also at the specialist level- before they develop foot sores!

What exactly does the protective team do? They will check the blood circulation, preferably with a hand-held Doppler or a toe pressure gadget. Secondly, they assess the need for offloading certain areas of the foot and have to come up with solutions on how to solve this with the resources available. Equally important is the educational role they have – providing easy-to-understand information for the patient about the prevention of foot sores.

The patients who already have developed foot ulcers should, under optimal circumstances, be treated by a multidisciplinary team consisting of at least some of these specialties: tissue viability nurse, other nursing specialties like endocrinology ( diabetic nurse), podiatrist, orthopedic engineer, orthopedic surgeon ( or general surgeon) and vascular surgeon. Some teams also have an endocrinologist and sometimes also a plastic surgeon integrated into the team.

If you think that most diabetic foot patients in western countries have access to such multidisciplinary teams, you are wrong. Organizing such big teams, for example, two days a month requires some logistics and resources. Remember, also, in western countries, you cannot just clap your hands and expect a vascular surgeon to participate in such teams. They would usually rather stand in the operation theatre doing vascular surgery rather than assessing the blood circulation of a diabetic foot patient. For these teams to be successful, it is essential that each team member fully understands the necessity of having a multidisciplinary team approach to these challenges, and they all must be interested in wound care.

Figure 2 Patient education is essential for preventing diabetic foot ulcers. Many countries have made simple brochures as handouts to patients. A lot of these brochures are based on leaflets produced by the NHS in Scotland. These include easy-to-understand information for patients and their caregivers. There are separate leaflets for each risk category. They have two sides and can be printed out on an A4 sheet of paper. You can click on each image above to get to a downloadable version of these recommendations. You could then adapt these to your local situations and translate them into the language of your area. copyright: NHS Scotland

Practical advice about foot care for patients with diabetes

The following points are some of the important information which you have to educate your patient about. You could also include these in the leaflet, which you can make to give to the patient.

Check your feet every day before you go to bed ( alternatively, when you get up-there may be better light to check the feet).

If you have stiff joints and cannot manage to look under your feet, have a family member inspect them for you daily.

Try to avoid going around barefoot as this will increase your chance of developing a foot sore. Even though slippers/ sandals only provide partial protection, they are better than walking barefoot.

When you work in wet fields, you should wear rubber boots if these are available to you.

Never use shoes that feel too tight/small! When you have diabetes, your shoes must fit comfortably. It is wise to buy new shoes in the afternoons when feet usually are slightly swollen. In that way, you will avoid purchasing too-small shoes.

As a rule of thumb, you should at least be 1-2 cm longer than your foot measured from the base of the heel to the end of your longest toe.

If your existing shoes have given you a blister previously, they are useless to you. You have to find another pair of shoes.

Whenever you go for a medical checkup, always ask the doctor/medical assistant/nurse to check your feet.

Patients who have previously had foot ulcers should ideally get shoes from an orthopedic engineer – at least get inline soles that are a good fit. Patients with foot deformities will need individually made shoes, and this will not be available in many areas in Africa.

When you buy new shoes, your feet have to get used to them. Only wear them for a few hours every day at the start to make sure that they do not cause you blisters. Usually, shoes tend to get a bit wider and softer after you have worn them for some days.

If you live in an urban area where this service is available and can afford it- try to go to a certified podiatrist a few times a year. This is especially important if you have difficulties cutting your own nails.

We do not recommend footbaths for patients with diabetes because dampness can collect between the toes leading to fungal infections. If you feel the need for a footbath, limit this to a few minutes and be careful to dry the areas between the toes thoroughly.

If you use footbaths, make sure that the water is not too hot. If you have decreased feeling in the feet, you can burn yourself. Ideally, the water should not be more than 40 C.

It is advised to keep the skin of the feet smooth by applying lotion daily. However, avoid using lotion between the toes, which can lead to moisture accumulating there.

If you have cold feet, never use a heating bottle to warm your feet, as this can cause severe skin damage. Never heat your feet in front of an electrical heater or even a fireplace!

The role of podiatrists in preventing/treating diabetic foot problems.

Certified podiatrists have a central role in preventing and treating diabetic foot challenges. Not only do they have a sound understanding of how feet work, but they can also share the workload with other specialists by following up with this patient group. According to diabetesafrica.org, there are only about 500 trained podiatrists in Africa ( 2020)! In rural Africa, it will be near impossible to find such a podiatrist. It is difficult to find a podiatrist with special knowledge about diabetic feet, even in urban settings. Many podiatrists there focus on the cosmetic aspect of feet treatments to make an income.

If you are working in a wound clinic in an urban setting, we strongly advise you to try to attach a podiatrist interested in wound prevention/ treatment to your team. Train them with the resources which are available online. If you are working at a rural clinic where no podiatrist is available, you may consider appointing a nurse or medical assistant to get some basic training in this field. The main focus should be on acquiring techniques for offloading pressure-prone areas of the feet, such as self-adhesive felt or silicone orthotics that can easily be made yourself with basic training.

Also, podiatrists with special training in diabetic feet may be hard to find in many Western countries. In some western countries ( for example, Germany), patients will get several treatments from a podiatrist refunded. In other countries, the patients have to pay for a visit to a podiatrist by themselves. We are trying to say that not everything in the world of wound care is perfectly rosy in western countries either. This is a paradox. Politicians usually like to talk about the importance of preventing diseases, but when it comes down to it, many health care budgets ignore the needs of patients with diabetic feet.

It is noteworthy that the education of podiatrists varies a lot from country to country. In the USA, for example, podiatrists often take the roles of medical doctors and can even be authorized to do advanced surgical procedures. In fact, they can have the title doctor of podiatry. In most European countries, podiatrists cannot perform surgical procedures. Be aware of these differences when you read the literature on the role of podiatrists.

A podiatrist with special training in the diabetic foot will quickly establish if a patient is in a high-risk group to develop a foot ulcer. In this case, they usually refer the patient to a higher level of care for further examination/treatment. At the same time, the podiatrist should already have made a plan for how the foot best be offloaded.

Figure 4 According to diabetesafrica.org, there are only about 500 trained podiatrists in Africa today. In contrast to this, there are about 11.000 podiatrists registered in the UK today ( statista.com). The University of Johannesburg has a Bachelor of Health Sciences in Podiatry, which is the only academic curriculum available in Africa. image copyright: diabetesafrica.org

Video 1 A short video from the " Rethinking Podiatry Care in Africa" Campaign from 2020 copyright: diabetesafrica.org

We need a lot more certified podiatrists in Africa. Did you know that your chances of employment are very high if you undergo education and training in this profession? Many graduates from the University of Johannesburg find job opportunities in the public sector, but there are also good career possibilities as a private podiatrist. Below is an interview from the University of Johannesburg informing about the educational program and job opportunities.

Video 2 An interesting interview from the University of Johannesburg about career possibilities in podiatry in Africa. It also clears up some misconceptions about podiatry. Podiatry is not only about cutting toenails. It is a wide field of medical health care with exciting career possibilities in both the public and private sectors.

Prevention of diabetic foot ulcers by offloading

Most diabetic foot injuries occur due to a mechanical injury- either pressure or friction. In western countries, this is often due to inadequate shoewear or foreign objects lying in the shoes- for example, small pieces of gravel. In Africa, many diabetic patients get a wound because of walking barefoot and stepping onto something sharp.

If we see deformities of the feet or even callosities due to pressure, we have to do something to prevent ulcers from developing in these areas. If this resource is available, it is good to refer the patient to a podiatrist for offloading techniques. Most likely, you will not have a podiatrist or orthopedic technician, and in this case, you will have to find a way to unload these areas yourself. In the chapter on treating diabetic foot ulcers, we will look more closely at off-loading tools. In this chapter, we will only present you with a brief overview.

Practical tools for immediate offloading are:

Self-adhesive felt. Hapla felt is one of the most known brands. It is an immensely useful offloading tool. It can be used to protect and offload any body area but is mainly used on the feet. It is pretty cheap and is also useful for preventing and protecting feet ulcerations of other causes.

Small, self-adhesive felt plasters for covering calluses over joints of the toes, for example.

Soft, cushioned insoles, either prefabricated or individually made.

Individually made silicone orthotics to protect, for example, prominent joints in a claw- or hammertoes.

Prefabricated special shoes. These are usually wider than regular shoes and have a soft insole and a high toe-cap area.

Individually made shoes made by an orthopedic engineer/technician

Figure 4 Some standard tools for offloading certain foot areas to prevent ulcerations. A) Inlay soles are either prefabricated or preferably custom-made. B) Self-adhesive wool felt C) Foam pads, preferably self-adhesive D & E) Custom-made silicone toe spacers, F) Cushioning rings, G) Shoes with adequate length and width, especially in the forefoot area. Make sure that the height of the toe cap is also adequate.

The role of the orthopedic technician in preventing diabetic foot complications

Like certified podiatrists, there are only a few orthopedic technicians in Africa. It must be one of the careers with the biggest chances of getting employed in Africa. If you consider working in healthcare and have practical abilities, we strongly recommend looking into either podiatry or training as an orthopedic technician. The demand for these professions will continue to rise in Africa for many years ahead.

Orthopedic technicians have many roles in diabetic foot care. Their expertise covers a wide range of orthotics, from simple offloading devices to complicated prostheses after amputations. Since we are discussing the prevention of diabetic foot ulcers in this chapter, let us take a closer look at how orthopedic technicians are involved here.

In clinics with multidisciplinary teams for diabetic foot care, both podiatrists and orthopedic technicians are a standard part of the team. There can sometimes be a slight overlap between these two professions as some podiatrists also deal with customized shoes. Usually, however, the orthopedic technician makes customized inlay soles, has access to prefabricated shoes with different widths and heights, and can create custom-made shoes to fit severe deformities. A good orthopedic technician will always find a solution. However, be aware that the first orthotic* device or shoe the technician has come up with often may not always be a perfect fit. We recently spoke to an orthopedic technician, and she acknowledged that at least 30-50% of orthotics are not perfect on the first try. This doesn't mean that the technician is poorly trained. For example, it can be immensely difficult to foresee how the foot will behave when putting a customized inlay sole beneath it. Therefore it is essential that you take the patient in for a check-up a couple of weeks after starting with a new orthotic device.

An orthopedic technician needs a workshop to perform their job. It is a practical trade that requires specific tools and moldable materials. The technological advancements in the field of orthopedic technics have been enormous. 3D scanners and 3D printers can now precisely analyze the foot and make custom orthoses that fit very well. In some areas of Africa, such modern technology is, in fact, available to some orthopedic technicians. However, in most parts of Africa, you will be lucky if you have access to an orthopedic technician at all.

* the term orthotic device ( also called orthoses) is a very vague term. This implies most types of shoe inserts, special shoes, braces, and splints, used to treat conditions on the upper or lower limbs.

Figure 5 An orthopedic technician can make customized soles, shoes, splints, and braces for almost any type of situation and is an essential part of the diabetic foot team. In a few areas of Africa, modern 3D printers are available to produce high-tech orthotics within a few hours after scanning a patient. The images above are from a project in Mali, Togo, and Niger called "3D Impact," which started in 2017. copyright: medicalxpress

Figure 6 There is a huge demand for orthopedic technicians in Africa. This is a challenging and rewarding career with many possibilities. The Tanzania Training Centre for Orthopaedic Technologists (TATCOT) is an example of an institution providing this education. If you are interested in what types of courses an institution like TATCOT provide, click on the image above. You can choose between a Bachelor of Science degree, diploma- or certificate courses.

Controlling blood sugar levels for the prevention of foot ulcers

Keeping blood sugar levels at an optimized level is an essential part of preventing the development of foot ulcerations. Checkups are usually done by a medical doctor but can also be done by specially trained medical officers or nurses. As a rule of thumb, it is advised to keep the « long term blood sugar» ( HbA1C) < 7, but this is age-dependent and whether the patient has diabetes-related complications like a macro-vascular disease. Be aware that modern laboratories now measure Hba1c in mmol/mol instead of percentage. In addition, it is important to check blood pressure and cholesterol levels.

Figure 7 Glycemic target ranges (HbA1c) according to age and the presence of macro-vascular complications. Note that in the elderly population, we accept a slightly higher target range. The Hba1c is shown as both the new values as mmol/mol and in percent. Source: Ceriello et al., Personalized therapy algorithms for type 2 diabetes: a phenotype-based approach, 2014

The role of the vascular surgeon in preventing diabetic foot ulcers

In many western countries, there has been an enormous technological development in the possibilities for improving blood circulation in the legs/feet. Perhaps the most significant development has been in the field of mini-invasive techniques to unblock clogged arteries. When possible, these are done by an endovascular procedure which means that the entire procedure is done from within the arteries. This procedure is also known as angioplasty. Using a very thin catheter that is usually introduced into the artery in the groin area, a balloon at the end of the catheter is inflated. The pressure from this balloon forces the walls of the blood vessels apart, which can significantly improve the blood flow. Sometimes a metal mesh called a stent is left in place in the artery once the catheter is withdrawn. The stent serves to keep the lumen of the blood vessel open over a more extended period. Be aware that very often, over the course of some years usually, the artery gradually will get clogged again. However, by this time, the patient hopefully will have developed some new collateral arteries which can compensate for this.

Today, mainly patients with already existing foot ulcers are referred for this type of treatment. Internationally, the recommendation is to refer more of the high-risk patients for this treatment as well. In other words – we would like to see more of the patients who have not yet developed foot sores ( but who most likely will do so in the future) to be referred for endovascular procedures so that we can prevent these complications.

There are significant differences in the attitude of vascular surgeons towards treating diabetic patients without existing foot ulcers. Some vascular surgeons are conservative and will instead wait and see. Modern vascular surgeons who are regularly involved in wound care and see the devastating complications of diabetic feet often advocate for early endovascular intervention.

In Africa, of course, it all comes down to the economic aspect. If the patient has the financial resources, it is possible to find a vascular specialist at private centers in urban areas who perform endovascular procedures. Only patients with severe diabetic foot problems may be selected for these limb-saving procedures at most African government hospitals. In most rural areas of Africa, the patients will never see a vascular specialist.

Ideally, which diabetic patients should be referred to a vascular specialist?

Patients with no palpable puls over arteria dorsalis pedis or arteria tibialis posterior.
Patients with ABI < 0,8
Patients with ABI > 1,3 ( remember that a high ABI also is an indicator of vascular disease)
Patients with intermittent claudication( leg pain while walking)
Patients with ischemic pain while resting

Note that age itself is usually not a contraindication for endovascular procedures. However, it is important that the patient is in adequate general health, can cooperate, and has no contractions in the knee joint. Contractions in the knee can make it impossible to advance the catheter past the knee area.

When these patients are referred to a vascular specialist, a CT or MRI angiography is usually done to visualize the stenotic regions. This will determine whether an endovascular procedure is at all possible to do. If the stenotic lesions are very long or very distally in the leg, this type of procedure is usually not possible. Remember also that angiography requires the use of contrasting substances. These are potentially toxic for the kidneys- patients with renal disease may not tolerate the procedure or need intravenous fluid supplementation, especially after the procedure to rinse the contrasting substance out of the bloodstream.

Endovascular procedures are performed under a special x-ray technique called fluoroscopy using intravascular contrast. In most countries, these procedures are performed by specially trained radiologists.

Sometimes, when an endovascular procedure is not feasible due to the location or lengths of the stenosis, the vascular surgeon may be able to improve the arterial circulation by doing open surgery using some type of bypass.

Figure 8 There is a severe need to train more doctors in Africa to perform endovascular procedures like angioplasties. In most countries, specially trained radiologists perform such procedures. The most expensive part of the equipment needed is a good-quality fluoroscope.

Video 3 An illustrative video explaining the basics of how a peripheral angioplasty is performed in a leg. copyright: American Medical Center- American Heart Institute

Figure 9 Recently ( November 2021), a three-day vascular surgery conference was held in Egypt. These sorts of events are essential for sharing knowledge across the continent. Information about this sort of event is not always known to us. If you are aware of similar events arranged in Africa which are not on our events calendar, please let us know. Incidentally, we are delighted when we see vascular surgeons discussing of-loading devices! Vascular surgery is more than just surgery! copyright: Xinhua/Ahmed Gomaa