Minimally invasive interventional radiology is opening up entirely new pathways in the treatment of vascular diseases and chronic circulatory disorders. Instead of major surgery, highly precise, image-guided catheter procedures are used to gently access and treat diseased vessels in a targeted manner. These modern techniques make it possible to restore blood flow, significantly relieve symptoms, and prevent complications — without general anesthesia and with a short recovery time. Interventional radiology therefore combines medical precision with maximum patient comfort. The editorial team at Leading Medicine Guide wanted to learn more and spoke with Dr. med. Arun Kumarasamy.
Diabetic foot syndrome is a complex and potentially dangerous complication of diabetes in which several pathological processes interact. Persistently elevated blood sugar levels damage the nerves — a condition known as diabetic polyneuropathy. Peripheral arterial disease (PAD) is a chronic circulatory disorder affecting the legs that develops due to deposits in the arteries. These deposits — usually consisting of fats, calcium, and inflammatory cells — progressively narrow the vessels.
„Claudication is largely hereditary. About seventy percent of those affected have a genetic predisposition. It typically occurs in older adults from around the age of sixty, who then present with gradually worsening symptoms. The term itself dates back to a time when elderly patients were embarrassed that they could no longer walk long distances. To conceal the need to stop, they would appear to linger with interest in front of shop windows — hence the name. At its core, this is a disease of the vascular system: the vessels narrow, similar to what is seen in coronary artery disease. Many patients who have constrictions in the heart also develop such narrowing in the pelvic and leg vessels or even in the carotid arteries, because the entire body consists of an interconnected vascular tree. This is how claudication became widely known as a term for PAD. Diabetic foot syndrome differs fundamentally from this. It is generally a complication of diabetes in which both nerve damage and circulatory disorders cause foot injuries to go unnoticed and wounds to heal poorly. Due to insufficient blood supply, infections can spread easily. It is a typical late complication of diabetes, with persistently elevated blood sugar as the central trigger. Patients with well-controlled diabetes usually develop such problems much later because they manage their metabolism carefully and remain stable for a long time. However, those who ignore the disease face a significantly higher risk of developing complications more quickly. Factors such as smoking, high blood pressure, chronically poorly controlled blood sugar, lack of exercise, and high stress further exacerbate the situation. They increase risk factors and cause the vessels — which are often affected in diabetic foot syndrome as well — to age faster and sustain damage“, explains Dr. Kumarasamy.
Today, interventional radiology plays a central role in modern vascular medicine because it combines diagnostics and therapy in a particularly gentle yet highly precise way.
„Interventional radiology plays a key role in both conditions because it addresses the problem exactly where it arises: in the narrowed or blocked arteries. Fundamentally, two forms of vascular disease are distinguished. On the one hand, there are constrictions that begin higher up in the pelvic region. On the other — and this primarily affects patients with diabetes — narrowing develops further down, in the arteries of the lower leg and foot. These lower vessels are significantly more difficult to treat because they are much smaller and anatomically more complex. While the arteries in the thigh still have a diameter of four to six millimeters, the vessels in the lower leg often measure only 3.5 to 2 millimeters. In the foot arteries, it becomes even tighter: here we are talking about just 1.5 to 2 millimeters. It becomes particularly challenging when the very fine terminal branches that supply the toes are affected. Interventional radiology therefore attempts to advance extremely fine catheters and wires into these smallest arteries in order to improve blood supply as much as possible. The goal is always the same: the tissue must once again receive adequate blood flow — and therefore oxygen, nutrients, and immune cells that fight infection. Only when circulation is restored can inflammation subside, wounds heal, and medications such as antibiotics reach the right location at all. This is precisely where the special significance of interventional radiology lies: it creates the conditions necessary for tissue survival and recovery“, Dr. Kumarasamy explains.
In recent years, interventional radiology has gained enormous importance in the treatment of diabetic foot syndrome. Whereas in the past patients with severe circulatory disorders of the foot or lower leg had few alternatives to open vascular surgery or even amputation, modern endovascular procedures now enable therapies that are both significantly gentler and more effective.
„Treatment usually begins with obtaining the most accurate possible picture of the vessels. Although constrictions or occlusions can already be detected by MRI, CT, or duplex ultrasound, the true gold standard is angiography. In this procedure, a contrast agent is introduced into the artery via a fine needle so that blood flow can be visualized in real time. These images immediately reveal whether a vessel is narrowed, blocked, or heavily calcified — and whether this change can explain the patient’s symptoms, such as poorly healing wounds, nighttime rest pain, or infections in the foot. Angiography is performed in what is known as an intervention-ready setting. This means that once the diagnosis is made and a relevant constriction becomes visible, treatment can be carried out immediately during the same procedure. Using very fine wires and catheters, physicians then attempt to reopen the narrowed or blocked arteries and improve circulation to the point that the tissue is adequately supplied again. It is not always necessary to reopen the originally responsible artery. If a vessel is completely blocked, blood supply to the affected area can also be restored indirectly via another artery. What matters is that sufficient blood — and thus oxygen, nutrients, and immune cells — ultimately reaches the tissue so that wounds can heal and infections can be fought. This work is particularly demanding in the lower leg and foot because the vessels there are extremely small. Reaching these areas requires extensive experience, precision, and a level of specialization offered by only a few clinics“, explains Dr. Kumarasamy, continuing:
„When vessels need to be widened, several minimally invasive techniques are available and can be combined depending on the situation. The easiest to imagine are balloons that are placed within the narrowed vessel and carefully expanded. There are also drug-coated balloons that release medication to prevent the constriction from closing again. If that is not sufficient, atherectomy is used — a procedure that can indeed be imagined as a tiny drill. When a vessel is so heavily calcified that a balloon cannot pass through or expand, the hard material is removed with a rotating burr. These instruments spin at enormous speed, creating space so that the balloon can subsequently pass without difficulty and widen the vessel. Only when all these methods are insufficient are stents used — small vascular supports that keep the vessel permanently open. However, modern concepts follow the principle of ‘Leave Nothing Behind,’ meaning that no permanent material should remain in the body whenever possible. For this reason, stents are used only when truly necessary. All of these procedures are applied both in peripheral arterial disease and in diabetic foot syndrome. In both cases, the aim is to improve blood flow sufficiently so that the tissue is once again supplied with oxygen and nutrients and wounds have a real chance to heal“.
Angiography_Bürgerhospital Frankfurt
Complex procedures on lower leg and foot arteries require many years of experience, numerous independently performed treatments, and ongoing exchange with specialized colleagues. Only a few clinics possess this expertise, which is why specialized centers are known far beyond their regions. Patients benefit from a high level of experience and safe, well-established processes, including very high revascularization rates.
The close collaboration between the diabetic foot center and the largest diabetology department in Frankfurt creates care that is significantly faster, more coordinated, and medically more precise than treatment within separate structures.
Dr. Kumarasamy describes it as follows: „The collaboration with the diabetic foot center is designed to form a true unit in which the entire spectrum of expertise surrounding the diabetic foot is consolidated. In Frankfurt, one of Germany’s largest and most highly certified diabetology departments is available under the leadership of Christian-Dominik Müller — a division that fulfills all the criteria necessary for top-level certification. This strong diabetology foundation is complemented by interventional radiology, which offers minimally invasive vascular treatments at the highest level. The two areas do not merely operate side by side but truly hand in hand, allowing patients to benefit from tightly integrated, interdisciplinary care. Since January, the team has also welcomed a new chief physician, PD Dr. med. Sebastian Fischer, a foot surgeon who previously worked at BGU Frankfurt and is regarded as a recognized expert. With him, the center’s profile is further rounded out, as he contributes the surgical expertise essential for complex wounds, deformities, or operative procedures on the diabetic foot. The result is a team that occupies a special position both regionally and nationally and can present itself jointly. In addition to diabetology, interventional radiology, and foot surgery, other specialties also play an important role. The internal medicine department supports the management of comorbidities, and the strong women’s health clinic enables procedures such as fibroid embolization — another example of how catheter-based techniques are used across different disciplines. Overall, this creates a network in which various specialties collaborate closely to provide a level of care offered by only a few clinics“.
Through this direct cooperation, patients who are at increased risk for poorly healing wounds or circulatory disorders can be identified much earlier. Diabetologists recognize warning signs such as neuropathies, infections, or emerging vascular problems and refer patients to the foot center without delay. There, specialized surgeons, wound experts, and vascular specialists are ready to initiate diagnostics and therapy immediately. Particularly in diabetic foot syndrome, timely care is critical because infections can spread quickly and tissue loss is a real threat.
A center of excellence for diabetic foot syndrome thrives on the fact that multiple highly specialized disciplines work not alongside one another but truly together. Each discipline contributes its own indispensable expertise — and it is only through this collaboration that care becomes so effective. For patients, this results in a treatment pathway that is faster, safer, and far more targeted than in conventional structures.
Interdisciplinary collaboration between diabetology, interventional radiology, and foot surgery is one of the decisive factors ensuring that patients with diabetic foot syndrome and PAD now have significantly better chances of recovery than they did just a few years ago.
„The treatment of vascular diseases such as claudication and diabetic foot syndrome has undergone a long evolution. Procedures such as balloon dilation and stent implantation have existed for many decades, but in the past they were used far less frequently. Over time, guidelines have changed and strengthened the importance of minimally invasive therapy. Today, not only interventional radiologists work with these methods, but also cardiologists, angiologists, and increasingly vascular surgeons who once operated exclusively. What matters less is the specialty than the ability to master interventional techniques safely. Over the years, numerous new technologies have been added that have significantly expanded treatment options. These include atherectomy, in which calcifications are mechanically removed; drug-coated balloons and stents; and modern procedures such as lithotripsy, which uses ultrasound to break up hard calcium deposits. These technological advances have made procedures safer, reduced complication rates, and improved outcomes“, says Dr. Kumarasamy, adding:
„At the same time, patients benefit from shorter hospital stays, less pain, and a lower risk of infection because major surgeries are becoming increasingly rare. As experience grows, so does the quality of care. Clinics that treat several hundred patients each year develop a distinctive level of expertise from which those affected benefit directly. Interdisciplinary collaboration among different specialties further amplifies this effect. Larger hospitals can offer a broader spectrum of services, and close cooperation with hospital leadership creates favorable conditions for modern, patient-centered medicine. How long a patient remains hospitalized after a procedure now depends largely on the individual severity of the condition. The goal is always to discharge patients back to their daily lives as quickly as possible without compromising medical safety. If necessary, they can be readmitted at any time or continue to receive inpatient care — the decisive factors are always the individual situation and seamless coordination between outpatient and inpatient treatment“.
3D Medical Animation Vascular Bypass._Grafting
After an interventional vascular procedure, there are several important points patients should keep in mind to ensure the long-term success of the treatment.
„As a rule, an initial follow-up examination takes place within two weeks. During this visit, we assess how well blood flow has been restored and how symptoms or wounds are progressing. Throughout the inpatient stay, patients are seen daily, circulation is measured regularly, and any changes are identified immediately. If something does not proceed optimally, additional treatment can be provided right away — a major advantage of this close monitoring. Many patients notice an improvement in their walking distance relatively quickly. Although bruising, mild pain at the puncture site, or a pulling sensation in the calf may occur during the first few days after treatment, resilience usually increases rapidly. Even wounds that previously refused to heal often show clear progress within just a few weeks. The relief from reduced pain or the ability to walk longer distances is immediately noticeable for many patients. In the long term, however, one fact remains important: a vascular patient remains a vascular patient. The disease does not disappear completely, and the vessels continue to age. Some patients remain symptom-free for many years, while others require another procedure after two to four years — particularly when constrictions are located in very small lower leg or foot arteries. Larger vessels in the pelvic region typically remain open much longer. What matters most is that patients attend regular checkups so that changes can be detected early and treated in time. In principle, treatment can be repeated as often as necessary. How long success lasts depends on many factors: the location of the constriction, overall health, and lifestyle. Smoking, poorly controlled diabetes, lack of exercise, or high blood pressure accelerate disease progression. Those who manage their risk factors well usually benefit significantly longer from a procedure“, explains Dr. Kumarasamy, concluding our conversation by emphasizing:
„In specialized centers, several hundred such interventions are performed each year — a wealth of experience that significantly influences the quality of treatment. Modern technologies such as intravascular ultrasound or ultrasound-based lithotripsy, which shatters hard calcifications, further expand the possibilities. The goal always remains the same: to open chronic or acute vascular occlusions, secure blood flow, and avoid amputations. Although around 50,000 major amputations are performed annually in Germany, regions with specialized centers demonstrate significantly lower rates. There, it is more often possible to prevent major procedures and limit the need to minor amputations such as the loss of a toe“.
Thank you very much, Dr. Kumarasamy, for these comprehensive insights into interventional radiology!
- Specialist in interventional radiology with an excellent reputation and many years of experience in minimally invasive, image-guided vascular procedures
- Chief Physician of the Clinic for Interventional Radiology at Bürgerhospital Frankfurt
- Focus on catheter-based vascular therapies for the treatment of narrowed or blocked arteries
- Proven expertise in the treatment of peripheral arterial disease (PAD)
- Use of state-of-the-art endovascular techniques to restore circulation and prevent severe complications
- High level of competence in diagnosing complex vascular diseases using CT, MRI, and angiography
- Treatment of chronic circulatory disorders, particularly in patients with diabetes, hypertension, and nicotine use
- Close interdisciplinary collaboration with angiologists, diabetologists, and vascular and foot surgeons
- Represents precision medicine, modern technology, and patient-centered, compassionate care
