Critical limb ischaemia in a diabetic population from an Asian Centre: angiographic pattern of disease and 3-year limb salvage rate with percutaneous angioplasty as first line of treatment

Abstract

Purpose:Lower extremity amputation prevention (LEAP) is an ongoing program in our institution aimed at salvaging limbs in patients with critical limb ischemia (CLI). Patients in the LEAP program with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We present the 3 year limb salvage rate and angiographic disease patterns in 42 consecutive diabetic patients with CLI who received PTA in 2005.Methods and Material:26 women and 16 men with diabetes between the ages of 45 and 91 years old (mean age, 70.8 years) received PTA in 2005. Presenting symptoms were rest pain (n = 22), pre-existing gangrene (n = 17), non-healing ulcer (n = 16) and cellulitis (n = 2). The aim of the PTA was to achieve straight-line flow from the abdominal aorta down to the patent dorsalis pedis or plantar arch, with limb salvage as the ultimate outcome. Failure of treatment was defined as any amputation above the level of a Syme’s amputation or the need for further surgical bypass. Technical success was achieved in 90% (38 out of 42 patients).Results:Limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months, 78% at 1 year, 69% at 2 years and 66% at 3 years. Mortality was 17% (n = 7) at 3 years. Of the 13 patients with failed therapy, 3 underwent bypass, 9 had amputations and 1 had bypass followed by amputation. Four of the cases required further intervention due to worsening gangrene and infection, while the remaining was due to persistent rest pain. The rest of the 32 patients had no lower limb related issues at the end of 3 years, with improvement of the presenting symptoms. Patterns of treated segments were aortoiliac occlusions (n = 3), pure infrapopliteal disease (n = 3), femoropopliteal with at least 1 good infrapopliteal run-off vessel (n = 14) and combined femoropopliteal and infrapopliteal disease (n = 25).Conclusion:Involvement of infrapopliteal vessels that needs to be treated is common in Asian diabetics. While early limb salvage rates up to 1 year are similar, the 3 year limb salvage rates in Asian diabetics are lower than the western population.

Long Term Effects of Below-the-Knee Angioplasty in Diabetic Patients with Critical Ischemia of Lower Limbs Referred to Sina Hospital During 2010-2011

“…There are many evidences that distal artery revascularization is the best chance for diabetics with vascular insufficiency (10). According to Tan, the success rate of maintaining an affected limb over a year was 78% (21). The results of the present study showed that successful endovascular treatment leads to maintaining a high percentage of limbs with critical limb ischemia and isolated tibial artery and peroneal feet artery during follow-up.…”

“…So less blood flow is needed to keep the improved wounds than wound healing. In addition, the majority of patients were improved in terms of symptoms such as pain and gangrene of the extremities (21). During the follow-up procedures, after 100 PTA, only three patients out of 94 patients who had success with this treatment again suffered from critical limb ischemia in the same limb.…”

“…Many patients suffered from other diseases in addition to diabetes. Issues such as sepsis can be involved (21).…”

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

“…A prospective cohort study by Tan et al 7 ) in 2010 included 46 patients with CLI enrolled into the PTA treatment arm of the LEAP study done in Singapore. PTA in diabetic patients with CLI had a high technical success rate, and resulted in improvement in ankle-brachial index, reduction in pain and improvement in ulcer healing during the perioperative period, with a 66% limb salvage rate at 3 years of follow-up.…”

Limb Salvage in Patients With Peripheral Arterial Disease Managed by Endovascular First Approach

“…Many of them had infrapopliteal disease, which is compatible to the data reported by a previous Singapore study (55%). 15 Some suggested endovascular procedures in diabetic patients are not as durable as those nondiabetics due to increased calcification seen in diabetes. 3 On the other hand, there were reports of effective limb salvage in diabetic patients with PAD having endovascular intervention, [16][17][18] but multiple revascularization procedures may be required.…”