Early and Five-year Amputation and Survival Rate of Diabetic Patients with Critical Limb Ischemia: Data of a Cohort Study of 564 Patients

Abstract

Objective To evaluate the early and late major amputation and survival rates and related risk factors in diabetic patients with critical limb ischemia (CLI).Design Retrospective study. Methods Revascularization feasibility, major amputation, survival rate and related risk factors were recorded in 564 diabetic patients consecutively hospitalized for CLI from 1999 to 2003 and followed until June 2005.Results Peripheral angioplasty (PTA) was carried out in 420 (74.5%), bypass graft (BPG) in 117 (20.7%) patients. In 27 (4.8%) patients both PTA and BPG were not possible. Twenty-three above-the-ankle amputations (4.1%) were performed at 30 days: 6 in PTA patients, 3 in BPG patients, 14 in non revascularized patients. In the follow-up of 558 patients (98.9%), 62 repeated PTAs and 9 new BPGs, 32 new major amputations (16 in PTA patients, 14 in BPG patients and 2 in non-revascularized patients) were performed. Major amputation was associated with absence of revascularization (OR 35.9, pϽ0.001, CI 12.9 -99.7), occlusion of each of the three crural arteries (OR 8.20, pϭ0.022,), wound infection (OR 2.1, pϭ0.004 CI 1.3-3.6), dialysis (OR 4.7, pϭ0.001 CI 1.9 -11.7) increase in TcPO 2 after revascularization (OR 0.80, pϽ0.001 CI 0.74 -0.87).One hundred seventy three patients died during follow-up and this was associated with age (HR 1.05, pϽ0.001 CI 1.03-1.07), history of cardiac disease (HR 2.16, pϽ0.001 CI 1.53-3.06), dialysis (HR 3.52, pϽ0.001 CI 2.08 -5.97), absence of revascularization (HR 1.68, pϽ0.001,) and impaired ejection fraction (HR 1.08, pϽ0.001, CI 1.05-1.09).Conclusions In diabetic patients with CLI the revascularization is feasible in most cases and allows a low rate of early major amputation. This rate is higher in the follow-up period. Major amputation is very high in patients where revascularization is not feasible while the high mortality rate is due to the serious comorbidities observed in these patients.

Limb Salvage in Diabetic Patients: The Italian Experience

“…Usually a large part of diabetic patients affected by CLI are elderly with several comorbidity. Therefore they can't tolerate a surgical procedure for the high operative risk and secondly it is often no possible to pack a by-pass because of the absence of a suitable vein and due to the presence of a local infection that may not guarantee an adequate anastomosis site [43,45,46,[52][53][54][55].…”

Medical Management of Peripheral Artery Disease in Patient with Diabetic Foot Ulcer: A Case Report

“…Diabetes has been reported to be a major independent predictor of death in patients with intermittent claudication [6]. Critical limb ischemia (CLI) is more likely to occur in diabetic patients with PAD than in patients with PAD not associated with diabetes [7]. Ulceration and infection of leg or foot trauma in diabetic patient is often due to the micro-vascular pathophysiology of the lower extremity which includes neuroischemia and sensory neuropathy [6,7].…”

“…Critical limb ischemia (CLI) is more likely to occur in diabetic patients with PAD than in patients with PAD not associated with diabetes [7]. Ulceration and infection of leg or foot trauma in diabetic patient is often due to the micro-vascular pathophysiology of the lower extremity which includes neuroischemia and sensory neuropathy [6,7]. The peripheral sensory neuropathy causes the diabetic foot not to respond to dynia and temperature sensitivity.…”

“…The patient is therefore not capable of identifying strain and compression on the affected foot. Foot damage can go unnoticed because sensation is limited [7]. All these pathological factors contribute to increasing the incidence of CLI.…”

“…All these pathological factors contribute to increasing the incidence of CLI. In addition, these factors can worsen the ulceration due to the microcirculation damage and reduce the ability to combat infection secondary to poor perfusion [6,7]. Amputation may be required to prevent sepsis and death.…”