Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients

Abstract

Objective: Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limbthreatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood.Methods: We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using c 2 , Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S.

Chronic limb threatening ischemia and diabetes mellitus: the severity of tibial atherosclerosis and outcome after infrapopliteal revascularization

“…Previously, insulin-treated diabetics have been demonstrated to present more severe disease at a relatively young age. 27 In this study, the median age for insulin users at revascularization was 72.4 (IQR: 64.0–79.5), which is significantly younger than in non-insulin diabetics and non-diabetics (NIT-DM 76.0, IQR: 67.9–83.6 versus non-DM 77.3, IQR: 68.5–83.7, p < 0.001). In the previous literature, insulin use has been particularly associated with a multitude of comorbidities.…”

“…This same treatment strategy of “endovascular first” has been reported in multiple studies and vascular centers. 27 –29 In infrapopliteal CLTI patients overall, endovascular methods can be efficient in short and stenotic lesions, whereas long occlusions may require surgical revascularization for better outcomes. 3…”

“…As stated before, an evident explanation is patient selection that directs these patients toward endovascular strategy. In addition, in previous literature, insulin regimen has been associated with increased limb loss: Darling et al (27) reported better durability with surgery compared to endovascular procedure in patients on insulin. A study conducted by Dosluoglu et al (28) reported that primary patency was poorer in insulin users after endovascular revascularization and insulin was associated with worse limb salvage.…”

“…Most of the studies with a diabetic cohort do not have differentiated patients using the on-going hypoglycemic medication as criteria: therefore, the effect of different diabetic regimen on revascularization strategies and outcomes has not been thoroughly evaluated. Previously, insulin-treated diabetics have been demonstrated to present more severe disease at a relatively young age (27). In this study, the median age for insulin users at revascularization was 72.4 (IQr: 64.0-79.5), which is significantly younger than in noninsulin diabetics and non-diabetics (nIT-DM 76.0, IQr: 67.9-83.6 versus non-DM 77.3, IQr: 68.5-83.7, p < 0.001).…”

Frequency of limb salvage after infra-inguinal bypasses for chronic limb-threatening ischemia in diabetics: a retrospective study

“…All patients with ulcers, gangrene or pain in the foot attributable to PAD should be considered for urgent care and should be referred Heavy calcifications, infra-popliteal vessel involvement, long and multilevel lesions, frequently associated foot infection and associated medical comorbidity render diabetics at much higher risk of major amputation. 11,12 Bypass surgery remains a more durable revascularisation option in relatively fit patients with expected life expectancy of > 2 years. 13 Recent studies have shown excellent results with bypass surgery in diabetics, both in the short and long term.…”