Diabetes Linked to Failure Of Limb Ischemia Repair

By Mark S. Lesney

Diabetes, preprocedure presence of ulcer or gangrene, and the severity of lesion type were found to be associated with failure of endovascular repair for chronic limb ischemia, according to Dr. Evan Ryer, department of vascular surgery, New York Presbyterian Hospital-Weill Medical College, Cornell University, New York.

"Many patients who are afflicted with peripheral arterial disease are at increased surgical risk due to their advanced age and multiple comorbidities. Minimally invasive percutaneous interventions may minimize perioperative complications in these predominantly frail and elderly patients," according to Dr. Ryer.

Among patients with a failed intervention, 83% were candidates for a second procedure. DR. FARIES

In a study that sought to examine the consequences of failed percutaneous angioplasty of infrainguinal lesions presenting with disabling intermittent claudication or critical limb ischemia, Dr. Ryer and colleagues at Cornell University and at the College of Physicians and Surgeons of Columbia University, followed 246 patients who underwent treatment for chronic limb ischemia (CLI).

Patients undergoing percutaneous angioplasty with and without stenting for infra-inguinal lesions between 2002 and 2004 were prospectively entered into a computerized database.

Their lesions were morphologically classified according to the TransAtlantic Society's Consensus (TASC) stratification. Follow-up included physical exam, arterial brachial index, and duplex ultrasound at less than 30 days, 3 and 6 months, and annually. Dr. Ryer presented the data at the 16th annual winter meeting of the Peripheral Vascular Surgery Society in Park City, Utah.

A total of 18% of the procedures (46 patients) were considered an intervention failure as determined by restenosis, returning clinical symptoms, a nonhealing foot lesion, or the absence of a previous palpable pulse.

Age, sex, smoking, and comorbidities such as hypertension, MI, COPD, CABG, and hypercholesterolemia were not significantly associated with failure.

Only the presence of diabetes melitis, a preprocedural indication of ulcer or gangrene, and a TASC D category were significantly predictive of failure, the investigators said.

In those patients with procedural failure, there was a 12-month primary patency rate of 67% in patients with diabetes mellitus, compared with 84% for those without. TASC lesion grade results associated with failure were A (0%), B and C (both 18%), and D (64%).

It was important, however, to note, that, "failure of endoluminal therapy for treatment of lower extremity arterial occlusive disease is frequently amenable to subsequent endovascular intervention for limb salvage with limited morbidity and mortality," reported Dr. Peter Faries, principal investigator of the study.

Open procedures were also still an option, he added.

In this cohort of patients who had a failed percutaneous intervention, 83% were candidates for a second endovascular procedure, 11% were deemed suitable for only traditional open bypass. Only 4% of patients demonstrated progression of disease necessitating amputation, and 2% were managed medically secondary to accompanying terminal illness, according to Dr. Faries.