Diabetes Leads to Poor Endoluminal TherapyOutcomes in CLI

By Sharon Worcester  

RIO GRANDE, P.R. -- Diabetic patients presenting with critical limb ischemia who undergo endoluminal therapy for superficial femoral artery disease are more likely to have poor outcomes than are nondiabetics, Dr. Andrew M. Bakken reported at the annual meeting of the Southern Association for Vascular Surgery.

For example, among patients in a recent study who presented with claudication, those with insulin-dependent diabetes had worse cumulative patency rates and were more likely to have restenosis at the sites of intervention, and both insulin-dependent and non-insulin-dependent diabetics presenting with critical ischemia had worse limb salvage rates than did nondiabetics, said Dr. Bakken, at the University of Rochester (N.Y.), and colleagues, including Dr. Mark G. Davies.

The findings are from a retrospective review of endoluminal interventions for critical limb ischemia (CLI) performed between 1986 and 2005 in 525 limbs of 437 patients. In 219 nondiabetic patients (265 limbs treated), 114 non-insulin-dependent diabetics (133 limbs treated), and 104 insulin-dependent diabetics (127 limbs treated), there were no significant differences between the groups in 30-day mortality or operative complications. However, among those presenting with claudication, cumulative patency at 3 years was about 65% in the insulin-dependent diabetic patients vs. 81% in the nondiabetic patients, and freedom from restenosis at 3 years was 43% in the insulin-dependent diabetic patients vs. 57% in nondiabetics. This finding is particularly striking given the fact that the insulin-dependent diabetic patients had lesser TransAtlantic Inter-Society Consensus (TASC) lesion severity than did both non-insulin-dependent diabetics and nondiabetics (TASC type A or B lesions: 77% vs. 52% in non-insulin-dependent diabetics and 65% in nondiabetics, respectively, and TASC type C or D lesions: 23% vs. 48% and 35%, respectively), Dr. Bakken noted.

"Whether increasing percutaneous tibial intervention will impact this remains unknown," he said.

Among those presenting with critical limb ischemia, limb salvage rates at 2 years were about 60% for both diabetic groups vs. nearly 89% for nondiabetics.

Factors significantly associated with decreased patency included TASC type C or D lesions; calcification, occlusion, embolization, or acute perforation; and progression of distal disease. Factors associated with reduced limb salvage included heart failure, coronary artery disease, end-stage renal disease, embolization, and progression of distal disease, Dr. Bakken said.

Patients in all three groups (nondiabetics, non-insulin-dependent diabetics, and insulin-dependent diabetics) had a mean age of 66 years, and about 66% were male. Average follow-up was about 18 months. Insulin-dependent diabetics were significantly more likely than non-insulin-dependent diabetics and nondiabetics to have coronary artery disease (74% vs. 61% and 55%, respectively), a history of myocardial infarction (71% vs. 55% and 51%), cerebrovascular disease (41% vs. 26% and 28%), and end-stage renal disease (25% vs. 5% and 3%). Both insulin-dependent and non-insulin-dependent diabetics were more likely than nondiabetics to have heart failure (61% and 31% vs. 19%) and hyperlipidemia (68% in both diabetic groups vs. 48%).

Claudication was significantly more common in nondiabetics (74%) than in non-insulin-dependent and insulin-dependent diabetics (52% and 43%, respectively), whereas rest pain was significantly more common in insulin-dependent diabetics (23% vs. 14% in the other two groups). Tissue loss was significantly more common in both groups of diabetics (34% and 35%, respectively vs. 12% in nondiabetics).

There was no difference in the location of the lesions in the superficial femoral artery or in the runoff between the groups, and tibial outflow lesions were treated where appropriate.