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Effect Of Diabetes On Outcome Of Percutaneous Lower Extremity Intervention : A Cautionary Tale

Objectives: Persons with diabetes are at increased risk of amputation. Diabetic patients have equivalent bypass patency rates as non-diabetics. Diabetics, however, have reduced patency of percutaneous coronary angioplasty. We sought to assess differential outcomes in between diabetics and non-diabetics in lower extremity percutaneous interventions.
Methods: We retrospectively studied LE percutaneous interventions between 2002-2006. Tibial vessel run-off was assessed by angiography. Patency (assessed arterial duplex) was expressed by Kaplan-Meier method. Mean follow-up was 13.7 months (range 1 to 56 months).
Results: A total of 303 interventions for peripheral occlusive disease with claudication (51%), rest pain (12%), or tissue loss (37%) were analyzed, including 258 primary interventions and 45 re-interventions in 221 patients (mean age 73 years, 57% male). Comorbidities included DM (47%), CRI (16%), hemodialysis (4%), HTN (77%), hypercholesterolemia (47%), CAD (49%), tobacco use (76%). Overall primary patency (± SE) at 6, 12 and 18 months was 88.1±0.02%, 74.0±0.04% and 64.4±0.05% respectively. Diabetes significantly impacted patency, with decreased patency demonstrated at one year compared to non-diabetics (see Figure 1). Primary assisted patency at 6, 12 and 18 months was 90.1±0.02%, 85.4±0.03 and 81.9±0.03% respectively. For non-diabetics, primary patency was 92.1±0.02%, 86.8±0.03 and 83.9±0.03% at 6, 12, and 18 months, while for diabetics it was 85.1±0.02%, 58.8.4±0.03 and 57.0±0.03%, respectively (p=0.002). Overall secondary patency at 6, 12 and 18 months was 96.2±0.01%, 91.7±0.02%, and 87.8±0.03%. One-year limb salvage rate was 87% for patients with limb-threatening ischemia. Tibial vessel run-off was also directly related to patency (3 vessel: 83.2±0.06%, 2 vessel: 76.2±0.07%, 1 vessel: 59.±0.08%, P<0.01).
Conclusions: While percutaneous treatment of lower extremity occlusive disease is an acceptable alternative to open surgical bypass in selective patients, patients with diabetes or poor distal tibial vessel run-off demonstrate reduced patency rates. Surgical bypass may be more beneficial than percutaneous intervention in these patients.