Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia - A nationwide propensity score adjusted analysis.

Erika Lilja,Anders Gottsäter,Moncef Zarrouk,Björn Eliasson,Mervete Miftaraj,Stefan Acosta,Jan Ekelund,Ann-Marie Svensson

doi:10.1177/1358863x211008249

Abstract

The risk of major amputation is higher after urgently planned endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes mellitus (DM). The aim of this nationwide cohort study was to compare outcomes between patients with and without DM following urgently planned open revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered in the Swedish Vascular Registry, 569 were registered in the National Diabetes Register. A propensity score adjusted Cox regression analysis was conducted to compare outcome between the groups with and without DM. Median follow-up was 4.3 years and 4.5 years for patients with and without DM, respectively. Patients with DM more often had foot ulcers (p = 0.034) and had undergone more previous amputations (p = 0.001) at baseline. No differences in mortality, cardiovascular death, major adverse cardiovascular events (MACE), or major amputation were observed between groups. The incidence rate of stroke was 70% higher (95% CI: 1.11–2.59; p = 0.0137) and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI: 1.00–1.92; p = 0.0472) among patients with DM in comparison to those without. Open vascular surgery remains a first-line option for a substantial number of patients with CLTI, especially for limb salvage in patients with DM. The higher incidence rates of stroke and AMI among patients with DM following open vascular surgery for infrainguinal CLTI require specific consideration preoperatively with the aim of optimizing medical treatment to improve cardiovascular outcome postoperatively.

Highlights

Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral artery disease (PAD) and should be viewed as a sign of systemic atherosclerosis with a high mortality in stroke and myocardial infarction.[1]
Endovascular therapy was associated with a lower risk of mortality in patients with type 2 diabetes compared to those without diabetes mellitus (DM) among patients with infrainguinal chronic limb-threatening ischemia (CLTI).[8]
The main aim of this study was to evaluate the risk of major amputation and mortality after urgently planned open vascular surgery in patients with CLTI and infrainguinal arterial disease, comparing patients with DM and without DM in a nationwide propensity score adjusted analysis

Summary

Introduction

Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral artery disease (PAD) and should be viewed as a sign of systemic atherosclerosis with a high mortality in stroke and myocardial infarction.[1]. Smoking and diabetes mellitus (DM) are the strongest risk factors for PAD,[4] with an expected increase of the DM incidence in the United States by 200% from 2005 to 2050.5. Individuals with both DM and PAD have a more distal distribution of the arterial disease, and tend to have more significant comorbidities.[6] In view of these factors, minimal invasive endovascular therapy for CLTI among patients with DM might induce less myocardial stress[7] compared to open surgery, and be more beneficial to achieve higher amputation-free survival. Endovascular therapy was associated with a higher risk of major amputation in patients

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