Edetate Disodium-Based Treatment in a Patient With Diabetes and Critical Limb Ischemia After Unsuccessful Peripheral Arterial Revascularizations: A Case Report.

Abstract

Peripheral artery disease (PAD) is a progressive form of atherosclerosis that affects the lower extremities, particularly in patients with diabetes. Critical limb ischemia (CLI), the end-stage manifestation of this disease, is associated with an increased risk of chronic leg ulcerations, infections, amputations, and mortality. At presentation, 30% of CLI patients require amputation, and 25% will die within 1 year (1). Toxic metal exposure, particularly to cadmium, has been associated with an increased risk of vascular disease in epidemiological studies and PAD severity in patients with coronary artery disease (CAD) (2–4). Toxic metals are ubiquitous and can induce increased oxidative stress, endothelial dysfunction, and inflammation (4). Similarly, chronic cadmium exposure has been found to play a role in the acceleration of vascular disease in animal models (5,6). Edetate disodium is a chelating agent with high affinity for lead and cadmium (7). The Trial to Assess Chelation Therapy (TACT) demonstrated that edetate disodium–based chelation reduced cardiovascular events, especially in patients with diabetes after myocardial infarction (8,9). An 81-year-old man with a 35-year history of insulin-dependent diabetes, a 20 pack-year smoking history (quit date October 2001), atrial fibrillation, and CAD requiring coronary artery bypass in 2001 presented to the vascular service. His medications at baseline included sotalol, rivaroxaban, pentoxifylline, clopidogrel, aspirin, insulin, pregabalin, and atorvastatin. His baseline serum creatinine was 0.77 mg/dL, and his BMI was 22 kg/m2. He had progressive CLI with nonhealing ulcers and pain unimproved by medical therapy. Noninvasive tests demonstrated abnormal ankle-brachial indices bilaterally. Lower-extremity angiography revealed total occlusions of the left external iliac artery, left superficial femoral artery, distal right …