Outcomes After First-time Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia in Insulin-Dependent Diabetic Patients

Abstract

Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood. We reviewed all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty/stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as insulin administration at baseline to control blood glucose levels. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S using χ2, Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S. Of 2869 infrainguinal revascularizations from 2005 to 2014, there were 703 limbs (343 BPG, 361 PTA/S) in 682 patients that fit our criteria. BPG patients, compared with PTA/S patients, were similar in age (69 vs 68 years; P = .51), rates of tissue loss (87% vs 91%; P = .055), and dialysis dependence (25% vs 28%; P = .34); they were less likely to be hypertensive (84% vs 93%; P < .01) and more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S in mean hemoglobin A1c levels (7.9 vs 8.0; P = .52) or mean fasting blood glucose levels (152 vs 156; P = .47). Perioperative complications did not differ, including acute kidney injury (20% vs 23%; P = .26), hematoma (7.3% vs 4.2%; P = .07), acute myocardial infarction (1.5% vs 2.2%; P = .46), and mortality (3.8% vs 2.8%; P = .45). Unadjusted 6-month rates of incomplete wound healing (51% vs 59%) and 5-year rates of restenosis (48% vs 64%) and reintervention (49% vs 60%) were all significantly higher after PTA/S (P < .05; Table). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.6; 95% confidence interval, 1.1-2.4) and reintervention (2.0 [1.3-3.0]); these results remained robust after inverse probability weighting. Among patients with CLTI, IDDM is associated with a high risk of adverse events. Ultimately, our data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients within this vulnerable population.TableFive-year outcomes of lower extremity revascularization for chronic limb-threatening ischemia (CLTI) in patients with insulin-dependent diabetes mellitus (IDDM)BPG (n = 342), %PTA/S (n = 361), %Log-rank P valueAdjusted P valueaIncomplete wound healing (6 months)5159.01.35Restenosis4864<.01.02Reintervention4960.04<.01Major amputation2827.99.90RAS events6976<.001<.001Major adverse limb events4432.21.21Mortality6471.10.20BPG, Bypass graft; PTA/S, percutaneous transluminal angioplasty/stenting; RAS, revascularization, major amputation, or stenosis.aAdjusted for procedure year, race, sex, age, coronary artery disease, hypertension, dialysis dependence, congestive heart failure, chronic obstructive pulmonary disease, ambulatory status, indication for intervention, history of smoking, femoropopliteal TransAtlantic Inter-Society Consensus (TASC) class, tibial TASC class. Open table in a new tab