Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation (original) (raw)
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Journal of Vascular Surgery, 2007
The optimal revascularization strategy in diabetic patients with chronic critical limb ischemia (CLI) is unclear. This study assessed the efficacy of tailored endovascular-first vs surgical-first revascularization stratified for the presence of diabetes. Methods: This prospective cohort study, with 1-year follow up, was conducted in a tertiary referral center in a consecutive series of 383 patients (45.7% had diabetes) presenting 426 limbs with chronic CLI. Interventions were endovascular (PTA cohort, 207 limbs) or surgical (SURG cohort, 85 limbs) revascularization. Conservatively treated patients without revascularization (NON REVASC cohort, 108 limbs) were used as a reference. The main outcome measures were sustained clinical success, defined as survival without major amputation or repeated target extremity revascularization (TER), and a categoric upward shift in clinical symptoms according to the Rutherford classification. Results: Sustained clinical success of revascularization was significantly better in nondiabetic patients (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.29 to 0.72; P ؍ .001 [SURG cohort]; HR, 0.53; 95% CI, 0.35 to 0.78; P ؍ .002 [PTA cohort]) compared with diabetic patients (HR, 0.78; 95% CI, 0.44 to 1.43, P ؍ .45 [SURG cohort]; HR, 0.83; 95% CI, 0.55 to 1.27, P ؍ .40 [PTA cohort]). Repeated TER significantly improved clinical success, which became equivalent between diabetic and nondiabetic patients (HR, 1.02; 95% CI, 0.7 to 1.4). In multivariate analysis, treatment success was not influenced by mode of initial revascularization, neither in diabetic nor in nondiabetic patients. Cumulative 1-year mortality was 30.4%, with a trend of increased mortality in patients with diabetes (HR, 1.45; 95% CI, 0.98 to 2.17; P ؍ .064). Limb salvage rates were similar in treatment cohorts, also if stratified for diabetes (HR, 1.04; 95% CI, 0.62 to 1.75). Conclusion: Diabetic patients with chronic CLI benefit from early revascularization. To achieve this benefit, multiple revascularization procedures may be required, and close surveillance is therefore mandatory. Choice of initial revascularization modality seems not to influence clinical success.
Journal of Clinical Medicine, 2020
The study aimed to evaluate clinical and vascular characteristics, as well as outcomes, for diabetic persons with foot ulceration and no-option critical limb ischemia (CLI). The study group included a sample of patients admitted to our diabetic foot unit because of a new diabetic foot ulcer and CLI. All subjects were managed using a limb salvage protocol which includes lower-limb revascularization. According to whether or not the revascularization procedure was a success, patients were respectively divided into two groups: successfully treated CLI patients (ST-CLI) and no-option CLI patients (NO-CLI). Failed revascularization was considered in the case of technical recanalization failure of occluded vessels (inability to overcome the obstruction) and/or absence of arterial flow to the foot. Limb salvage, major amputation, and death after 1 year of follow-up were evaluated and compared between the two groups. Overall, 239 patients were included, 74.9% belonging to ST-CLI and 25.1% to...
Surgical treatment of lower limb ischemia in diabetic patients – long-term results
Archives of Medical Science, 2013
A b s t r a c t I In nt tr ro od du uc ct ti io on n: : Lower limb ischemia may cause nonhealing ulcers, infection, amputation and even mortality in diabetic patients. In this study, we review our data of ischemic lower limb revascularization procedures in diabetic patients and present the early, mid-and long-term results. M Ma at te er ri ia al l a an nd d m me et th ho od ds s: : From March 2004 to September 2008, 83 patients with lower limb ischemia in Fontaine class III and IV underwent distal arterial bypass procedures. Saphenous vein grafts were used for below-knee arterial bypasses in all patients. In 16 (19%) patients femoropopliteal bypasses were performed with PTFE grafts. Short-term and long-term surgical results were evaluated. R Re es su ul lt ts s: : Ulcer recovery was determined in 36% of patients. Graft patency was 95% and 1 death (1%) occurred in short-term follow-up. In long-term followup the total effectiveness rate was 74%. Graft patency was 79% and 6 deaths (7%) occurred during the follow-up. C Co on nc cl lu us si io on ns s: : Lower limb ischemia is a serious event in patients with diabetes mellitus. The consequences may include increased mortality and morbidity in this particular patient population. However, distal arterial revascularizations are considerably effective procedures to avoid amputation, to eliminate symptoms, to promote ulcer recovery and to help the patient participate in social life with acceptable short, mid-and long-term follow-up results.
Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges
Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges, 2015
The worldwide number of people suffering from diabetes is anticipated to exceed 350 million by 2030 and the risk for developing critical limb ischemia (CLI) has been documented to reach considerably higher levels in these patients. Contemporary data show that 40% to 50% among diabetics may experience an amputation while 20% to 25% are prone to die, during the first year of CLI diagnosis. Despite remarkable advances in peripheral arterial revascularization in the last two decades, major amputation rate seems scarcely affected in this group of patients by simultaneous increase of CLI presentations each year. The present article proposes a succinct review of main revascularization techniques currently reported using surgical, endovascular, or hybrid approaches together with new strategies in enhancing wound-targeted arterial flow reconstruction. Planning to achieve pulsatile flow toward specific foot territories and ischemic ulcers seems to considerably improve the time and quality of tissue healing in diabetic CLI presentation with better limb salvage rates. Novel clinical data equally highlight the importance of parallel macro- and microcirculatory CLI diagnosis inside the multifaceted “diabetic foot syndrome”, probably a new paradigm in maximizing postoperative tissue regeneration. In sum, CLI invariably unfolds a multifarious limb-threatening phenomenon particularly pictured in diabetic patients that always have and will request multidisciplinary advises and high-priority local wound and revascularization treatment.
Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers
Journal of Clinical Medicine, 2021
The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) majo...
European Journal of Vascular and Endovascular Surgery, 2006
Objective. To evaluate the early and late major amputation and survival rates and related risk factors in diabetic patients with critical limb ischemia (CLI). Design. Retrospective study. Methods. Revascularization feasibility, major amputation, survival rate and related risk factors were recorded in 564 diabetic patients consecutively hospitalized for CLI from 1999 to 2003 and followed until June 2005. Results. Peripheral angioplasty (PTA) was carried out in 420 (74.5%), bypass graft (BPG) in 117 (20.7%) patients. In 27 (4.8%) patients both PTA and BPG were not possible. Twenty-three above-the-ankle amputations (4.1%) were performed at 30 days: 6 in PTA patients, 3 in BPG patients, 14 in non revascularized patients. In the follow-up of 558 patients (98.9%), 62 repeated PTAs and 9 new BPGs, 32 new major amputations (16 in PTA patients, 14 in BPG patients and 2 in nonrevascularized patients) were performed. Major amputation was associated with absence of revascularization (OR 35.9, p < 0.001, CI 12.9e99.7), occlusion of each of the three crural arteries (OR 8.20, p ¼ 0.022, CI 1.35e49.6), wound infection (OR 2.1, p ¼ 0.004 CI 1.3e3.6), dialysis (OR 4.7, p ¼ 0.001 CI 1.9e11.7) increase in TcPO 2 after revascularization (OR 0.80, p < 0.001 CI 0.74e0.87).