Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease

Abstract

Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.

Keywords: amputation; atherosclerosis; diabetes mellitus; lower extremity; peripheral artery disease.

Figure 1:

Trends in Incidence and Prevalence of Diagnosed Diabetes Among Adults Aged 18 or Older, United States, 1980–2015.

Figure 2:

Trends in endovascular interventions, major amputation, and lower extremity bypass surgery 1996–2011. RR, Risk ratio; CI, confidence interval.

Figure 3:

Percentage of patients undergoing revascularization prior to amputation. *P < .0001.

Figure 4:

Percent of diabetic Medicare beneficiaries receiving hemoglobin A1c testing (2010). Dartmouth Atlas.