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. 2021 Dec;110(4):472-482.
doi: 10.1177/1457496920968679. Epub 2020 Nov 23.

Chronic limb threatening ischemia and diabetes mellitus: the severity of tibial atherosclerosis and outcome after infrapopliteal revascularization

Veerakaisa Koivunen  1 , Markus Juonala  2 , Kimmo Mikkola  3 , Harri Hakovirta  4
Affiliations

Chronic limb threatening ischemia and diabetes mellitus: the severity of tibial atherosclerosis and outcome after infrapopliteal revascularization

Veerakaisa Koivunen et al. Scand J Surg. 2021 Dec.

Abstract

Background and objective: Diabetes mellitus associates with poor outcomes in chronic limb threatening ischemia but data on different hypoglycemic regimens and outcomes are lacking. We analyzed insulin-treated diabetes mellitus, non-insulin-treated diabetes mellitus, and patients without diabetes mellitus.

Methods: All patients with peripheral artery disease and/or diabetes mellitus and infrapopliteal revascularization in the Department of Vascular Surgery, Turku University Hospital during 2007-2015 were included. Tibial atherosclerosis was categorized into crural index classes of I-IV.

Results: Of the 497 patients, 180 were insulin-treated diabetes mellitus, 94 non-insulin-treated diabetes mellitus, and 223 patients without diabetes mellitus groups (diabetes mellitus 55.1%). Insulin-treated diabetes mellitus was the most ill, youngest (insulin-treated diabetes mellitus-median: 72.4, interquartile range: 64.0-79.5 versus non-insulin-treated diabetes mellitus-76.0, interquartile range: 67.9-83.6 versus patients without diabetes mellitus-77.3, interquartile range: 68.5-83.7, p < 0.001), had the highest body mass index (insulin-treated diabetes mellitus-median: 27.7, interquartile range: 24.0-31.8 versus non-insulin-treated diabetes mellitus-26.3, interquartile range: 23.2-30.3 versus patients without diabetes mellitus-23.9, interquartile range: 21.5-26.9, p < 0.001), and Charlson comorbidity index (insulin-treated diabetes mellitus-65.6% versus non-insulin-treated diabetes mellitus-46.8% versus patients without diabetes mellitus-10.8%, p < 0.001). After endovascular revascularization, limb salvage was poorer for insulin-treated diabetes mellitus (p = 0.046) and non-insulin-treated diabetes mellitus groups (p = 0.011) compared to surgery, but not for patients without diabetes mellitus (p = 0.15). Patients with crural index IV in insulin-treated diabetes mellitus (p = 0.001) and non-insulin-treated diabetes mellitus (p = 0.013) had higher mortality after revascularization. Crural index IV was a risk factor for limb loss (hazard ratio: 1.37, 95% confidence interval: 1.08-1.74, p = 0.008).

Conclusions: Limb salvage after bypass is better for insulin and non-insulin diabetics, compared to the endovascular approach. Extensive tibial atherosclerosis is an independent risk factor for limb loss. It associates with increased mortality in both insulin and non-insulin diabetics.

Keywords: Peripheral artery disease; amputation; chronic limb threatening ischemia; crural index; diabetes mellitus; endovascular; open surgery bypass; revascularization; risk factor; tibial atherosclerosis.

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Figures

Fig. 1.
Fig. 1.
Comparisons of infrapopliteal revascularization treatments from 1 January 2007 to 31 December 2015 in the Department of Vascular Surgery of Turku University Hospital. (A) Bypass procedures. (B) Endovascular procedures. (C) Total number of revascularization procedures.
Fig. 2.
Fig. 2.
Survival analyses of IT-DM. (A) AFS between bypass versus endovascular revascularization. (B) OS between bypass versus endovascular revascularization. (C) AFS between CIx I–III versus CIx IV. (D) OS between CIx I–III versus CIx IV. IT-DM: insulin-treated diabetics; AFS: amputation-free survival; OS: overall survival; CIx: crural index.
Fig. 3.
Fig. 3.
Survival analyses of NIT-DM. (A) AFS between bypass versus endovascular revascularization. (B) OS between bypass versus endovascular revascularization. (C) AFS between CIx I–III versus CIx IV. (D) OS between CIx I–III versus CIx IV. NIT-DM: non-insulin-treated diabetics; AFS: amputation-free survival; OS: overall survival; CIx: crural index.
Fig. 4.
Fig. 4.
Survival analyses of non-DM. (A) AFS between bypass versus endovascular revascularization. (B) OS between bypass versus endovascular revascularization. (C) AFS between CIx I–III versus CIx IV. (D) OS between CIx I–III versus CIx IV. Non-DM: patients without DM; AFS: amputation-free survival; OS: overall survival; CIx: crural index.
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