Impact of Critical Limb Ischemia on Long-Term Cardiac Mortality in Diabetic Patients Undergoing Percutaneous Coronary Revascularization

Abstract

OBJECTIVEDevelopment of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD).RESEARCH DESIGN AND METHODSWe designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study.RESULTSAmong the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89–3.85]; P = 0.1).CONCLUSIONSThe development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD.

Drug-Eluting Balloon in Peripheral Intervention for Below the Knee Angioplasty Evaluation (DEBATE-BTK)

“…8,21 We previously showed the long-term benefit of this integrated multidisciplinary framework in this high-risk subset of patients. 7 The safety of DEB, moreover, was similar to that of conventional balloons, as no acute thrombosis occurred on 1-month dual antiplatelet therapy in both arms. In few cases, DEBs were associated with a limited increase in reference vessel diameter at follow-up.…”

“…The outcome of medical therapy is unsatisfactory, 3 and early, aggressive percutaneous revascularization with the aim of obtaining direct flow to the foot is increasingly considered a first-line strategy. 4,5 Indeed, although vessel patency alone cannot match patient-centered clinical end points 6 and any endovascular program has to be integrated into a network-based system of care involving different professionals, 7,8 an increased cutaneous oxygen pressure resulting from successful revascularization promotes infection clearance and ulcer granulation at a crucial time point. 9 The efficacy of percutaneous transluminal angioplasty (PTA) with conventional balloons, however, is limited by the high 12-month restenosis and target lesion revascularization (TLR) rates.…”

“…7 Office visits were scheduled twice a week for the first 2 months, once a week for the third month, and then every 2 weeks. Minor amputations planned before the interventions were performed 2 to 4 weeks after revascularization and included finger amputations and metatarsal amputations resulting from necrosis/ infection of tissues and bones with preservation of healthy surrounding tissue.…”

Endovascular treatment of chronic lower limb ischemia - the first experience of consecutive patients in the Kyrgyz Republic

“…These patients over the age of 50 have 68% and 42% cardiac and cerebrovascular adverse events, respectively (11). In addition to this, the study of Liistro et al in 2013, demonstrated that aggressively endovascular treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially coming up with symptomatic coronary artery disease (12). On the other hand a mortality rate of 20% within 6 months after the diagnosis and 50% ending up with fatal outcome in 5 years has been reported (13,14).…”

Emergency Coronary and Peripheral Arteries Combined With Percutaneous Intervention in the Elderly: Success Or Therapeutic excess?

“…In the field of PAD few and inconclusive data are available on the prognosis of percutaneous interventions for acute lower extremities ischemia throughout all age subpopulations though recent evidences support a potential improvement in mid-to long-term results [2]. Conversely, broad literature exists on the invasive approach of non-ST-elevation acute coronary syndromes, but also in this context specific data referring to elderly patients are missing.…”