The Influence of Glycemic Control on the Prognosis of Japanese Patients Undergoing Percutaneous Transluminal Angioplasty for Critical Limb Ischemia

Abstract

OBJECTIVETo reveal the influence of preoperative factors on the prognosis of patients undergoing percutaneous transluminal angioplasty (PTA) for critical limb ischemia (CLI).RESEACH DESIGN AND METHODSWe recruited 278 Japanese patients who underwent PTA for CLI between 2003 and 2009. The outcome measures were mortality and major amputation. Cox proportional hazards regression analyses were performed.RESULTSThe prevalence of diabetes was 71%, and A1C was 7.0 ± 1.4%. The follow-up period was 90 ± 72 weeks, and 48 patients underwent major amputations and 89 died. The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age (P = 0.007), impaired activities of daily living (P < 0.001), hemodialysis (P < 0.001), and albumin level (P = 0.010). In contrast, the presence of diabetes and A1C level had significant association with major amputation (P = 0.012 and P = 0.007, respectively). The quartile analysis showed that diabetic subjects with an A1C ≥6.8%, but not <6.8%, had a significantly higher risk of major amputation than nondiabetic subjects. The adjusted hazard ratio of diabetes with A1C ≥6.8% was 2.907 (95% CI 1.606–5.264) (P < 0.001).CONCLUSIONSDiabetes with poor glycemic control is associated with major amputation, but not mortality, in CLI patients undergoing PTA. Prognostic indicators seem somewhat different between survival and limb salvage in the population.

Impact of cilostazol after endovascular treatment for infrainguinal disease in patients with critical limb ischemia

“…Previous findings showed that the presence of diabetes and the HbA 1C level have no relationship with death in patients with CLI who underwent EVT, but are prognostic factors for major amputation, 21 and the results of this study supported these findings. In diabetic patients, cilostazol improved AFS (HR, 0.68; 95% CI, 0.50-0.90; unadjusted P ϭ .008) and the limb salvage rate (HR, 0.49; 95% CI, 0.30-0.78; unadjusted P ϭ .003), but was ineffective for all-cause mortality (HR, 0.84; 95% CI, 0.60-1.16; P ϭ .28).…”

No Association of Diabetic Duration or Insulin Use with the Prognosis of Critical Limb Ischemia after Endovascular Therapy

“…A few recent studies reported that poor glycemic control 10,11) and insulin use 19) were associated with limb prognosis in CLI patients, but each study adopted only one DM-related variable and lacked adjustment for other diabetic conditions, including diabetic duration. DM patients under insulin therapy would tend to have a longer diabetic duration and a poorer glycemic control.…”

“…These unfavorable phenomena could cause a poor prognosis of CLI and a few recent studies have shown that poor glycemic control evaluated with hemoglobin A1c (HbA1c) was significantly associated with limb loss 10,11) ; however, no reports have ever discussed the diabetic duration. Long exposure to DM is associated with the progression of atherosclerosis 12) and it is well known that longer diabetic duration increases the risk of coronary heart disease and stroke in diabetic patients, independently of their glycemic control 13,14) .…”

Increased plasma serotonin metabolite 5-hydroxyindole acetic acid concentrations are associated with impaired systolic and late diastolic forward flows during cardiac cycle and elevated resistive index at popliteal artery and renal insufficiency in type 2 diabetic patients with microalbuminuria

“…Lower extremity arterial disease is a major cause of ischemic limb, delayed wound healing, and leg amputation in diabetic patients [11]. Diabetic patients have higher arterial rigidity and greater vascular resistance to blood flow, resulting in reduced blood supply in the lower-extremity arteries despite normal ankle-brachial index (ABI) [12].…”