Lower extremity arterial reconstruction for critical limb ischemia in diabetes

The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with CLI over a 17-year period.

Details on all consecutive patients undergoing primary IAR at our institution were stored prospectively in a vascular registry from 1995 to 2011. Demographics, risk factors, indications for surgery, inflow sources and outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination, duplex scans, and ankle-brachial index measurements in all patients at discharge, 1 and 6 months after surgery, and every 6 months thereafter. End points were patency, limb salvage, survival, and amputation-free survival rates, and were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance.

Overall, 1407 IARs were performed in 1310 patients with CLI by the same surgeon, 705 (50.2%) in 643 diabetic patients and 702 in 667 nondiabetic patients. Autogenous vein conduits were used in 87% of the IARs. There were no perioperative deaths. Diabetic patients had significantly more major (16.7% vs 11.8%; P = .02) and minor complications (9.7% vs 6.5%; P = .02) than nondiabetic patients. At 5 and 10 years, there were no significant differences between diabetic and nondiabetic patients in the rates of primary patency (65% and 46% vs 69.5% and 57%; log-rank test, P = .09), secondary patency (76% and 60% vs 80% and 68%; log-rank test, P = .20), limb salvage (88% and 76% vs 91% and 83%; log-rank test, P = .12) survival (51% and 34% vs 57% and 38%; log-rank test, P = .41), or amputation-free survival (45.5% and 27% vs 51% and 29%; log-rank test, P = .19). The type of conduit did not affect patency or limb salvage rates in either group.

Diabetic patients receiving IAR for CLI can have the same survival and amputation-free survival rates as nondiabetic patients. Their comparable technical and clinical outcomes strongly demonstrate that diabetics with CLI can expect the same quantity and quality of life as nondiabetics with CLI, and aggressive attempts at limb salvage in patients with diabetes mellitus, including distal and foot level bypass grafting, should not be discouraged.