Darling JD, et al. - Authors performed this study to assess the effect of diabetes type and insulin dependence on short- and long-term outcomes after lower extremity revascularization for chronic limb-threatening ischemia (CLTI). For this purpose, they evaluated outcomes in insulin-dependent and noninsulin-dependent patients after any first-time revascularization. Insulin-dependent diabetes (IDDM) and no diabetes (NDM) seemed to have a similar association with perioperative and long-term mortality. However, compared with NDM, patients with IDDM had a higher risk of incomplete wound healing, major amputation, and future RAS events, especially after a percutaneous transluminal angioplasty with or without stenting (PTA/S)-first approach. noninsulin-dependent diabetes (NIDDM), on the other hand, seemed related to lower long-term mortality and few adverse limb events. These data thus suggested both the relevance of distinguishing between diabetes types and the potential long-term benefit of a bypass grafting (BPG)-first strategy in appropriately selected IDDM patients with CLTI.

Methods

• All limbs undergoing first-time infrainguinal bypass grafting (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at the institution from 2005 to 2014 were reviewed.
• As per preoperative medication regimen, authors categorized patients as having insulin-dependent diabetes (IDDM), noninsulin-dependent diabetes (NIDDM), or no diabetes (NDM).
• For this study, outcomes assessed were wound healing; major amputation; RAS events (reintervention, major amputation, or stenosis); major adverse limb events; and mortality.
• Using X², Kaplan-Meier, and Cox regression analyses, they evaluated outcomes.

Results

• 2869 infrainguinal revascularizations were identified from 2005 to 2014, 1294/2869 limbs (646 BPG, 648 PTA/S) fit the criteria.
• Overall, authors analyzed 703 IDDM, 262 NIDDM, and 329 NDM limbs.
• In this study, IDDM patients, compared with NIDDM and NDM patients, were younger (69 vs 73 vs 77 years; P < .001) and more often presented with tissue loss (89% vs 77% vs 67%; P < .001), coronary artery disease (57% vs 48% vs 43%; P < .001), and end-stage renal disease (26% vs 13% vs 12%; P < .001).
• The groups were similar regarding perioperative complications, including mortality (3% vs 2% vs 5%; P = .07); however, complete wound healing at 6-month follow-up was significantly worse among IDDM patients (41% vs 49% vs 61%; P < .001).
• IDDM patients indicated markedly higher 3-year major amputation rates (23% vs 11% vs 8%; P < .001).
• In multivariable analyses, compared with NDM, IDDM was associated with significantly greater risk of both major amputation and RAS events after any first-time intervention (hazard ratio, 2.0 [95% confidence interval, 1.1-4.1] and 1.4 [1.1-1.8], respectively).
• There appeared similar associations between IDDM and both major amputation and RAS events in patients undergoing a PTA/S-first intervention (4.1 [1.3-12.6] and 1.5 [1.1-2.2], respectively), whereas IDDM in BPG-first patients seemed associated with only incomplete wound healing (2.0 [1.4-4.5]).
• Last, compared with NDM, NIDDM seemed related with lower late mortality (0.7 [0.5-0.9]).