Influence Of Clinical Presentation Of Diabetic Patients With Chronic Limb Threatening Ischemia Submitted To Distal Revascularization
DOI:
https://doi.org/10.48729/pjctvs.477Keywords:
diabetes, CLTI, distal revascularization, infrapopliteal, infragenicular, bypass, diabetic foot ulcerAbstract
Objective: The purpose of this article was to evaluate the clinical impact of diabetic foot ulcer (DFU) severity in patients with chronic limb-threatening ischemia (CLTI) who underwent distal open revascularization.
Methods: This study included a single-center retrospective analysis of diabetic patients with CLTI who underwent distal revascularization between January 2012 and December 2019. The sample was divided into two groups according to DFU severity; group 1 was defined if observed Wound grade ≥ 2 and Infection grade ≥ 1 and group 2 was defined if observed Wound grade < 2 and Infection grade < 1, according to Wound, Ischemia, and foot Infection (WIfI) classification. The primary endpoint was achieving freedom from CLTI at 1 year. Secondary endpoints encompassed the recurrence of CLTI, limb salvage, amputation-free survival, overall survival, and primary patency over a 4-year follow-up period.
Results: A total of 258 distal bypasses were performed in diabetic patients with CLTI. Among these, 95 patients had infected major foot lesions (group 1), while the remaining 163 limbs comprised group 2. Group 1 patients were slightly younger, with a median age of 72 years (IQR 14), compared to 74 years (IQR 14) in group 2 (p=0.045). Most of the patients achieved freedom from CLTI at 12 months (82%), with no significant differences between groups (HR 0.75, CI 0.53-1.04, p=0.084; aHR 0.77, CI 0.54-1.08, p=0.130). At 4 years of follow-up, recurrence rates of CLTI and limb salvage were no different between groups (HR 0.68, CI 0.34-1.35, p=0.266; aHR 0.71, CI 0.34-1.48, p=0.355 and HR 1.18, CI 0.63-2.24, p=0.591; aHR 1.81, CI 0.80-4.11, p=0.155, respectively). Survival-related end points were not different between groups, except when adjusted for baseline characteristics and graft type (survival: HR 1.50, CI 0.96-2.33, p=0.072; aHR 2.49, CI 1.54-4.05, p<0.001; amputation-free survival: HR 1.37, CI 0.97-1.92, p=0.071; aHR 2.03, CI 1.40-2.93, p<0.001).
Conclusion: The present study emphasizes the value of distal revascularization in limb salvage of patients with diabetic foot, independently of the DFU severity. However, these results suggest a lower survival in patients with infected major foot lesions. Further studies are needed to assert these findings.
Downloads
References
World Health Organization. (2016). Global diabetes report (pp. 6–33). Geneva, Switzerland: WHO.
Baltzis, D., Eleftheriadou, I., & Veves, A. (2014). Pathogenesis and treatment of impaired wound healing in diabetes mellitus: New insights. Advances in Therapy, 31(8), 817–836. https://doi.org/10.1007/s12225-014-0130-x
Luo, Y., Liu, C., Li, C., Jin, M., Pi, L., & Jin, Z. (2024). The incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers: A meta-analysis. International Wound Journal, 21(7), e14931. https://doi.org/10.1111/lwj.14931
Armstrong, D. G., Tan, T., Boulton, A. J. M., & Bus, S. A. (2023). Diabetic foot ulcers: A review. JAMA, 330(1), 62–75. https://doi.org/10.1001/jama.2023.10578
Wautrecht, J. C., Brisbois, D., & De Wilde, J. P. (2010). Ischemic critique chronique des membres inférieurs, athérosclérose. In Traité de médecine vasculaire.
Dick, F., Ricco, J. B., Davies, A. H., et al. (2011). Chapter VI: Follow-up after revascularization. European Journal of Vascular and Endovascular Surgery, 42(Suppl), 575–590. https://doi.org/10.1016/j.ejvs.2011.09.003
Conte, M. S., Bradbury, A. W., Kolh, P., et al. (2019). Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of Vascular Surgery, 69(68), 35–1255. e40. https://doi.org/10.1016/j.jvs.2019.02.016
Farber, A., Menard, M. T., Conte, M. S., et al. (2022). Surgery or endovascular therapy for chronic limb-threatening ischemia. The New England Journal of Medicine, 387(25), 2305–2316. https://doi.org/10.1056/nejmoa2207899
Mills, J. L., Conte, M. S., Armstrong, D. G., et al. (2014). The Society for Vascular Surgery lower extremity threatened limb classification system: Risk stratification based on wound, ischemia, and foot infection (Wifi). Journal of Vascular Surgery, 59(1), 220–234.e2. https://doi.org/10.1016/j.jvs.2013.08.003
Monteiro-Soares, M., Boyko, E. J., Jeffcoate, W., Mills, J. L., Russell, D., Morbach, S., & Game, F. (2020). Diabetic foot ulcer classifications: A critical review. Diabetes/Metabolism Research and Reviews, 36(Suppl 1), e3272. https://doi.org/10.1002/dmr.3272
Hicks, C. W., Canner, J. K., Sherman, R. L., et al. (2021). Evaluation of revascularization benefit quartiles using the wound, ischemia, and foot infection classification system for diabetic patients with chronic limb-threatening ischemia. Journal of Vascular Surgery, 74(5), 1232–1239.e3. https://doi.org/10.1016/j.jvs.2021.04.042
Elgzyri, T., Larsson, J., Nyberg, P., et al. (2014). Early revascularization after admittance to a diabetic foot center affects the healing probability of ischemic foot ulcer in patients with diabetes. European Journal of Vascular and Endovascular Surgery, 48(4), 440–446. https://doi.org/10.1016/j.ejvs.2014.05.004
Weaver, M. L., Hicks, C. W., Canner, J. K., et al. (2018). The Society for Vascular Surgery wound, ischemia, and foot infection (Wifi) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds. Journal of Vascular Surgery, 68(5), 1473–1481. https://doi.org/10.1016/j.jvs.2018.01.044
Faglia, E., Cleird, G., Clerissi, J., et al. (2006). Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: Data of a cohort study of 564 patients. European Journal of Vascular and Endovascular Surgery, 32(5), 484–490. https://doi.org/10.1016/j.ejvs.2006.03.015
Farber, A., Menard, M. T., Conte, M. S., et al. (2022). Surgery or endovascular therapy for chronic limb-threatening ischemia. The New England Journal of Medicine, 387(25), 2305–2316. https://doi.org/10.1056/nejmoa2207899
Downloads
Published
How to Cite
License
Copyright (c) 2025 Portuguese Journal of Cardiac Thoracic and Vascular Surgery

This work is licensed under a Creative Commons Attribution 4.0 International License.