Long-Term Prognosis of Diabetic Patients With Critical Limb Ischemia: A population-based cohort study

OBJECTIVE\u2014 To evaluate the long-term prognosis of critical limb ischemia (CLI) in diabetic patients. RESEARCH DESIGN AND METHODS\u2014 A total of 564 consecutive diabetic patients were hospitalized for CLI from January 1999 to December 2003; 554 were followed until December 2007. RESULTS\u2014 The mean follow-up was 5.93 1.28 years. Peripheral angioplasty (PTA) was performed in 420 (74.5%) and bypass graft (BPG) in 117 (20.6%) patients. Neither PTA nor BPG were possible in 27 (4.9%) patients. Major amputations were performed in 74 (13.4%) patients: 34 (8.2%) in PTA, 24 (21.1%) in BPG, and 16 (59.2%) in a group that received no revascularization. Restenosis occurred in 94 patients, bypass failures in 36 patients, and recurrent ulcers in 71 patients. CLI was observed in the contralateral limb of 225 (39.9%) patients; of these, 15 (6.7%) required major amputations (rate in contralateral compared with initial limb, P 0.007). At total of 276 (49.82%) patients died. The Cox model showed significant hazard ratios (HRs) for mortality with age (1.05 for 1 year [95% CI 1.03\u20131.07]), unfeasible revascularization (3.06 [1.40\u20136.70]), dialysis (3.00 [1.63\u20135.53]), cardiac disease history (1.37 [1.05\u20131.79]), and impaired ejection fraction (1.08 for 1% point [1.05\u20131.09]). CONCLUSIONS\u2014 Diabetic patients with CLI have high risks of amputation and death. In a dedicated diabetic foot center, the major amputation, ulcer recurrence, and major contralateral limb amputation rates were low. Coronary artery disease (CAD) is the leading cause of death, and in patients with CAD history the impaired ejection fraction is the major independent prognostic factor

Advanced Leg Salvage of the Critically Ischemic Leg With Major Tissue Loss by Vascular and Plastic Surgeon Teamwork: Long-term Outcome

OBJECTIVE: To assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects. SUMMARY BACKGROUND DATA: Combined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended. METHODS: During 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37–85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, ±34 months). RESULTS: One- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation. CONCLUSIONS: A combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage