PMID- 30360841 OWN - NLM STAT- MEDLINE DCOM- 20190314 LR - 20221207 IS - 1097-6809 (Electronic) IS - 0741-5214 (Print) IS - 0741-5214 (Linking) VI - 68 IP - 5 DP - 2018 Nov TI - Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients. PG - 1455-1464.e1 LID - S0741-5214(18)30411-7 [pii] LID - 10.1016/j.jvs.2018.01.055 [doi] AB - OBJECTIVE: Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood. METHODS: We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using chi(2), Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S. RESULTS: Of 2869 infrainguinal revascularizations from 2005 to 2014, 655 limbs (316 BPG, 339 PTA/S) in 580 patients fit our criteria and underwent a first-time revascularization for CLTI. Patients undergoing BPG, compared with PTA/S, were similar in age (69 vs 68 years; P = .55), had similar rates of tissue loss (87% vs 91%; P = .07) and dialysis dependence (26% vs 28%; P = .55), were less likely to be hypertensive (84% vs 92%; P < .001), and were more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S patients in mean glycated hemoglobin levels (8.1% vs 8.0%; P = .51) or mean fasting blood glucose levels (158 vs 150 mg/dL; P = .18). Although total hospital length of stay was significantly longer among BPG patients (11 vs 8 days; P < .001), perioperative complications did not differ, including acute kidney injury (19% vs 23%; P = .24), hematoma (6.0% vs 3.8%; P = .20), acute myocardial infarction (1.3% vs 2.1%; P = .43), and mortality (3.8% vs 3.0%; P = .55). BPG-first patients had significantly lower unadjusted 6-month rates of incomplete wound healing (49% vs 57%) and 5-year rates of restenosis (53% vs 72%) and reintervention (47% vs 58%; all P < .05). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.9; 95% confidence interval, 1.3-2.7) and reintervention (1.9 [1.2-2.7]). These results remained robust after inverse probability weighting. CONCLUSIONS: Among patients with IDDM and CLTI, a bypass-first strategy is associated with similar 30-day outcomes and lower restenosis and reintervention rates. These data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients with IDDM and pedal ischemia that requires revascularization. CI - Copyright (c) 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. FAU - Darling, Jeremy D AU - Darling JD AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - O'Donnell, Thomas F X AU - O'Donnell TFX AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass. FAU - Deery, Sarah E AU - Deery SE AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass. FAU - Norman, Anthony V AU - Norman AV AD - Tufts University School of Medicine, Boston, Mass. FAU - Vu, Giap H AU - Vu GH AD - University of Rochester School of Medicine and Dentistry, Rochester, NY. FAU - Guzman, Raul J AU - Guzman RJ AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Wyers, Mark C AU - Wyers MC AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Hamdan, Allen D AU - Hamdan AD AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Schermerhorn, Marc L AU - Schermerhorn ML AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu. LA - eng GR - T32 HL007734/HL/NHLBI NIH HHS/United States GR - T35 HL110843/HL/NHLBI NIH HHS/United States PT - Comparative Study PT - Journal Article PT - Research Support, N.I.H., Extramural PL - United States TA - J Vasc Surg JT - Journal of vascular surgery JID - 8407742 RN - 0 (Biomarkers) RN - 0 (Blood Glucose) RN - 0 (Glycated Hemoglobin A) RN - 0 (Hypoglycemic Agents) RN - 0 (Insulin) RN - 0 (hemoglobin A1c protein, human) SB - IM MH - Aged MH - Aged, 80 and over MH - *Angioplasty, Balloon/adverse effects/instrumentation MH - Biomarkers/blood MH - Blood Glucose/*drug effects/metabolism MH - *Blood Vessel Prosthesis Implantation/adverse effects MH - Chronic Disease MH - Clinical Decision-Making MH - Diabetes Mellitus/blood/diagnosis/*drug therapy MH - Female MH - Glycated Hemoglobin/metabolism MH - Humans MH - Hypoglycemic Agents/*therapeutic use MH - Insulin/*therapeutic use MH - Ischemia/diagnostic imaging/physiopathology/*surgery MH - Length of Stay MH - Lower Extremity/*blood supply MH - Male MH - Middle Aged MH - Patient Selection MH - Peripheral Arterial Disease/diagnostic imaging/physiopathology/*surgery MH - Postoperative Complications/surgery MH - Recurrence MH - Reoperation MH - Retrospective Studies MH - Risk Factors MH - Stents MH - Time Factors MH - Treatment Outcome MH - Vascular Patency PMC - PMC7106939 MID - NIHMS1507760 OTO - NOTNLM OT - Bypass OT - Diabetes OT - Endovascular OT - Limb salvage OT - Revascularization EDAT- 2018/10/27 06:00 MHDA- 2019/03/15 06:00 PMCR- 2020/03/31 CRDT- 2018/10/27 06:00 PHST- 2017/08/19 00:00 [received] PHST- 2018/01/06 00:00 [accepted] PHST- 2018/10/27 06:00 [entrez] PHST- 2018/10/27 06:00 [pubmed] PHST- 2019/03/15 06:00 [medline] PHST- 2020/03/31 00:00 [pmc-release] AID - S0741-5214(18)30411-7 [pii] AID - 10.1016/j.jvs.2018.01.055 [doi] PST - ppublish SO - J Vasc Surg. 2018 Nov;68(5):1455-1464.e1. doi: 10.1016/j.jvs.2018.01.055.