Surgical aspects on patients with diabetes mellitus and chronic limb-threatening ischemia

Abstract: Background: During the 21st century, diabetes mellitus (DM) and peripheral artery disease (PAD) have become global problems. It is estimated that 19-34% of individuals with DM will develop a foot ulcer during their lifetime, and many will be amputated.Aim:-To study dietary and lifestyle factors associated with prevention of PAD among individuals with DM. -To evaluate outcomes after vascular and endovascular treatment in patients with DM and chronic limb- threatening ischemia (CLTI).Methods: Paper I, based on the Malmö Diet and Cancer study focuses on patients with prevalent DM. Papers II and III are based on the Swedish Vascular Register and the Swedish National Diabetes Register. A propensity score adjusted Cox regression analysis was conducted to compare outcomes following endovascular therapy and open vascular surgery, respectively, between patients with and without DM. Paper IV compares outcome following open and endovascular surgery for patients with DM, PAD, and heel ulcers presenting at the multidisciplinary diabetes foot clinic.Results: A higher intake of fish and shellfish tended to confer a protective effect against the development of PAD among individuals with DM (HR per additional gram per week 0.99, 95% CI 0.99-1.00, p=0.051). Incidence rates (IR) of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1-67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM following endovascular therapy for CLTI. IR of major amputation or death was 13% higher (95% CI 1.04-1.23; p=0.004) higher among patients with DM after endovascular therapy for CLTI.IR of stroke and AMI were 70% (95% CI 1.11-2.59) and 39% (95% CI 1.00-1.92) higher, among patients with DM compared to patients without DM following open vascular surgery, whereas there was no difference in major amputation (HR 1.28, 95% CI 0.98-1.66; p=0.070) or the compound variable major amputation or death (HR 1.15, 95% CI 0.98-1.35; p=0.090) following open vascular surgery.Open vascular surgery was associated with higher amputation-free survival (AFS, HR 2.1, 95% CI 1.1-3.9) compared to endovascular therapy among patients with DM, PAD, and heel ulcers.Conclusions: A higher intake of fish and shellfish tended to confer a protective effect against the development of PAD among individuals with DM. In contrast to patients undergoing endovascular therapy, there was no difference in major amputation or death after open vascular surgery between those with and without DM. Amputation-free survival (AFS) was higher after open than endovascular surgery among patients with DM and PAD with heel ulcers. Open vascular surgery remains a first-line option for a substantial part of patients with CLTI, especially for limb salvage in patients with DM. These results suggest that open vascular surgery should be offered more often as opposed to current practice.