Long-Term Outcomes of Diabetic Patients With Critical Limb Ischemia Followed in a Tertiary Referral Diabetic Foot Clinic

• DOI: 10.2337/dc09-0831
• Publication Date: 2010-03-04T02:55:33Z
• Authors: Luigi Uccioli; Roberto Gandini; Laura Giurato; Sebastiano Fabiano; Enrico Pampana; Vincenza Spallone; Erika Vainieri; Giovanni Simonetti
• Keywords: Male; Outpatient Clinics, Hospital; Bacterial Infection; Amputation, Surgical; Follow-Up Studie; Gangrene; Hospitals, University; Outcome Assessment (Health Care); Hospital; 03 medical and health sciences; 0302 clinical medicine; Ischemia; Anti-Bacterial Agent; Outcome Assessment, Health Care; Humans; Amputation; Outpatient Clinics; Referral and Consultation; Settore MED/36 - DIAGNOSTICA PER IMMAGINI E RADIOTERAPIA; Original Research; Aged; University; Wound Healing; Angioplasty; Settore MED/09 - MEDICINA INTERNA; Settore MED/13 - ENDOCRINOLOGIA; Bacterial Infections; Combined Modality Therapy; Hospitals; Diabetic Foot; Anti-Bacterial Agents; 3. Good health; Treatment Outcome; Debridement; Diabetic Foot; Amputation; Debridement; Gangrene; Ischemia; Humans; Wound Healing; Outcome Assessment (Health Care); Follow-Up Studies; Outpatient Clinics, Hospital; Bacterial Infections; Hospitals, University; Aged; Angioplasty, Balloon; Anti-Bacterial Agents; Combined Modality Therapy; Referral and Consultation; Treatment Outcome; Male; Female; Female; Balloon; Angioplasty, Balloon; Human; Follow-Up Studies

OBJECTIVE We describe the long-term outcomes of 510 diabetic patients with critical limb ischemia (CLI) and an active foot ulcer or gangrene, seen at the University Hospital of Rome Tor Vergata, a tertiary care clinic.

RESEARCH DESIGN AND METHODS These patients were seen between November 2002 and November 2007 (mean follow-up 20 ± 13 months [range 1–66 months]). The Texas Wound Classification was used to grade these wounds that were either class C (ischemia) and D (ischemia+infection) and grade 2–3 (deep–very deep). This comprehensive treatment protocol includes rapid and extensive initial debridement, aggressive use of peripheral percutaneous angioplasty, empirical intravenous antibiotic therapy, and strict follow-up.

RESULTS The protocol was totally applied (with percutaneous angioplasty [PA+]) in 456 (89.4%) patients and partially (without percutaneous angioplasty [PA−]) in 54 (10.6%) patients. Outcomes for the whole group and PA+ and PA− patients are, respectively: healing, n = 310 (60.8%), n = 284 (62.3%), and n = 26 (48.1%); major amputation, n = 80 (15.7%), n = 67 (14.7%), and n = 13 (24.1%); death, n = 83 (16.25%), n = 68 (14.9%), and n = 15 (27.8%); and nonhealing, n = 37 (7.25%), n = 37 (8.1%), and n = 0 (0%) (χ2 <0.0009). Predicting variables at multivariate analysis were the following: for healing, ulcer dimension, infection, and ischemic heart disease; and for major amputation, ulcer dimension, number of minor amputations, and age. Additional predicting variables for PA+ patients were the following: for healing, transcutaneous oxygen tension [ΔTcPo2]; and for major amputation, basal TcPo2, basal A1C, ΔTcPo2, and percutaneous angioplasty technical failure.

CONCLUSIONS Early diagnosis of CLI, aggressive treatment of infection, and extensive use of percutaneous angioplasty in ischemic affected ulcers offers improved outcome for many previously at-risk limbs. Ulcer size >5 cm2 indicates a reduced chance of healing and increased risk of major amputation. It was thought that all ulcers warrant aggressive treatment including percutaneous angioplasty and that treatment should be considered even for small ischemic ulcers.