Midterm Results of Endovascular Management of Multilevel Arterial Disease in Lower Limb in Diabetic Patients

Abstract Background: The most common cause of mortality and morbidity in diabetics is diabetic vasculopathy. The multilevel arteriosclerosis leads to a massive decrease in blood perfusion distally. Aim of Study: The aim of this retrospective review is to assess the midterm results of 1ry & 2ry patency & limb salvage rates after endovascular management of multilevel arterial disease in lower limb of diabetic patients suffering from incapacitating intermittent claudication or Critical lower limb ischemia (CLI). Patients and Methods: Diabetic patients presented with incapacitating claudication or critical lower limb ischemia (CLI) due to multilevel vascular arterial disease with no history of previous attempts of lower limb revascularization, were included, whom angioplasty was done, from the beginning of January 2013 till the end of December 2013. Results: 101 diabetic patients with multi-level arterial disease in lower limbs were studied. Their mean age was (64.4±14 years) and 62.4% of patients were male. We classified the patients to sub-groups (A, B, C & D) depending on the level of the proximal lesion, Group A lesion start from level of the aorta or CIA to tibials 5.9%, Group B lesion start from level of EIA or CFA to tibials 5%, Group C lesion start from level of SFA to tibials 83.2%, Group D lesion start from upper level of Popliteal artery to tibials 5.9%. We also classified the patients to 2 group: Group (F) (n.=83) 82% which included all patients had full revascular-ization for all diseased arterial levels & group (P) (n.=18) 18% which included all patients had revascularization for proximal levels only. The worst presentations were associated with worse morphological nature of the lesions & its level. (p=0.042). Initial technical success was significantly better in patients with Minor tissue loss (97.0%) & in patients with rest pain & intermittent claudication (94.7%) than patients with major tissue loss (75%) (p=.029). With no significant difference in comparison of sub groups (A, B, C&D) (p=.443). 1ry patency at 3, 6 & 12 months showed no significant difference in comparison of sub groups (A, B, C & D). But 1ry patency was significantly higher in group (F) than in group (P), The 1ry patency rate decreased significantly in group (P) where we failed to deal with the distal level, 2ry patency at 6 months was (77.2%) & at 12 months was (71.3%) with no significant difference of 2ry patency between sub-groups (A, B, C & D) (p=.078), The 2ry patency was significantly higher in group F compared to group P (p=.001) at 6 month & (p=.001) at 12 month.
Patients achieved limb salvage in (81 patients) 80.2% & a major amputation rate was needed in (20 patients) 19.8% over 1 year. Group (F) patients showed significantly higher limb salvage rate & significant lower amputation rate than group (P). (p=.001). Complications were significantly higher in sub-groups A & C, which were mostly dissection (p-value =0.001). Mortality rate was 3%. Conclusion: Full correction for multilevel arterial lesions with direct pulsatile flow to the foot shows better 1ry, 2ry patency & limb salvage rates than correction of the proximal level only. Limb salvage & patency rates in management of multilevel arterial lesions were significantly affected by the increasing number of co-morbidities, risk factors & worse presentation of the patients.