Long-Term Prognosis of Diabetic Patients With Critical Limb Ischemia

A population-based cohort study

  1. Ezio Faglia, MD1,
  2. Giacomo Clerici, MD1,
  3. Jacques Clerissi, MD2,
  4. Livio Gabrielli, MD3,
  5. Sergio Losa, MD3,
  6. Manuela Mantero, MD1,
  7. Maurizio Caminiti, MD1,
  8. Vincenzo Curci, MD1,
  9. Antonella Quarantiello, MD1,
  10. Tommaso Luppattelli, MD2 and
  11. Alberto Morabito, PHD4
  1. 1Diabetology Center, Diabetic Foot Center, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Multimedica, Sesto San Giovanni, Milano, Italy;
  2. 2Interventional Radiology Laboratory, IRCCS Multimedica, Sesto San Giovanni, Milano, Italy;
  3. 3Vascular Surgery Unit, University of Milan, Milan, Italy;
  4. 4Medical Statistics Unit, University of Milan, Milan, Italy.
  1. Corresponding author: Giacomo Clerici, giacomo.clerici{at}multimedica.it


OBJECTIVE To evaluate the long-term prognosis of critical limb ischemia (CLI) in diabetic patients.

RESEARCH DESIGN AND METHODS A total of 564 consecutive diabetic patients were hospitalized for CLI from January 1999 to December 2003; 554 were followed until December 2007.

RESULTS 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 1.03–1.07]), unfeasible revascularization (3.06 [1.40–6.70]), dialysis (3.00 [1.63–5.53]), cardiac disease history (1.37 [1.05–1.79]), and impaired ejection fraction (1.08 for 1% point [1.05–1.09]).

CONCLUSIONS 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.


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    • Received July 2, 2008.
    • Accepted February 3, 2009.
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