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Contemporary Revascularization Strategies and Outcomes Among Patients With Diabetes With Critical Limb Ischemia: Insights From the National Inpatient Sample

https://doi.org/10.1016/j.jcin.2020.11.032Get rights and content
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Abstract

Objectives

The purpose of this study was to evaluate temporal trends in the frequency of revascularization and associated outcomes in patients with diabetes mellitus and critical limb ischemia (CLI).

Background

Little is known about outcomes following revascularization for CLI in patients with diabetes mellitus.

Methods

Temporal trends in hospitalization for CLI among patients with diabetes were determined using the 2002–2015 National Inpatient Sample database. Propensity score matching was used to compare patients who underwent revascularization with those who did not and, separately, to compare those who underwent endovascular versus surgical revascularization. The main study outcome was in-hospital mortality.

Results

The analysis included 1,222,324 hospitalizations. The number of hospitalizations for CLI among patients with diabetes increased over time (ptrend < 0.001). There was an increase in the use of lower extremity revascularization, paralleled by a decline in in-hospital mortality during the study period. In the matched cohort, patients who were revascularized had lower in-hospital mortality (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.63 to 0.72) and major amputation (OR: 0.25; 95% CI: 0.24 to 0.27) compared with those who were treated medically. Compared with endovascular revascularization, those who underwent surgical revascularization had higher rates of in-hospital mortality (OR: 1.18; 95% CI: 1.04 to 1.35) but lower rates of major amputation (OR: 0.75; 95% CI: 0.70 to 0.81). Major bleeding, blood transfusion, post-operative infection, respiratory complications, discharges to nursing facility, and longer length of hospital stay were also more common among those who underwent surgery.

Conclusions

In this national analysis of patients with DM and CLI, we demonstrated an increase in hospitalization for CLI among patients with diabetes in the United States. Although in-hospital mortality decreased over time regardless of the treatment strategy used, this outcome occurred less frequently among those who underwent revascularization than not. Compared with surgical revascularization, endovascular revascularization was associated with lower in-hospital mortality but higher rates of major amputation.

Key Words

critical limb ischemia
diabetes mellitus
endovascular revascularization
surgical revascularization

Abbreviations and Acronyms

CI
confidence interval
CLI
critical limb ischemia
DM
diabetes mellitus
ESRD
end-stage renal disease
HCUP
Healthcare Cost and Utilization Project
HD
hemodialysis
ICD-9
International Classification of Diseases-9th Revision
IQR
interquartile range
MI
myocardial infarction
NIS
National Inpatient Sample
OR
odds ratio
PAD
peripheral artery disease

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