Long-term outcomes of diabetic patients with critical limb ischemia followed in a tertiary referral diabetic foot clinic.
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.


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%) (chi(2) <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 [DeltaTcPo(2)]; and for major amputation, basal TcPo(2), basal A1C, DeltaTcPo(2), 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 cm(2) 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.
Uccioli
Luigi
L
1Department of Internal Medicine, University of Tor Vergata, Rome, Italy. luigi.uccioli@ptvonline.it
Gandini
Roberto
R
Giurato
Laura
L
Fabiano
Sebastiano
S
Pampana
Enrico
E
Spallone
Vincenza
V
Vainieri
Erika
E
Simonetti
Giovanni
G
D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data; D000800:Angioplasty, Balloon; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000188:drug therapy / Q000401:mortality / Q000473:pathology; D003131:Combined Modality Therapy; D003646:Debridement; D017719:Diabetic Foot / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D005734:Gangrene / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy; D006785:Hospitals, University; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy*; D008297:Male; D017063:Outcome Assessment, Health Care; D010044:Outpatient Clinics, Hospital; D012017:Referral and Consultation; D016896:Treatment Outcome; D014945:Wound Healing
D000900:Anti-Bacterial Agents