title: Diabetes does not worsen outcomes following infrageniculate bypass or endovascular intervention for patients with critical limb ischemia.
abstract: OBJECTIVE
  Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral arterial disease, but minimal data exist comparing outcomes performed at and below the knee among patients with diabetes (DM) specifically. The purpose of this study is to compare outcomes following open bypass (lower extremity bypass [LEB]) and peripheral vascular intervention (PVI) at and below the knee in patients with DM vs patients without DM (non-DM) with critical limb ischemia.
  
  
  METHODS
  Data from the 2008-2014 Vascular Quality Initiative (VQI) were analyzed. All patients undergoing LEB or PVI at or below the knee for rest pain or tissue loss were included. One-year primary patency, major amputation, and mortality were compared for patients with DM vs patients without DM stratified by treatment approach.
  
  
  RESULTS
  Overall, 2566 patients were included, including 500 patients (19%) undergoing LEB (DM = 355 vs non-DM = 145) and 2066 patients (81%) undergoing PVI (DM = 1463 vs non-DM = 603). Patients with DM were more frequently black (18% vs 14%), had more comorbidities, and more frequently underwent revascularization for tissue loss (85% vs 58%) compared with patients without DM (all, P < .001). Within the LEB group, there were no significant differences in 1-year primary patency (74% vs 71%; P =.52), major amputation (16% vs 12%; P = .39), or mortality (10% vs 6%; P =.16) between DM vs non-DM patients. There were also no significant differences in 1-year primary patency (81% vs 79%; P = .36), major amputation (14% vs 11%; P =.09) or mortality (6% vs 7%; P =.30) among patients with DM vs patients without DM undergoing PVI. Multivariable analysis adjusting for baseline differences between groups demonstrated a nonsignificant trend toward better primary patency in the DM group following both LEB (hazard ratio, 1.55; 95% confidence interval, 1.00-2.42; P = .05) and PVI (hazard ratio, 1.23; 95% confidence interval, 0.97-1.56; P = .09). There were no significant differences in 1-year major amputation or mortality comparing patients with DM vs patients without DM for either LEB or PVI after risk adjustment (all, P ≥ .16).
  
  
  CONCLUSIONS
  Critical limb ischemia resulting from arterial occlusive disease at or below the knee can be treated successfully with either open surgical bypass or endovascular interventions in both DM and non-DM patients. Aggressive attempts at limb salvage among patients with critical limb ischemia should be pursued regardless of DM status.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Alireza
authors.initials: A
authors.lastname: Najafian
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Menard
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md. Electronic address: cabular1@jhmi.edu.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D016208:Databases, Factual; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D058017:Vascular Grafting / Q000009:adverse effects / Q000401:mortality; D014654:Vascular Patency