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Submitted May 19, 2007; accepted Jun 25, 2007.

Additional material for this article may be found online

at www.jvascsurg.org.

DISCUSSION

Dr Bruce M. Elliott (Charleston, SC). I’d like to thank theauthors for providing me a copy of their manuscript prior to themeeting and the Society for the honor of discussing their worktoday. The authors assert that much has been published on lowerextremity bypass grafting and the corresponding impact of diabeteson both patency and limb salvage rates. Despite recent zealousenthusiasm for all things endovascular in the superficial femoralartery, little has been written about the impact of diabetes onendovascular interventions in the SFA.

The authors report a 20-year experience with 525 limbs in 427patients undergoing endoluminal treatment of the SFA, enteredinto their vascular registry database. One-half of the patients andone-half of the limbs were in nondiabetic patients, while thediabetic limbs were equally composed of insulin and non-insulin-requiring diabetes. There were significantly more advanced comor-bidities in the insulin-requiring diabetics than in the nondiabetics,all associated with either reduced limb salvage or survival, notablyend stage renal disease and congestive heart failure.

The indications for intervention were significantly differentbetween patients with diabetes and those without. Only 25% of thenondiabetic patients were treated for critical ischemia, while overhalf of those with diabetes had critical ischemia and fully one-thirdof those had tissue necrosis three times the incidence observed inthe non-diabetic patients. Despite the more advanced degree ofischemia in those patients with diabetes as opposed to thosewithout, tibial outflow status and distribution of TASC A/B andC/D lesions were seemingly unrelated.

Initial technical success was achieved in 93% of patients with-out any difference between those with and without diabetes.Although primary patency approximating 60% in 2 years wasequivalent in all groups and assisted patency only slightly worse inthose with insulin-requiring diabetes, limb salvage was substan-tially worse in diabetic limbs as opposed to those without, 74%versus 94% at two years.

The authors correctly observed, using Cox proportional haz-ard analysis, that the more advanced the disease (ie, TASC C/D),calcification, acute versus chronic occlusion or embolism, technicalcomplications such as perforation or embolization, all influenced

served, the presence of end-stage renal disease or dialysis indepen-dently and negatively influenced limb salvage.

The authors conclude that endoluminal therapy for SFA oc-clusive disease results in lower limb salvage rates for patients withdiabetes as compared to those without, despite similar patencyrates.

I have several questions for the authors. Was there a significantdifference in limb salvage between those with and without diabeteswho had tissue necrosis as their presenting symptom? Was there asignificant difference in limb salvage between those with andwithout diabetes when matched for comparable TASC lesions andtibial continuity? Did the location of the treated lesion, a proximalSFA versus a distal SFA or popliteal lesion, influence outcome? Andfinally, in how many patients were stents utilized, and were youable to compare their results in similar TASC lesions betweendiabetic patients and those without diabetes?

I’d like to thank the Society for the honor of discussing thispaper and congratulate the authors on a worthwhile endeavor.

Dr Andrew M. Bakken. With respect to your first question,we did separate out the patients based on whether they hadclaudication or critical ischemia. The limb salvage rates were sig-nificantly reduced for diabetic groups in those presenting withcritical ischemia. We did not separate out those presenting withtissue loss.

One of your follow-up questions was whether TASC lesionsseverity impacted this or tibial continuity. The tibial outflow wasequivalent between all of our groups regardless of mode of presen-tation. If we look specifically at those lesions that were TASC C orD among the patients presenting with critical ischemia, reducedlimb salvage did persist. Among patients with TASC A or B lesionspresenting with critical ischemia, diabetes did not significantlyimpact limb salvage.

With respect to the disease location, we did find a significantassociation. Those patients presenting with critical ischemia hadgreater below knee popliteal disease involvement and significantlyreduced limb salvage rates.

The final question related to stent usage. Overall stent usage inthese patients was about 37% and whether or not patients receivingstents were diabetic fared better or worse than those who were not

diabetic was not shown to be significant.