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WIFI Scores Predict Outcomes After Tibial Intervention In Patients With Diabetes And ESRD
Mark G. Davies, MD PhD MBA1, Georges M. Haider, MD1, Taylor D. Hicks, MD1, Hosam E. ElSayad, MD2.
1University of Texas Health Science Center - San Antonio, San Antonio, TX, USA, 2University of Ohio, Columbus, OH, USA.
Background: There is an increase in the incidence of endovascular interventions in patients with Diabetes Mellitus (DM) and chronic renal insufficiency (Renal). The aim of this study is to examine the outcomes of endovascular interventions in patients presenting with tissue loss and suffering from both DM and RENAL.
Methods: A database of patients undergoing lower extremity endovascular interventions between 2000 and 2015 was retrospectively queried. Patients with diabetes and tissue loss (Rutherford five and six) were identified and categorized by their eGFR ( ≥ 60 or <60 ml/min or on renal replacement therapy [HD or PD). They were further characterized by their WIfI score. Patient orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated.
Results: 486 diabetic patients (61% male, age 67±14years, mean±SD) underwent lower extremity interventions for tissue loss. The average PREVENT III amputation risk score (PIII score) was 4.6±1.6 (mean±SD) with 8% considered high risk overall. The average WIfI was 6.9± 2.7 (mean±SD) with 18% considered WIfI stage 3 /4. Technical success was 96%. Overall MACE was 3% and MALE was 24% at 30 days. Major amputation rate was 9% at 30 days. At 5 years, overall CE was 41±4%, (Mean±SEM), overall AFS 34±3% and overall MALE 45±4%. When stratified by eGFR and need for renal replacement therapy, those patients on HD had worse short-term and long-term outcomes (Table). On Cox proportional hazard analysis, a high WIfI score predicted poor outcomes.
|Number Limbs at Risk (n)||198||185||103|
|Male Gender (%)||60%||65%||49%**|
|Age (mean±SD) yrs||67±15||66±14||65±11|
|High Risk PIII score (%)||1%||5%||53%**|
|WIfI Stage 3/4||4%||10%*||60%**|
|30day MACE (%)||1%||3%||6%**|
|30day-Amputation Rate (%)||8%||8%||13%*|
|5yr-CE (Mean±SEM %)||48±5||40±6||23±9**|
|5yr-AFS (Mean±SEM %)||45±5||27±6*||18±7**|
|5yr-MALE (Mean±SEM %)||50±5||46±5||22±9**|
* P<0.05, **p<0.01 vs. eGFR≥ 60Conclusions
: Endovascular therapy for tissue loss in diabetics is significantly influenced by chronic renal insufficiency with the maximal impact when on renal replacement therapy. There is a high MACE and a high 30-day amputation rate in HD/PD. Longer-term outcomes remain very poor with less that a 25% success in patient-centered outcomes at 5 years in patients on HD/PD and this can be guided by WIfI score and staging
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