Diabetes, Atherectomy, and Critical Limb Ischemia
George Adams, MD
Patients with diabetes and critical limb threatening ischemia (CLTI) are at significantly higher risk of limb loss and death. Recently published in JCLI, Outcomes of Orbital Atherectomy in Patients With Critical Limb Threatening Ischemia and Diabetes evaluates the outcomes of orbital atherectomy for the treatment of CLTI in patients with and without diabetes. Study co-author George Adams, MD, offers further insight into the topic in the video commentary below.
My name is George Adams. I'm from Raleigh, North Carolina. I'm an interventional cardiologist out of the UNC Rex System.
Today, we're going to discuss one of my recent papers published in the Journal of Critical Limb Ischemia, looking at the outcomes of patients who have diabetes and are treated with orbital atherectomy, who have critical limb ischemia. The reason we did this work was for a couple of reasons. First, these epidemics are currently happening not only in the United States but also worldwide. If you look at these epidemics, include the patient population in terms of age, people are getting older. In fact, in the United States the fastest growing age population are those who are over the age of 65, specifically those older than the age of 80. Of those people who are older than the age of 65, 1 out of 4 of these have diabetes. So, that's the second epidemic. And then, third is renal insufficiency. The majority of people who have renal insufficiency have diabetes. These demographics set you up to have peripheral arterial disease, and not just peripheral arterial disease, but the worst of the worst form of peripheral arterial disease, which is critical limb ischemia. Now that gives us our next question -- is those people who have rest pain or wounds that aren't healing, should we even be trying to open up these vessels in the lower extremity? Or should we just go straight to an amputation? This paper looks at that question.
Looking at a population that was older and diabetic who had critical limb ischemia, we evaluated that question. What we found was that if you performed endovascular intervention on these vessels in the lower extremity, not only did you decrease morbidity, but you also decreased mortality. Not only was it safe, but it was also efficacious. Now, the third thing is when you look at the end of vascular interventions that we studied – and there is a whole slew of tools that we can use, for example, we can use balloon angioplasty, we can use atherectomy, we can use stents, thrombectomy, etc. But, there's also always been a controversy of whether prepping the vessel with atherectomy is safe, and also is it efficacious. Well, we know technically it helps to open the vessel, but does it improve outcomes? So, this was also addressed in the paper in the sense that we looked at atherectomy and the Liberty series. Most, the majority of them were orbital atherectomy, and what we found was, that not only was it safe, but it was also efficacious. Not only did we decrease mortality, we decreased amputation rates, we decreased target lesion reintervention rates. So, again, the first question in this higher-risk population who have critical limb ischemia, I believe, and what we've shown in this paper, is that it is important to offer these patients an intervention because not only does it help save the leg, but it also improves quality of life. When you look at the tools that we have to offer, remember, a carpenter is only as good as his tools, orbital atherectomy or atherectomy in general, helps to prep the vessel, yes, but more than that, it helps to improve outcomes over the long term. More recently, we actually did a sub analysis looking at orbital atherectomy patients within the Liberty set, and what we found is not only was it safe and efficacious but it was also cost effective. And, today it is always important to have a modality that is not only beneficial to the patient but also cost effective to the system so we can offer it to the masses rather than just an individualized subset.