Long-term Outcomes of an Endovascular-First Approach for Diabetic Patients with Predominantly Tibial Disease Treated in a Multidisciplinary Setting

Abstract Objective Randomized studies suggest that open lower extremity revascularization procedures are associated with improved outcomes compared to endovascular peripheral vascular interventions (PVI). However, advances in endovascular technologies and treatment by multidisciplinary limb preservation teams have shown improved outcomes. The aim of our study was to compare perioperative and long-term outcomes following open vs. PVI procedures in diabetic patients with chronic limb-threatening ischemia (CLTI) treated in a multidisciplinary setting. Methods All patients presenting to our multidisciplinary diabetic limb preservation service from 6/2012-07/2018 were enrolled in a prospective database. Patients who underwent either open lower extremity bypass (LEB) or PVI for CLTI were included in the analysis. Perioperative (30-day) complications and 4-year patency and limb salvage rates were compared for PVI vs. LEB using chi-square tests, Kaplan-Meier curve analyses, and stepwise multivariable Cox proportional hazards models. Results A total of 195 lower extremity revascularization procedures were performed in 120 patients (mean age 65.0±1.0 years, 61.7% male, 63.3% black), including 53 (27.2%) open and 142 (72.8%) PVI. Nearly two-thirds of procedures (65.6%) treated multilevel disease, while 27.2% treated isolated tibial disease and 7.2% treated isolated femoro-popliteal disease. More than half of procedures (53.3%) were performed for WIfI stage 4 limbs, 25.1% for stage 3, and 21.6% for stage 1/2. In the LEB group, 67.9% of targets were infrapopliteal. In the PVI group, 63.4% of procedures were isolated tibial interventions or were multilevel interventions including the tibial segment. Perioperative complications occurred in 52.8% of LEB vs. 12.0% of PVI (P Conclusions In this cohort of diabetic patients with CLTI undergoing predominantly tibial interventions, open revascularization was associated with a higher risk of perioperative complications than PVI. While secondary patency rates were better following LEB, our data suggest that an endovascular-first approach results in equivalent long-term amputation-free survival for diabetic patients treated in a multidisciplinary setting.