慢性肢体威胁缺血患者血运重建术后的糖尿病状况、长期死亡率和主要截肢结局。

IF 3.9 2区医学 Q1 PERIPHERAL VASCULAR DISEASE

Journal of Vascular Surgery Pub Date : 2025-05-08 DOI:10.1016/j.jvs.2025.04.065

Santiago Callegari, Gaëlle Romain, Abhinav Aggarwal, Jacob Cleman, Kim G Smolderen, Carlos Mena-Hurtado

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Cumulative incidence of mortality and hazard ratio were assessed with a Kaplan-Meier and Cox regression model, respectively. To account for the competing risk of death, major amputation was evaluated with Aalen-Johansen and Fine-Gray model for cumulative incidence and sub-hazard ratio (sHR), respectively. The interaction between DM and PVI vs LEB was tested.Results: Of 4,218 patients were included (70.7 ± 10.7 years old, 30.6% female), 62.3% had DM. . The 5-year cumulative incidence of death was lower in LEB vs PVI regardless of DM status (LEB vs. PVI without DM: P=0.005, and with DM: P = 0.004). The 5-year risk of death after LEB was 26% less than after PVI, regardless of DM status (P interaction = 0.490). There was no association between 5-year mortality risk and DM status (HR 1.16 95% CI 0.99-1.34, P = 0.060). 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引用次数: 0

摘要

糖尿病（DM）影响超过60%的慢性肢体威胁缺血（CLTI）患者。糖尿病与下肢搭桥（LEB）或外周血管干预（PVI）后的预后之间的关系尚不清楚。我们的研究旨在评估糖尿病与5年全因死亡率和CLTI患者LEB与PVI术后主要截肢之间的关系。方法：对2014-2019年间行LEB或PVI的CLTI患者进行VQI登记，并根据DM状态进行分层。结果来源于相关的医疗保险索赔数据。PVI与LEB队列采用倾向评分1:1匹配。累积死亡率和风险比分别采用Kaplan-Meier和Cox回归模型进行评估。为了考虑死亡的竞争风险，我们分别用aallen - johansen和Fine-Gray模型评估了主要截肢的累积发生率和亚危险比（sHR）。测定DM与PVI对LEB的交互作用。结果：4218例患者（70.7±10.7岁，女性30.6%）中，糖尿病发生率为62.3%。LEB与PVI的5年累积死亡发生率较低，与DM状态无关（无DM的LEB与PVI: P=0.005，有DM的LEB与PVI: P= 0.004）。LEB后的5年死亡风险比PVI后低26%，无论DM状态如何（相互作用P = 0.490）。5年死亡风险与糖尿病状态无相关性（HR 1.16, 95% CI 0.99-1.34, P = 0.060）。LEB与PVI的5年主要截肢累积发生率无差异，与糖尿病状态无关（LEB与PVI无糖尿病队列：P=0.955，与DM队列：P=0.955）。5年截肢风险与血运重建类型无关（sHR 0.79 95% CI 0.57-1.08， P=0.140）。无论治疗队列如何，糖尿病患者的截肢率是无糖尿病患者的两倍（sHR为1.98,95% CI为1.55-2.54，P< 0.001）（P相互作用= 0.869）。无论胰岛素依赖状态如何，结果都相似。结论：糖尿病影响大多数CLTI患者。无论糖尿病状态如何，LEB患者的5年死亡率较低。LEB与PVI的主要截肢和5年的死亡率或主要截肢没有差异，但糖尿病患者与无糖尿病患者的主要截肢风险更高。在糖尿病患者血运重建途径的背景下，需要共同决策、以团队为基础的护理和综合护理。

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Diabetes Status and Long-Term Mortality and Major Amputation Outcomes Following Revascularization in Chronic Limb Threatening Ischemia.

Introduction: Diabetes mellitus (DM) affects over 60% of patients with chronic limb-threatening ischemia (CLTI). The association between DM in outcomes after lower-extremity bypass (LEB) or peripheral vascular interventions (PVI) remains unclear. Our study aims to assess the association between DM and 5-year all-cause mortality and major amputation following LEB vs. PVI for CLTI.

Methods: Patients with CLTI undergoing LEB or PVI between 2014-2019 were studied in the VQI registry and stratified according to DM status. Outcomes were derived from linked Medicare claims data. Propensity score 1:1 matching between PVI and LEB cohort was used. Cumulative incidence of mortality and hazard ratio were assessed with a Kaplan-Meier and Cox regression model, respectively. To account for the competing risk of death, major amputation was evaluated with Aalen-Johansen and Fine-Gray model for cumulative incidence and sub-hazard ratio (sHR), respectively. The interaction between DM and PVI vs LEB was tested.

Results: Of 4,218 patients were included (70.7 ± 10.7 years old, 30.6% female), 62.3% had DM. . The 5-year cumulative incidence of death was lower in LEB vs PVI regardless of DM status (LEB vs. PVI without DM: P=0.005, and with DM: P = 0.004). The 5-year risk of death after LEB was 26% less than after PVI, regardless of DM status (P interaction = 0.490). There was no association between 5-year mortality risk and DM status (HR 1.16 95% CI 0.99-1.34, P = 0.060). The cumulative incidence of major amputation at 5 years did not differ in LEB vs. PVI regardless of DM status (LEB vs. PVI without DM cohort: P = 0.955, and with DM cohort: P=0.955). The 5-year risk of major amputation was not associated with the type of revascularization (sHR 0.79 95% CI 0.57-1.08, P=0.140). Major amputation was twice higher in patients with DM than in those without DM (sHR 1.98 95% CI 1.55-2.54, P< 0.001), regardless of treatment cohort (P interaction = 0.869). Similar results were seen regardless of insulin-dependent status.

Conclusion: DM affects the majority of patients with CLTI. Regardless of DM status, mortality at 5 years was lower among patients undergoing LEB. There was no difference in major amputation in LEB vs PVI and mortality or major amputation at 5 years, but patients with DM vs. no DM had a higher risk of major amputation. Shared decision-making, team-based care, and integrated care offerings are needed within the context of a revascularization pathway for patients with DM.

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来源期刊

Journal of Vascular Surgery 医学-外科

CiteScore

7.70

自引率

18.60%

发文量

1469

审稿时长

54 days

期刊介绍： Journal of Vascular Surgery ® aims to be the premier international journal of medical, endovascular and surgical care of vascular diseases. It is dedicated to the science and art of vascular surgery and aims to improve the management of patients with vascular diseases by publishing relevant papers that report important medical advances, test new hypotheses, and address current controversies. To acheive this goal, the Journal will publish original clinical and laboratory studies, and reports and papers that comment on the social, economic, ethical, legal, and political factors, which relate to these aims. As the official publication of The Society for Vascular Surgery, the Journal will publish, after peer review, selected papers presented at the annual meeting of this organization and affiliated vascular societies, as well as original articles from members and non-members.