Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga; Surgical Service Line, Atlanta VA Medical Center, Decatur, Ga.
Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Ga.
J Vasc Surg. 2018 Jan;67(1):217-228.e1. doi: 10.1016/j.jvs.2017.06.101. Epub 2017 Aug 31.
Diabetes and peripheral arterial disease (PAD) are independently associated with increased risk of amputation. However, the effect of poor glycemic control on adverse limb events has not been studied. We examined the effects of poor glycemic control (high hemoglobin A level) on the risk of amputation and modified major adverse limb events (mMALEs) after lower extremity revascularization.
Patients undergoing PAD revascularization who had hemoglobin A (HbA) levels available within 6 months were identified in the Veterans Affairs database of 2003 to 2014 (N = 26,799). The diagnosis of preoperative diabetes mellitus (PreopDM) was defined using diabetes diagnosis codes and evidence of treatment. Amputation and mMALE risk was compared for HbA levels using Kaplan-Meier analysis. Cox proportional hazards models were created to assess the effect of high HbA levels on amputation and mMALE (adjusted for age, gender, race, socioeconomic status, comorbidities, cholesterol levels, creatinine concentration, suprainguinal or infrainguinal procedure, open or endovascular procedure, severity of PAD, year of cohort entry, and medications) for all patients and stratified by PreopDM.
High HbA levels were present in 33.2% of the cohort, whereas 59.9% had PreopDM. Amputations occurred in 4359 (16.3%) patients, and 10,580 (39.5%) had mMALE. Kaplan-Meier curves showed the worst outcomes in patient with PreopDM and high HbA levels. In the Cox model, incremental HbA levels of 6.1% to 7.0%, 7.1% to 8.0%, and >8% were associated with 26% (hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.15-1.39), 53% (HR, 1.53; 95% CI, 1.37-1.7), and 105% (HR, 2.05; 95% CI, 1.87-2.26) higher risk of amputation, respectively. Similarly, the risk of mMALE also increased by 5% (HR, 1.05; 95% CI, 0.99-1.11), 21% (HR, 1.21; 95% CI, 1.13-1.29), and 33% (HR, 1.33, 95% CI, 1.25-1.42) with worsening HbA levels of 6.1% to 7.0%, 7.1% to 8.0%, and >8%, respectively (vs HbA ≤6.0%). In stratified analysis by established PreopDM, the relative risk of amputation or mMALE was much higher with poor glycemic control (HbA >7.0%) in patients without PreopDM.
PAD patients with worse perioperative glycemic control have a significantly higher risk of amputation and mMALE. Incremental increases in HbA levels are associated with higher hazards of adverse limb outcomes independent of PreopDM status. Poor glycemic control (HbA >7.0%) in patients without a PreopDM diagnosis carries twice the relative risk of amputation and mMALE than in those with good glycemic control. These results suggest that screening of diabetic status and better management of glycemic control could be a target for improvement of perioperative and long-term outcomes in PAD patients.
糖尿病和外周动脉疾病（PAD）均与截肢风险增加独立相关。然而，血糖控制不佳对不良肢体事件的影响尚未得到研究。我们研究了血糖控制不佳（高血红蛋白 A 水平）对下肢血运重建后截肢和改良主要不良肢体事件（mMALEs）风险的影响。
在 2003 年至 2014 年退伍军人事务部的数据库中，确定了血红蛋白 A（HbA）水平在 6 个月内的 PAD 血运重建患者（N=26799）。术前糖尿病（PreopDM）的诊断使用糖尿病诊断代码和治疗证据定义。使用 Kaplan-Meier 分析比较 HbA 水平的截肢和 mMALE 风险。创建 Cox 比例风险模型评估高 HbA 水平对所有患者截肢和 mMALE 的影响（调整年龄、性别、种族、社会经济地位、合并症、胆固醇水平、肌酐浓度、锁骨下或股下手术、开放或血管内手术、PAD 严重程度、队列进入年份和药物），并按 PreopDM 分层。
队列中有 33.2%的患者存在高 HbA 水平，而 59.9%的患者有 PreopDM。4359 例（16.3%）患者发生截肢，10580 例（39.5%）患者发生 mMALE。Kaplan-Meier 曲线显示 PreopDM 和高 HbA 水平患者的预后最差。在 Cox 模型中，HbA 水平增加 6.1%至 7.0%、7.1%至 8.0%和>8%分别与 26%（风险比[HR]，1.26；95%置信区间[CI]，1.15-1.39）、53%（HR，1.53；95% CI，1.37-1.7）和 105%（HR，2.05；95% CI，1.87-2.26）的截肢风险增加相关。同样，mMALE 的风险也分别增加了 5%（HR，1.05；95% CI，0.99-1.11）、21%（HR，1.21；95% CI，1.13-1.29）和 33%（HR，1.33，95% CI，1.25-1.42），HbA 水平分别为 6.1%至 7.0%、7.1%至 8.0%和>8%（HbA≤6.0%）。在按既定 PreopDM 分层的分析中，在无 PreopDM 的患者中，血糖控制不佳（HbA>7.0%）的截肢或 mMALE 风险显著更高。HbA 水平升高与不良肢体结局的风险增加独立相关，且不受 PreopDM 状态的影响。无 PreopDM 诊断患者的血糖控制不佳（HbA>7.0%）的截肢和 mMALE 相对风险是血糖控制良好患者的两倍。这些结果表明，筛查糖尿病状态和更好地控制血糖可能是改善 PAD 患者围手术期和长期结局的目标。
