Angiographic Features of Atherosclerotic Superficial Femoral Artery Disease in Diabetics and Non-diabetics Presenting with Claudication Atif Mohammad,

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Angiographic Features of Atherosclerotic Superficial Femoral Artery Disease in Diabetics and Non-diabetics Presenting with Claudication Atif Mohammad, MD Research Fellow VA North Texas Health Care System UT Southwestern Medical Center Dallas,TX On behalf of the investigators:

INVESTIGATORS Atif Mohammad, MD*† Avantika Banerjee* Omar Hadidi, MD† Gene Pershwitz, MD* Mirza Baig, MD*† Emmanouil S. Brilakis, MD, PhD*† *VA North Texas Health Care System, Dallas, TX; †University of Texas Southwestern Medical Center, Dallas, TX; Acknowledgements: Dallas VA Research Corporation

BACKGROUND & METHOD Though clinical outcomes following percutaneous revascularization of superficial femoral artery (SFA) varies between diabetics (DM) and non-diabetics, angiographic differences of their SFA disease has never been systemically analyzed We conducted blinded angiographic analysis of peripheral angiograms in 117 consecutive patients (79 DM and 38 non-DM) between January 2009 - January 2011, presenting to Veterans Affairs Haelth Care System (Veterans Integrated Service Network or VISN 17) with Rutherford category 3 claudication

METHOD: ANGIOGRAPHIC ANALYSIS

BOLLINGER SCORE RestenosisΨ Occlusion★ Stenosis >50% < 50% Plaques < 25% Location-Additive Score Points Change of length 4 2 1 Single 12 13 5 3 Multiple≤ Half segment 14 15 6 Multiple ≥ Half segment 16 Vectorial Score: ★Total occlusions less then half the length of arterial segment will be scored as 13 and more then half as 15. Ψ13 changes to 14 after change in length and restenosis.15 will change to 16 after restenosis and change in length of the segment. The total additive score is the Bollinger score.

RESULTS: Mean Bollinger Scores p=0.03 Non-DM DM

Lesion characteristics RESULTS: Lesion characteristics Non-DM (n=38) DM (n=79) All patients (n=117)Ψ p★ Age 64.3±8.9% 64.0±7.6% 64.5±9.3% 0.50 Bilateral SFA lesions 2.7% 23.0% 16.0% 0.01 Ostial SFA 10.8% 0.0% 3.0% Proximal SFA 51.0% 27.0% 25.0% 0.04 Mid SFA 57.0% 87% 76% 0.09 Distal SFA 69% 50% 0.02 Popliteal 8.0% 18.0% 14.0% Below the knee 9.0% 7.0% ★DM vs. Non-DM, all lengths and diameters expressed in mm; Ψrepresents all lesions SFA: superficial femoral artery

RESULTS: Angiographic Distribution of SFA in Diabetics & Non-Diabetics SFA: superficial femoral artery

RESULTS: Lesion Flow & Stenosis Characteristics in Diabetics & Non-Diabetics Characteristics Non-DM (n=38) DM (n=79) All patients (n=117)Ψ p★ Chronic total occlusion 30.0% 59.0% 49.0% 0.01 Bollinger score 9.0±4.3 12.0±4.8 11.0±5.3 0.03 Calcification 62.0% 87.0% 78.0% 0.09 Grade 1 38.0% 6.0% 16.0% Grade 2 54.0% 42.0% 45.0% 0.60 Grade 3 8.0% 50.0% 36.0% Thrombus 25.0% 81.0% 0.02 88.0% 19.0% 41.0% 0.06 11.0% 6.41% 7.7% 2.63% 1.7% Grade 4 5.0% Grade 5 33.0% Mean number of distal run-off vessels 2.5 2.3 2.4 0.04 ★DM vs. Non-DM, all lengths and diameters expressed in mm; Ψrepresents all lesions

Lesion characteristics RESULTS: Lesion Characteristics & Revascularization in Diabetics & Non-Diabetics Lesion characteristics Non-DM (n=38) DM (n=79) All patients (n=117)Ψ p★ Lesion length 143.0±72.0 84.0±51.2 116.0±62.0 0.02 Proximal diameter 3.7±1.1 0.04 Diameter diameter 3.6±1.2 3.1±1.1 3.4±1.8 0.01 Reference diameter 4.0±1.2 4.2±1.4 4.1±1.3 Segment MLD 2.2±0.09 1.5±1.0 1.18±1.0 0.63 Revascularization All patients (n=117) Stenting 33.0% 93.0% 63.0% Debulking 72.0% 10.0% 41.0% 0.008 Stent length 195.0±116.0 241.5±98.0 218.0±107.0 3±1.4 3.1±1.4 0.40 Distal diameter 3±1.3 3.5±1.4 3.3±1.37 0.17 Stent mean luminal diameter 1.8±0.5 2±0.9 1.9±0.5 0.20 ★DM vs. Non-DM, all lengths and diameters expressed in mm; Ψrepresents all lesions; MLD: minimal luminal diameter

Lesion characteristics RESULTS: Procedural Complications & Outcomes in Diabetics & Non-Diabetics Lesion characteristics Non-DM (n=38) DM (n=79) All patients (n=117)Ψ p★ Bend 13.0% 11.5% 12.0% 0.82 Eccentric lesions 8.0% 10.0% 0.70 Distal embolization 0.0% 1.00 Dissection 3.0% 0.20 Dissection length 0.0 9.1±4.0 50% 0.02 Abrupt Closure 6.0% 0.60 In segment % stenosis 34.0% 33.0% 0.80 In stent % stenosis 30.0% Patency at 6 month 100.0% 80.0% 87.0% 0.14 Patency at 12 months 63.0% 70.0% 0.004 ★DM vs. Non-DM, all lengths and diameters expressed in mm; Ψrepresents all lesions

CONCLUSIONS: These results indicate the greater severity of SFA disease in patients with diabetes mellitus, increased need for stenting & lower 12 month patency Our findings also indicate to the need for dedicated strategies for improving outcomes in diabetics with peripheral arterial disease undergoing endovascular revascularization procedures for life- style limiting claudication SFA: superficial femoral artery