1. Esiti del trattamento con angioplastica transluminale percutanea (PTA) agli arti inferiori nei pazienti diabetici in trattamento dialitico con ischemia critica dell’arto Dr. Marco Meloni Dipartimento di Medicina Interna Università degli Studi di Roma Tor Vergata

2. Peripheral arterial disease Diabetes and chronic kidney disease are strong risk factors for peripheral arterial disease (PAD) Diabetes and chronic kidney disease are strong risk factors for peripheral arterial disease (PAD) The prevalence of PAD among patients with end stage renal disease (ESRD) has been reported in up to 77% The prevalence of PAD among patients with end stage renal disease (ESRD) has been reported in up to 77% Scheiffer T. et al J Diabetes Compl 1998

3. Peripheral arterial disease Uraemia has a strong impact on endothelial function and passive properties of the arterial wall ESRD is a strong risk factor for both ulceration and amputation in diabetic patients Luksha N. et Al, Clinical Science 2011

4. Impaired resistance artery function in patients with end-stage renal disease Flow mediated dilatation is attenued in ESRD patients Flow mediated dilatation is attenued in ESRD patients Dilatation in response to acetylcholine was reduced Dilatation in response to acetylcholine was reduced Luksha N. et Al, Clinical Science 2011

5. Revascularization recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65–75% after revascularization among survivors. High 1- year mortality of 38% is reported in a recent review has to be taken into consideration Typically, half of the patients are reported to lose their legs despite open bypass.

7. Is PTA a right approach in diabetic patients with ESRD? The aim of our study is to assess the outcomes after percutaneus transluminal angioplasty (PTA) in diabetic patients with ESRD and PAD.

8. Materials and methods 456 patients (292 M, 164 W) were enrolled 456 patients (292 M, 164 W) were enrolled They presented diabetes, peripheral arterial disease complicated by critical limb ischaemia (CLI) and diabetic foot lesions They presented diabetes, peripheral arterial disease complicated by critical limb ischaemia (CLI) and diabetic foot lesions Follow-up: 12 months Follow-up: 12 months

9. Materials and methods Each patient was assessed for: Each patient was assessed for: - diabetes, diabetes complications and other risk factors and were divided in two groups according to the presence of dyalisis treatement : patients with ESRD (ESRD +) (n=60) patients with ESRD (ESRD +) (n=60) patients without ESRD (ESRD -) (n=396) patients without ESRD (ESRD -) (n=396) - Lesion features: dimension, deep, infection according to Texas wound classification

10. Materials and methods Every patients performed morfological evaluation before PTA: US color duplex scan or CT or MR angiography based on the renal function, in order to establish the road map during the revascularization Every patients performed morfological evaluation before PTA: US color duplex scan or CT or MR angiography based on the renal function, in order to establish the road map during the revascularization All patients were routinaly on double antiplatelet therapy (cardioaspirin plus clopidogrel) before PTA and for one month after. All patients were routinaly on double antiplatelet therapy (cardioaspirin plus clopidogrel) before PTA and for one month after.

11. Materials and methods Primary endpoint (at 12 months): Primary endpoint (at 12 months): - Alive without major amputation - Alive with major amputation - Death Secondary endpoint : Secondary endpoint : - Analyses of patients who needed Re-PTA - Outcomes after Re-PTA

12. PTA in 396 no ESRD diabetic patients 77.6 % 11,5% 10,9% Outcomes 12 months

13. PTA in 60 ESRD diabetic patients 60% 21.7% 18.3% Outcomes 12 months

14. Re-pta and radiological outcomes * 0.043 * 0.01

15. Conclusions Diabetes and Chronic Kidney disease are two strong risk factor for PAD Diabetes and Chronic Kidney disease are two strong risk factor for PAD ESRD is a strong risk factor for both ulceration and amputation in diabetic patients ESRD is a strong risk factor for both ulceration and amputation in diabetic patients PAD and ESRD increase the risk of hospitalisation, treatment failure and death PAD and ESRD increase the risk of hospitalisation, treatment failure and death

16. Conclusions Lower limbs revascularization in diabetic patients with ESRD has a low success due to difficulty to treat steno-obstructions, high risk of infections, poor healing and death Lower limbs revascularization in diabetic patients with ESRD has a low success due to difficulty to treat steno-obstructions, high risk of infections, poor healing and death Several studies have poor evidence on effectiveness of PTA treatment in diabetic patients with ESRD Several studies have poor evidence on effectiveness of PTA treatment in diabetic patients with ESRD

17. Conclusions In our study PTA allows a limbs salvage no different from results obtained with by-pass but in unselected patients and with a reduced 1-year mortality (22% vs 38%) In our study PTA allows a limbs salvage no different from results obtained with by-pass but in unselected patients and with a reduced 1-year mortality (22% vs 38%) Our data, after comparative evaluation, support PTA as first approach for treatment of PAD in patients with diabetes and ESRD Our data, after comparative evaluation, support PTA as first approach for treatment of PAD in patients with diabetes and ESRD