Distribution pattern of infrageniculate arterial obstructions in patients with diabetes mellitus and renal insufficiency - implications for revascularization

Background: Diabetes mellitus (DM) and renal insufficiency (RI) were shown to be associated with an obstructive lesion pattern favouring distal lower limb arterial segments in patients with peripheral arterial disease (PAD). We hypothesized that presence of DM is associated with pronounced involvement of the tibioperoneal arteries, whereas RI predominantly affects the pedal arch. Patients and methods: A consecutive series of PAD patients (mean age 75 +/- 10 years, 40 women) with RI alone (n = 15), RI and DM (n = 25), DM alone (n = 25) and without RI or DM (n = 25) underwent diagnostic angiography.We analyzed the obstructive burden of different segments of the infrageniculate arterial tree using the Bollinger score as well as accessibility of pedal arteries for bypass surgery. Results: In patients with DM and in patients with RI the mean total obstructive burden was higher in pedal as compared to tibioperoneal arteries (9.79 +/- 4.60 vs. 6.99 +/- 3.45, p = 0.03; 10.50 +/- 5.53 vs. 6.88 +/- 4.12, p = 0.05, respectively). However, rates of patency of at least one pedal artery were significantly lower in patients with RI and RI/DM as compared to controls (47% and 48% vs. 80%, respectively; p = 0.007), whereas patency was comparable between patients with diabetes alone and controls (72% vs. 80%, ns). Rates of viability of pedal arteries as an attachment site for distal bypass was 80%,68%,47% and 44% in controls, patients with DM alone, RI alone and RI/DM, respectively (p = 0.0042). Conclusions: In contrast to previous anecdotal observations, both DM and RI are associated with a high atherosclerotic burden of the pedal arch in the present angiographic series. The presence of RI, however, is associated with a lower patency of the pedal arch as compared to the presence of DM alone, and more than fifty percent patients are unsuitable for distal bypass grafting.