“The key message is that lower extremity revascularization is not a totally benign procedure and I do not think that knowledge is very widespread,” Dr Hiatt said. “As someone who practices vascular medicine, my approach is to only refer the most symptomatic patients, particularly those with chronic limb threatening ischemia, for a procedure. The asymptomatic patient or those with minimal claudication should be treated medically.”
To provide patients with a range of treatment options, Dr Hiatt described his practice’s team approach. “Our multispecialty practice includes vascular surgery, interventional radiology, interventional cardiology, and vascular medicine. We have a number of medical and exercise treatment options that we employ, not just lower extremity revascularization,” he said.
Patient Complexity Necessitates Collaboration
Adam J. Janas, MD, PhD, from the Center of Cardiovascular Research and Development American Heart of Poland in Katowice, Poland, and colleagues conducted a single-site retrospective study of patients with diabetes (n = 132; mean age, 68 years; 66% men) and without diabetes (n = 72; mean age, 75 years; 63% men) who underwent atherectomy for PAD. They found that long-term outcomes can be comparable between the 2 groups.4 The study’s end points included target lesion revascularization, amputation, and death.4
Differences for ischemia, amputation, and death at 6, 12, and 24 months were nonsignificant between patients with and without diabetes.4 Complications before and after the procedure were also similar between groups. The patients with diabetes, however, had a higher incidence of renal disease and more diffuse atherosclerotic lesions, despite being younger on average than patients without diabetes.4
“The multispecialty setting is the key for optimal PAD treatment,” said Dr Janas. “Efficient screening of PAD by a primary care clinician is the first step in diagnosing and referring a patient to a cardiologist practicing PAD treatment. Cardiologists assess PAD but also determine coronary artery disease risk and apply treatment for both, endovascular if necessary. If a patient has diabetes, endocrinologists optimize diabetes treatment to avoid PAD and coronary artery disease escalation and reduce risk for repeat revascularization, MI, stroke, and amputation.”
Dr Janas acknowledged the need for greater collaboration among specialists who treat patients with diabetes and cardiovascular disease. “Cooperation between endocrinologists and cardiologists increased recently due to a huge rate of patients with diabetes, PAD, and coronary artery disease. This cooperation will be even greater [because] we have more complex patients. The information flow among endocrinologists, cardiologists, and the patient is smoother due to digitalization and advancements in mobile technologies,” he said.
Summary & Clinical Applicability
As the link between diabetes and peripheral artery disease becomes more evident, clinicians can best serve patients with these comorbidities by working collaboratively to prevent serious sequelae of these diseases, such as the need for lower extremity revascularization and amputation.
Limitations & Disclosures
The EUCLID trial was funded by AstraZeneca. Please see original references for full listings of authors’ disclosures.
Content has been lightly edited for style by Endocrinology Advisor.
1. Armstrong EJ, Waldo SW, Valle JA. The heart and vascular team: time for endocrinologists to join the club? J Am Coll Cardiol. 2018;72(25):3285-3286.
2. Low Wang CC, Blomster JI, Heizer G, et al; Executive Committee and Investigators of the EUCLID Trial. Cardiovascular and limb outcomes in patients with diabetes and peripheral artery disease: the EUCLID trial. J Am Coll Cardiol. 2018;72(25):3274-3284.
3. Baumgartner I, Norgren L, Fowkes FGR, et al; Executive Committee and Investigators of the EUCLID Trial. Cardiovascular outcomes after lower extremity endovascular or surgical revascularization: the EUCLID trial. J Am Coll Cardiol. 2018;72(14):1563-1572.
4. Janas AJ, Milewski KP, Buszman PP, et al. Long term outcomes in diabetic patients treated with atherectomy for peripheral artery disease [published online October 19, 2018]. Cardiol J. doi:10.5603/CJ.a2018.0122