Comparação das alterações angiográficas entre pacientes diabéticos e não diabéticos com doença arterial periférica
Comparative study of angiographic changes in diabetic and non-diabetic patients with peripheral arterial disease
Giovanni Ortale Trainotti; Jamil Victor Mariúba; Matheus Bertanha; Marcone Lima Sobreira; Ricardo de Alvarenga Yoshida; Rodrigo Gibin Jaldin; Paula Angeleli Bueno de Camargo; Winston Bonetti Yoshida
Resumo
Palavras-chave
Abstract
Background: Diabetics are at 5-15 times greater risk of developing peripheral arterial disease (PAD) and few studies have compared risk factors and distribution and severity of arterial changes in diabetics compared with non-diabetics. Objectives: To compare angiographic changes between diabetic and non-diabetic patients with advanced PAD and correlate them with risk factors. Methods: A retrospective cross-sectional study was conducted of consecutive patients undergoing lower limb arteriography for PAD (Rutherford 3-6) using TASC II and Bollinger et al. angiographic scores. Exclusion criteria were upper limb angiographies, unclear images, incomplete laboratory test results, and previous arterial surgeries. Statistical analyses included chi-square tests, Fisher’s test for discrete data, and Student’s t test for continuous data (significance level: p < 0.05). Results: We studied 153 patients with a mean age of 67 years, 50.9% female and 58.2% diabetics. A total of 91 patients (59%) had trophic lesions (Rutherford 5 or 6) and 62 (41%) had resting pain or limiting claudication (Rutherford 3 and 4). Among diabetics, 81.7% were hypertensive, 29.4% had never smoked, and 14% had a history of acute myocardial infarction. According to the Bollinger et al. score, infra-popliteal arteries were more affected in diabetics, especially the anterior tibial artery (p = 0.005), while the superficial femoral artery was more affected in non-diabetics (p = 0.008). According to TASC II, the most severe angiographic changes in the femoral-popliteal segment occurred in non-diabetic patients (p = 0.019). Conclusions: The most frequently affected sectors were the infra-popliteal sectors in diabetics and the femoral sector in non-diabetics.
Keywords
References
1 Chacra APM, Santos RD Fo. Patogenia e fisiopatologia da aterosclerose. In: Maffei F, editor. Doenças vasculares periféricas. 5. ed. Rio de Janeiro: Guanabara Koogan; 2015. cap. 97. p. 1207-16.
2 Abbas AK, Fausto N, Kumar V, et al. Robbins Patologia Básica. USA: Elsevier Health Sciences; 2018.
3 Durazzo AES, Sitrângulo CJ Jr, Presti C, Silva ES, De Luccia N. Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes? J Vasc Bras. 2005;4(3):255-64.
4 Roth GA, Forouzanfar MH, Moran AE, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med. 2015;372(14):1333-41.
5 Mansur AP, Favarato D. Mortalidade por doenças cardiovasculares no Brasil e na região metropolitana de São Paulo: atualização 2011. Arq Bras Cardiol. 2012;99(2):755-61.
6 Jesus-Silva SG, Oliveira JP, Brianezi MHC, Silva MAM, Krupa AE, Cardoso RS. Análise dos fatores de risco relacionados às amputações maiores e menores de membros inferiores em hospital terciário. J Vasc Bras. 2017;16(1):16-22.
7 Yoshida RA, Matida CK, Sobreira ML, et al. Estudo comparativo da evolução e sobrevida de pacientes com claudicação intermitente, com ou sem limitação para exercícios, acompanhados em ambulatório específico. J Vasc Bras. 2008;7(2):112-22.
8 Welter HF, Kettmann R, Grothe A. Peripheral arterial occlusive disease. Symptoms, basic diagnosis and staged therapy. MMW Fortschr Med. 2002;144(24):39-41. PMid:12134724.
9 Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5-67.
10 Leite CF, Frankini AD, DeDavid EB, et al. Análise retrospectiva sobre a prevalência de amputações bilaterais de membros inferiores. J Vasc Bras. 2004;3:206-13.
11 Silva LR, Fernandes GM, Morales NU, et al. Results of One-Stage or Staged Amputations of Lower Limbs Consequent to Critical Limb Ischemia and Infection. Ann Vasc Surg. 2018;46:218-25.
12 Nunes MAP, Resende KF, Castro AA, Pitta GBB, Figueiredo LFP, Miranda F Jr. Fatores predisponentes para amputação de membro inferior em pacientes diabéticos internados com pés ulcerados no estado de Sergipe. J Vasc Bras. 2006;5(2):123-30.
13 Santos ICRV, Carvalho EF, Souza WV, Albuquerque EC. Factors associated with diabetic foot amputations. J Vasc Bras. 2015;14(1):37-45.
14 Dos Santos VP, da Silveira DR, Caffaro RA. Risk factors for primary major amputation in diabetic patients. Sao Paulo Med J. 2006;124(2):66-70.
15 Senefonte FRA, Rosa GRPS, Comparin ML, et al. Amputação primária no trauma: perfil de um hospital da região centro-oeste do Brasil. J Vasc Bras. 2012;11(4):269-76.
16 Cardoso NA, Cisneros LL, Machado CJ, Procópio RJ, Navarro TP. Risk factors for mortality among patients undergoing major amputations due to infected diabetic feet. J Vasc Bras. 2018;17(4):296-302.
17 De Luccia N. Doença vascular e diabetes. J Vasc Bras. 2003;2:49-60.
18 Santos VP, Alves CA, Fidelis C, Araújo JS Fo. Arteriographic findings in diabetic and non-diabetic with critical limb ischemia. Rev Assoc Med Bras (1992). 2013;59(6):557-62.
19 Santos VP, Caffaro RA, Pozzan G, Saieg MA, Castelli Júnior V. Comparative histological study of atherosclerotic lesions and microvascular changes in amputated lower limbs of diabetic and non-diabetic patients. Arq Bras Endocrinol Metabol. 2008;52(7):1115-23.
20 Brazeau NF, Pinto EG, Harvey HB, et al. Critical limb ischemia: an update for interventional radiologists. Diagn Interv Radiol. 2013;19(2):173-80. PMid:23233402.
21 Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg. 2010;52(3, Suppl):81S-91S.
22 Rueda CA, Nehler MR, Perry DJ, et al. Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: implications for clinical trial design. J Vasc Surg. 2008;47(5):995-9, discussion 999-1000.
23 Graziani L, Silvestro A, Bertone V, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg. 2007;33(4):453-60.
24 Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care. 2001;24(8):1433-7.
25 Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26(3):517-38.
26 Malachias M, Plavnik FL, Machado CA, Malta D, Scala LCN, Fuchs S. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 1-Conceituação, Epidemiologia e Prevenção Primária. Arq Bras Cardiol. 2016;107(3, Suppl 3):1-6.
27 Zhu C, Zhou B, Lu J, et al. Principles of STAGE Management for Diabetic Foot Ulcers Based on the Wagner and Texas Classification Systems. Int J Low Extrem Wounds. 2019;18(4):367-75.
28 Bollinger A, Breddin K, Hess H, et al. Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images. Atherosclerosis. 1981;38(3-4):339-46.
29 Stoner MC, Calligaro KD, Chaer RA, et al. Reporting standards of the Society for Vascular Surgery for endovascular treatment of chronic lower extremity peripheral artery disease. J Vasc Surg. 2016;64(1):e1-21.
30 Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin RB, Murray CJ. Distribution of major health risks: findings from the Global Burden of Disease study. PLoS Med. 2004;1(1):e27.
31 He C, Yang ZG, Chu ZG, et al. Carotid and cerebrovascular disease in symptomatic patients with type 2 diabetes: assessment of prevalence and plaque morphology by dual-source computed tomography angiography. Cardiovasc Diabetol. 2010;9(1):91.
32 Zhou M, Zhu L, Cui X, et al. The triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio as a predictor of insulin resistance but not of beta cell function in a Chinese population with different glucose tolerance status. Lipids Health Dis. 2016;15(1):104.
33 Mills JL, Sr., Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220-34.e1-2.
34 Berlanga-Acosta J, Schultz GS, Lopez-Mola E, Guillen-Nieto G, García-Siverio M, Herrera-Martínez L. Glucose toxic effects on granulation tissue productive cells: the diabetics’ impaired healing. BioMed Res Int. 2013;2013:256043.
35 Bradbury AW, Adam DJ, Bell J, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: a description of the severity and extent of disease using the Bollinger angiogram scoring method and the TransAtlantic Inter-Society Consensus II classification. J Vasc Surg. 2010;51(5, Suppl):32S-42S.
36 Han Y, Zhu Z, Guan M, et al. Diabetes-specific characteristics of atherosclerotic plaques in femoral arteries determined by three-dimensional magnetic resonance vessel wall imaging. Diabetes Metab Res Rev. 2020;36(1):e3201.
37 Yoshida RA, Silva CEC, Sobreira ML, Yoshida WB. Angioplastia infrapoplítea: quanto mais artérias tratar, melhor? J Vasc Bras. 2008;7(2):176-82.
38 Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S-125S.e40.
Submitted date:
04/21/2020
Accepted date:
08/05/2022