The aim of this study is to evaluate the outcomes of drug-eluting balloon angioplasty and vein bypass surgery in diabetic patients with critical limb ischemia due to infrapopliteal arterial disease.
Objective: To consider the clinical outcomes of drug-coated ballon angioplasty and vein bypass surgery in terms of amputation-free survival, overall survival, relief of symptoms, quality of life and to determine if limb revascularization contributes to diabetic peripheral neuropathy (DPN). All patients with type 2 diabetes mellitus and severe limb ischemia reffered to multidisciplinary diabetic foot team or endocrinology or vascular units can be considered. To be eligible for randomization, peripheral arterial occlusive disease must be located infra-popliteally; patients must have adequate inflow and outflow to support infrapopliteal interventions; have a good superficial vein for bypass surgery. If the patient is suitable for both treatment arms, they will be invited to enter the trial. If patient is suitable for both revascularization techniques randomization will be performed after diagnostic angiogram submission Patient will be randomised to one of the following groups: A. Vein bypass surgery first strategy B. Endovascular treatment first (drug coated balloon angioplasty) strategy Outcomes will be recorded at 1, 3, 6, 9, 12, 18, 24 month after revascularisation procedure. Information collected will include further interventions (vascular, non-vascular), hospitalisations (for whatever reason), other health problems, clinical and haemodinamic status of limbs, funcional status, quality of life, neuropathy.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
40
Vein bypass will be performed with standart anaesthetic and surgical techniques using reversed great saphenous vein conduit. Location of proximal and distal anastomosis will be recorded. Post surgery completion angiography imaging will be performed.
Endovascular treatment using drug-coated balloons will be performed under local anaesthetic via common femoral artery. Final angiography imaging will be demonstrated.
Lithuanian University of Health Sciences
Kaunas, LT, Lithuania
RECRUITINGPrimary, primary-assisted and secondary patency
Clinical and ultrasound assesment
Time frame: 24 months
Ischemic symptoms
Fontaine classification: I asymptomatic; IIa mild claudication; IIb moderate-to-severe claudication; III rest pain; IV ulceration or gangrene. Rutherford classification: 0 asymptomatic; 1 mild claudication; 2 moderate claudication; 3 severe claudication; 4 rest pain; 5 minor tissue loss; 6 severe tissue loss or gangrene.
Time frame: 24 months
Ankle-brachial index (ABI)
Ratio of the blood pressure at the ankle to the blood pressure in the upper arm. Norm 1.0-1.4
Time frame: 24 months
Toe-brachial index (TBI)
Ratio of the blood pressure of the great toe to the blood pressure in the upper arm. Norm 1.0-1.4
Time frame: 24 months
Transcutaneous oxygen tension (TcPO2)
A noninvasive test that directly measures the oxygen level of tissue beneath the skin. A TcPO2 greater than 55 mmHg is considered normal regardless of the site of measurement, whereas a value of 40 mmHg is the critical value below which wound healing is impaired and ischemia develops.
Time frame: 24 months
Healing of tissue loss (ulcers, gangrene)
Clinical examination and photo documentation.
Time frame: 24 months
Re- and cross-over intervention rates
Time frame: 24 months
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Major and minor amputation rates
Time frame: 24 months
In-hospital morbidity/mortality and overall survival
Time frame: 24 months
Relief of pain: Visual analog scale (VAS)
The Visual Analog Scale (VAS) is a 10 cm line with anchor statements on the left (no pain) and on the right (extreme pain).
Time frame: 24 months
Quality of life: EQ-5D-5L questionaire
Descriptive system for health-related quality of life states in adults, consisting of five dimensions (Mobility, Self-care, Usual activities, Pain \& discomfort, Anxiety \& depression), each of which has five severity levels that are described by statements appropriate to that dimension.
Time frame: 24 months
Diabetic neuropathy dinamics: clinical examination of foot sensation
Full hypoesthesia; Partial hypoesthesia; No changes; + Assymetry.
Time frame: 24 months
Diabetic neuropathy dinamics: neurometer
Perception threshold measurement. Neurometer® determines three sub-types of nerve fiber by producing transcutaneous electrical stimuli at frequencies of 2000, 250 and 5 Hz.
Time frame: 24 months
Diabetic neuropathy dinamics: electroneuromiography
Diagnostic procedure that evaluates the health condition of muscles and the nerve cells that control them. A nerve conduction velocity between 50 and 60 meters per second is generally considered in the normal range.
Time frame: 24 months