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Background: There is an increase in the incidence of Diabetes Mellitus (DM) and chronic renal insufficiency (Renal) in patients undergoing endovascular interventions, however the synergistic influence of diabetes and renal insufficiency on outcomes is not well described. The aim of this study is to examine the outcomes of endovascular interventions in patients presenting with an ulcerated diabetic foot and chronic renal insufficiency.
Methods: A database of patients undergoing lower extremity endovascular interventions between 1999 and 2009 was retrospectively queried. Patients with diabetes and tissue loss (Rutherford five and six) were identified and categorized by their eGFR ( ≥ 60 or <60 ml/min or on renal replacement therapy [HD or PD). Patient orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated.
Results: 355 diabetic patients (61% male, age 67±14years) underwent lower extremity interventions for tissue loss. 17% had both SFA and tibial interventions. The average PREVENT III amputation risk score (PIII score) was 4.6±1.6 with 8% considered high risk. Technical success was 96%. Overall MACE was 3% and MALE was 24% at 30 days. Major amputation rate was 9% at 30 days. At 5 years, overall CE was 41±4%, (Mean±SEM), overall AFS 34±3% and overall MALE 45±4%. When stratified by eGFR and need for renal replacement therapy, those patients on HD had worse short-term and long-term outcomes (Table).

	eGFR≥ 60	eGFR<60	HD/PD
Number Limbs at Risk (n)	148	155	53
Gender (%)	60%	65%	49%**
Age (mean±SD) yrs	67±15	66±14	65±11
High Risk PIII score (%)	1%	0%	53%**
Mortality (%)	1%	3%*	4%*
Morbidity (%)	10%	11%	15%*
30day MACE (%)	1%	3%	6%**
30day-MALE (%)	24%	25%	25%
30day-Amputation Rate (%)	8%	8%	13%*
5yr-CE (Mean±SEM %)	48±5	40±6	23±9**
5yr-AFS (Mean±SEM %)	45±5	27±6*	18±7**
5yr-MALE (Mean±SEM %)	50±5	46±5	22±9**

Conclusions: Endovascular therapy for ulceration in diabetics is significantly influenced by chronic renal insufficiency with the maximal impact when on renal replacement therapy. There is a high MACE but 30day amputation rate. Longer-term outcomes remain very poor with less that a 25% success in patient-centered outcomes at 5 years.