Are there differences of inflammatory bio-markers between diabetic and non-diabetic patients with critical limb ischemia?

AIM: This observational study was undertaken in order to analyse whether any differences could be detected between diabetic and non-diabetic patients with critical limb ischemia (CLI) concerning the inflammatory response. METHODS: A total number of 259 consecutive patients with CLI were treated between October 2001 and January 2003. RESULTS: Among the 259 patients, 135 (52%) had diabetes, previously known in 123, and detected during hospitalization in 12. The diabetic patients more often showed gangrene (P<0.05) and infra-inguinal atherosclerosis (84% vs 67%, P=0.001). The patients with diabetes showed a better lipid profile (total cholesterol 4.6 vs 5 mmol/L, P=0.006 and lower LDL-cholesterol (2.7 vs 3.1 mmol/L, P=0.010) despite the same frequency of statin treatment. They showed a higher creatinine (149 vs 117 micromol/L, P=0.0003) than the non-diabetic patients. Of the inflammatory markers, C-reactive protein (CRP) was equally elevated in both groups. Tumor necrosis factor-a (TNF-a) was increased among the diabetic patients (2.6 vs 1.8 pg/mL, P<0.05), and this difference was most evident in those with gangrene. Neopterin was also higher among the diabetic patients (31 vs 21 mmol/L, P<0.01), but CD40L was not different between groups. CONCLUSIONS: Diabetes mellitus was very common in CLI patients, and more often combined with renal impairment and infra-inguinal atherosclerosis. The inflammatory markers TNF-a and neopterin were elevated in patients with diabetes as compared to non-diabetic patients, but this difference cannot explain why CLI is 10 times more frequent in diabetic patients.

Suboptimal treatment of risk factor for atherosclerosis in critical limb ischemia.

AIM: The epidemiology of critical limb ischemia (CLI) is insufficiently studied, and treatment of risk factors for atherosclerosis has received less attention in CLI patients than in patients with coronary or precerebral atherosclerosis. The aim of this study was to establish the incidence of CLI and the quality of risk factor treatment in Swedish CLI patients. METHODS: During 14 months, 316 consecutive CLI patients were referred to the Malmo Department of Vascular Diseases. Two hundred and fifty-nine (82%) consented to evaluation of intercurrent disease, medication, ankle and arm blood pressures (BP), plasma glucose and lipid levels, p-homocysteine, cardiolipin antibodies and activated protein C (APC)-resistance. RESULTS: The incidence of CLI was 38/100,000 inhabitants/year. Patient age was 75 +/- 10 years, and BP 147 +/- 26/75 +/- 14 mmHg. Systolic or diastolic BP above recommended levels (140/90 mmHg) occurred in 137 (53%) patients. P-cholesterol was 4.8+/-1.2 mMol/L, but cholesterol above recommended level (5 mMol/L) or LDL above recommended level (3 mMol/L) occurred in 125 (48%) patients. Only 24% of patients met national recommendations for both BP and lipid levels. Diabetes mellitus was previously known in 123 (47%) patients, and another 12 (5%) patients showed diabetic fasting glucose levels during the hospital stay. Eighty-four (32%) patients were active, and 72 (28%) were former smokers. Myocardial infarction or angina pectoris had previously been diagnosed in 123 (47%) patients. P-homocysteine was 17 +/- 7 _mol/l, cardiolipin antibodies occurred in 71 (27%) and APC-resistance in 34 (13%) patients. CONCLUSIONS: Patients with CLI show high comorbidity in vascular diseases and high prevalence of modifiable risk factors for atherosclerotic vascular disease. The use of evidence-based medical therapy is suboptimal in this high-risk group.

Platelet and leukocyte activation during aortoiliac angiography and angioplasty.

OBJECTIVE: to evaluate platelet and leukocyte activation during aortoiliac angiography and percutaneous transluminal angioplasty (PTA). METHODS: an observational study of 14 patients with aortoiliac atherosclerotic disease, nine of whom underwent PTA. The proportion of fibrinogen-, and P-selectin positive platelets, P-selectin expression on platelets, intraplatelet cGMP and cAMP, CD18 positive granulocytes, CD18 expression on granulocytes, plasma (p)-neopterin, p-TNF alpha and p- interleukin-6 were repeatedly measured in arterial blood during angiography and in venous blood before and after. RESULTS: compared to a previous venous sample, arterial intraplatelet cAMP was increased proximal to the atherosclerotic lesion before contrast infusion and PTA (median 18 [range: 14-22] vs 16 [15-21] pmol/10(9) platelets p<0.05), and intraplatelet cGMP was increased proximal to the lesion after contrast infusion and PTA (1.2 [0.8-3.9] vs 0.9 [0.6-2.5] pmol/10(9) platelets p<0.05). Four hours after angiography, both the proportion of P-selectin positive platelets (28[11-55]%) and platelet P-selectin expression (9[6-40]) had decreased (p<0.05), from arterial values distal to the lesion before contrast infusion and PTA (57 [24-78]% and 26 [10-83]). Granulocyte CD18 expression was lower during angiography than in a previous venous sample. CONCLUSIONS: the results are compatible with platelet but not leukocyte activation during peripheral angiography.