Infrainguinal revascularization in the diabetic patient

The Role of Distal Arterial Reconstruction in Patients With Diabetic Foot Ischemia

The diabetic foot, a common complication that affects patients with diabetes mellitus, is a therapeutic challenge. It places an increasing burden on society; the patient and caregivers as well as health care systems and clinicians are touched by this problem. The management of the diabetic foot with ischemia consequent to peripheral arterial disease is vexing, often leading to successive amputations. Surgical reconstruction of the peripheral arteries has always been a consideration, although the concept of coexistent small vessel disease has prejudiced the notion of offering reconstructive surgery to these patients. This article examines some of the literature relating to bypass surgery with a view to addressing the aforementioned notion. An appraisal of the literature suggests that vascular reconstructive surgery offers benefits to the diabetic patient, albeit these papers have weaknesses related to study design and methodology. Improved studies are indicated to address the role of bypass surgery to help the diabetic patient with foot complications; it is reasonable to hope that our understanding of the fundamental concepts of the pathogenesis of diabetic foot disease will also improve.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained.

RESULTS

A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05).

CONCLUSION

Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Long-term results following operation for diabetic foot problems: arterial disease confers a poor prognosis

OBJECTIVES

to describe the long-term outcome of local amputations and debridements of diabetic feet, with special reference to the presence or absence of arterial disease.

MATERIALS AND METHODS

a consecutive series of 75 diabetic patients having local foot surgery during 1987-92 was reviewed in 1998. A total of 136 operations had been done on 92 limbs, of which 52 (60%) had evidence of arterial disease. Survivors were interrogated in 1998, with follow-up intervals of 69-120 (median 92) months after their index operations.

RESULTS

complete healing occurred in 48% feet, and 36% limbs required major amputation, after 1 day-7 years (median 24 days). Major amputation was more common in limbs with arterial disease (52% vs. 18%) -p;<0.001. At follow-up 20 (27%) patients were alive (five lost to long-term follow-up) - five of 44 (11%) arteriopaths, and 15 of 26 (58%) of those without arterial disease (p<0.001). No patient who had arterial reconstruction at the outset survived to follow-up. Among the survivors, 78% feet had remained healed, with no recurrent ulceration.

CONCLUSIONS

among diabetics requiring local foot surgery, the presence of arterial disease confers a poor long-term prognosis for both life and limb. Those with neuropathy alone tend to do well with good foot care.

Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end-stage renal failure: analysis of 83 limbs

PURPOSE

Both end-stage renal disease and diabetes have been demonstrated to have a negative effect on the outcome of infrainguinal arterial reconstruction, primarily because of increased perioperative morbidity and wound complications. This study was undertaken to determine whether the combination of these comorbid factors affects the outcome of distal arterial reconstruction.

METHODS

Eighty-three distal lower extremity arterial bypasses originating from the femoral artery and terminating at the peroneal, anterior, or posterior tibial artery were performed on 76 patients over a 5-year period at a tertiary care medical center. Autogenous greater saphenous vein was used as the bypass conduit in all instances. Combined inflow and composite vein procedures were excluded.

RESULTS

There was one perioperative death, for a mortality rate of 1.2%. The diabetes mellitus (DM) plus end-stage renal disease (DM+ESRD) cohort displayed a significantly lower 1-year primary patency rate compared with the diabetes mellitus cohort, 53% versus 82% (p < 0.02). However, the limb salvage rate for the DM+ESRD and DM cohorts during the same time interval were not significantly different, 63% versus 84% (p < 0.06). The 52% 1-year survival rate for the DM+ESRD cohort was strikingly lower than the 90% 1-year survival rate for the DM cohort (p < 0.002).

CONCLUSION

Despite the use of the optimal autogenous conduit, the combination of diabetes and end-stage renal disease can be expected to significantly decrease primary graft patency without affecting limb salvage. The greatest effect of these comorbid factors is on patient survival.

Patients with diabetes and critical limb ischemia have a high peripheral vascular resistance

Results of infrainguinal bypass surgery may be better in diabetic patients compared with nondiabetic patients. One important determinator of outcome in these operations is the peripheral vascular resistance (PR). The aim of the present prospective study is to evaluate whether there is a difference in PR in diabetic and nondiabetic patients with critical limb ischemia. The two patient groups (n = 11 for each) were matched for toe pressure, age, gender, and outflow vessel, PR was measured intraoperatively during infrainguinal bypass surgery by controlled infusions of autologous blood. The resistance was significantly higher in the diabetic group (p < 0.05), as compared to the nondiabetic group. Except for fibrinogen that tended to be higher in diabetics (p = 0.07), blood parameters, blood pressures and angiographic scoring of run-off were similar in both groups. This finding of higher PR in diabetic patients with critical limb ischemia compared with matched nondiabetic ischemic patients suggests that a low PR is not the reason for the positive results of infrainguinal bypass surgery in diabetic patients.

The influence of the combined presence of diabetes mellitus and hypercholesterolaemia on the function and morphology of experimental vein grafts

OBJECTIVES

Diabetes and hypercholesterolaemia are known risk factors for the development of atherosclerosis and are considered to influence the development of vein graft intimal hyperplasia. This study examines the combined effect of diabetes for 12 weeks (alloxan-induced) and hypercholesterolaemia for 8 weeks (1% cholesterol diet) on the formation of intimal hyperplasia and the vasomotor function of vein grafts. MATERIALS AND DESIGN: Thirty-two New Zealand White rabbits underwent a carotid vein bypass graft. Eight were controls, eight were diabetic, eight were hypercholesterolaemic and eight had both diabetes and hypercholesterolaemia. All vein grafts were harvested at 4 weeks postoperatively for morphology (n = 4) or contractility studies (n = 4).

RESULTS

Compared to controls, both diabetes and hypercholesterolaemia increased intimal thickness by 20% and 63% respectively; medial thicknesses of these vein grafts were unchanged compared to control. In contrast, diabetes with hypercholesterolaemia dramatically increased intimal and medial thickness (1.8 fold and 1.6 fold respectively, compared to control). Smooth muscle cell contractility was enhanced in both the diabetic and hypercholesterolaemic groups. The presence of diabetes with hypercholesterolaemia did not further alter the enhanced smooth muscle cell contractile responses.

CONCLUSIONS

This study suggests that the combination of both the atherogenic risk factors, hypercholesterolaemia and diabetes, significantly augments the formation of intimal hyperplasia in experimental vein grafts.