Is diabetes mellitus a risk factor for carotid endarterectomy? A prospective study

Outcomes for Adults with Metabolic Syndrome Undergoing Elective Carotid Endarterectomy

BACKGROUND

Metabolic syndrome (MetS) is a disorder characterized by a constellation of cardiometabolic risk factors including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance that has been associated with adverse perioperative outcomes. We evaluated outcomes for patients with MetS after carotid endarterectomy (CEA) in the largest population to date.

METHODS

We performed a matched cohort analysis using clinical data from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program. We used propensity scores to match patients to attain covariate balance and used logistic regression to assess odds of unfavorable outcomes, including a predefined primary outcome of composite cardiovascular incident.

RESULTS

We identified 50,423 eligible adult patients, of whom 14.2% qualified for MetS (n = 7156). Patients with MetS tended to have CEA at an earlier age, more functional dependence, and longer operative durations. After matching, MetS remained associated with the primary outcome of combined cardiovascular incident (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.18-1.72; P < 0.001), stroke (OR, 1.44; 95% CI, 1.12-1.85; P = 0.004), prolonged length of stay (OR, 1.31; 95% CI, 1.18-1.44; P < 0.001), and discharge to facility (OR, 1.32; 95% CI, 1.08-1.61; P = 0.007). We also found that obesity alone is protective against combined cardiovascular incident, whereas hypertension with diabetes and MetS increase odds of a cardiovascular complication.

CONCLUSIONS

Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.

Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre

PURPOSE

This single centre study investigates the influence of diabetes mellitus on outcomes following carotid artery endarterectomy or stenting.

METHODS

In total, 752 carotid revascularizations (58.2% carotid artery stenting and 41.8% carotid endarterectomy) were performed in 221 (29.4%) patients with diabetes and 532 (70.6%) patients without diabetes. The study outcomes were death, disabling and non-disabling stroke, transient ischaemic attack and restenosis within 36 months after the procedure.

RESULTS

Patients with diabetes had higher periprocedural risk of any stroke or death (3.6% diabetes vs 0.6% no diabetes; p < 0.05), transient ischaemic attack (1.8% diabetes vs 0.2% no diabetes; p > 0.05) and restenosis (2.7% diabetes vs 0.6% no diabetes; p < 0.05). During long-term follow-up, there were no significant differences in Kaplan-Meier estimates of freedom from death, any stroke and transient ischaemic attack, between people with and without diabetes for each carotid artery stenting and carotid endarterectomy subgroup. Patients with diabetes showed higher rates of restenosis during follow-up than patients without diabetes (36-months estimate risk of restenosis: 21.2% diabetes vs 12.5% no diabetes; p < 0.05).

CONCLUSION

The presence of diabetes was associated with increased periprocedural risk, but no further additional risk emerged during longer term follow-up. Restenosis rates were higher among patients with diabetes.

Diabetes Mellitus with Chronic Complications in Relation to Carotid Endarterectomy and Carotid Artery Stenting Outcomes

BACKGROUND

Carotid endarterectomy and carotid artery stenting are effective treatment procedures for carotid artery stenosis. Although diabetes mellitus is highly prevalent among patients undergoing these revascularization procedures, few studies have examined their impact on periprocedural outcomes.

OBJECTIVES

The study aimed to determine whether perioperative outcomes among patients undergoing carotid artery stenting and carotid endarterectomy varied depending on the presence of diabetes with or without chronic complications.

METHODS

We examined adults aged 45 and above hospitalized between 2007 and 2011 in U.S. hospitals who underwent carotid artery revascularization procedures. We used data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample and evaluated the influence of diabetes with or without chronic complications on outcomes.

RESULTS

Among patients receiving carotid artery stenting, diabetic patients with chronic complications had significantly increased odds of acute kidney injury (odds ratio [OR]: 3.17, 95% confidence interval [CI]: 2.31-4.35) and longer hospital stay (β: 1.98, 95% CI: 1.58-2.38) compared with nondiabetic patients. Diabetic patients with chronic complications receiving carotid endarterectomy experienced increased odds of myocardial infarction (OR: 1.12, 95% CI: .90-1.40), stroke (OR: 1.29, 95% CI: .97-1.72), perioperative infection (OR: 2.45, 95% CI: 1.29-4.65), mortality (OR: 1.48, 95% CI: 1.01-2.16), and longer hospital stay (β (days): 2.05, 95% CI: 1.90-2.20) compared with nondiabetic patients. No significant increased odds of perioperative outcomes were observed among diabetic patients without chronic complications.

CONCLUSIONS

Uncomplicated diabetes did not appear to convey a higher odds of perioperative outcomes among patients undergoing revascularization. However, the presence of diabetes with chronic complications is an important risk factor in the carotid endarterectomy category.

The perioperative outcomes of eversion carotid endarterectomy in diabetic patients aged 80 years or older

BACKGROUND

Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years.

METHODS

Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting.

RESULTS

Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance.

CONCLUSIONS

Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.

Successful Management of Carotid Stenosis in a High-Risk Population at an Inner-City Hospital

This is a retrospective review of all carotid endarterectomies (CEA) (n=91) done from 1993 to 2002 at an inner-city hospital (Group I). This group was compared to a randomly selected group of patients (n= 445) treated at a private hospital (Group II). The same high-volume surgeons performed CEAs at both hospitals. The majority of Group I patients (71.4%) were members of racial minority groups. They were also more likely to be younger (p<0.001), hypertensive (p< 0.03), diabetic (p< 0.001), and current smokers (p< 0.001); have contralateral carotid artery occlusion (p=0.04); and present with stroke (p<0.001) than Group II patients. Despite this, the incidence of postoperative myocardial infarction (2.2% vs 0.2%, p= 0.08), stroke (1.1% vs 1.6%, NS), and death (1.1% vs 0%, NS) was comparable between the 2 groups. Aggressive preoperative workup for occult cardiac disease in Group I revealed an incidence of 25.9% (n=15). Of these, 5 (33.3%) were found to have coronary artery disease severe enough to warrant intervention before CEA. In an inner-city population with increased medical comorbidities, more severe cerebrovascular disease, and relatively low volume of carotid surgery, the results of CEA were comparable to those in patients treated at a high-volume private hospital. The presence of high-volume surgeons, operating at the low-volume municipal hospital, may contribute to the low complication rate. Finally, aggressive preoperative cardiac workup in this underserved population revealed a meaningful incidence of occult coronary artery disease requiring intervention before CEA.

Factors Affecting Recurrent Carotid Stenosis

Recurrent carotid stenosis is an ongoing process that may develop at or near the site of an operational or interventional procedure to treat an atheromatous stenosis. Although such a restenosis is most often initially without symptoms, as the disease progresses it may become symptomatic, and thus endanger the patient's life. Such patients are therefore candidates for revisional surgery. Extensive research investigation and numerous studies have incriminated several risk factors as predisposing conditions for recurrent carotid stenosis. The definite role of each predisposing factor, however, is still widely debated. Clarifying the extent of involvement of each factor in the pathogenesis of carotid restenosis is indeed demanding, as it would contribute enormously to the identification of the group of high-risk patients, and, therefore, determine the therapeutic approach in these patients.

Characteristics that define high risk in carotid endarterectomy from the Vascular Study Group of New England

OBJECTIVE

The Stenting with Angioplasty and Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial compared carotid endarterectomy (CEA) to carotid artery stenting (CAS) among high-risk patients using a model of risk that has not been validated by previous publications. The objective of our study was to determine the accuracy of this high-risk model and to determine the true risk factors that result in patients being at high risk for CEA.

METHODS

Prospectively collected data for 3098 CEAs between 2003 and 2011 at 20 Vascular Surgery Group of New England (VSGNE) centers were used. SAPPHIRE general inclusion criteria and primary outcomes were assessed. Factors that were associated with the primary outcome by analysis of variance (P < .10) and not linearly dependent, as determined by a Pearson correlation analysis, were further assessed for an independent association by multivariate logistic regression. A risk index model was developed for these significant predictors to accurately define high-risk CEA.

RESULTS

The average patient age was 69.9 ± 9.5 years, 60% were male, and 45.7% were asymptomatic. The 1-year composite outcome event rate, defined as postoperative myocardial infarction and stroke or death, was 14.2%. Multivariate analysis (P < .05) found the following independently significant risk factors: age in years (95% confidence interval [CI], 1.0-1.1; P < .001), preadmission living in a nursing home (95% CI, 1.2-6.6; P = .020), congestive heart failure (95% CI, 1.4-2.8; P < .001), diabetes mellitus (DM; 95% CI, 1.1-1.3; P < .001), chronic obstructive pulmonary disease (95% CI, 1.2-1.5; P < .001), any previous cerebrovascular disease (95% CI, 1.1-1.9; P = .003), and contralateral internal carotid artery stenosis (95% CI, 1.0-1.2; P = .001). Three of the SAPPHIRE high-risk criteria-abnormal stress test, recurrent stenosis after CEA, and previous radiotherapy to the neck-were not independently associated with an adverse outcome. Independently significant risk factors not included in the SAPPHIRE criteria are inclusion of ages <80 years, preadmission living in a nursing home, DM, contralateral carotid stenosis, and any previous cerebrovascular accident. The risk index predictors are age in years (40-49: 0 points; 50-59: 2 points; 60-69: 4 points; 70-79: 6 points; 80-89: 8 points), living in a nursing home (4 points), any cardiovascular disease (2 points), congestive heart failure (5 points), chronic obstructive pulmonary disease (3 points), DM (2 points), degree of contralateral stenosis (<50%: 0 points; 50%-69%: 1 point; 70%-near occlusion: 2 points; occlusion: 3 points). High-risk CEA is defined as >13 points, representing adverse outcome rate of 22.5%.

CONCLUSIONS

SAPPHIRE and other previously reported high-risk CAS inclusion criteria do not include all of the factors found to be independently associated with outcomes. Further studies are required to determine whether CAS is inferior to CEA in high-risk patients using a validated model of risk. In addition, this preoperative assessment includes novel criteria that can be used to stratify risks.

MRI lesions after invasive therapy of carotid artery stenosis: a risk-modeling analysis

BACKGROUND

Diffusion-weighted imaging (DWI) abnormalities can frequently be detected after carotid endarterectomy (CEA) and carotid angioplasty with stent placement (CAS) of the carotid arteries. We looked for possible predictors for the development of DWI lesions during the intervention.

METHODS

We investigated 41 patients who underwent CAS without protection devices and 93 patients who underwent CEA. DWI studies were performed 1 day before and after the intervention.

RESULTS

Ischemic complications consisted of two strokes (2.2%) in the CEA group and one stroke (2.4%) in the CAS group. DWI lesions were detected in 28.0% of all patients after intervention. Using a multivariate regression analysis, diabetes mellitus (DM), hyperlipidemia, symptomatic stenosis, age and CAS were found to be significant predictors for the occurrence of DWI lesions.

CONCLUSIONS

DWI is an objective and highly sensitive method for monitoring interventions of the carotid arteries. Our results point to an increased risk of patients with diabetes and hyperlipidemia to develop DWI lesions during invasive therapy of the ICA.

The diagnosis and management of cerebrovascular disease in diabetes

Cerebrovascular disease is a leading cause of morbidity and mortality in diabetes. Compared with nondiabetic patients, diabetic patients have at least twice the risk for stroke, earlier onset of symptoms, and worse functional outcomes. Approximately 20 % of diabetic patients will die from stroke, making it one of the leading causes of death in this population. Effective strategies for primary and secondary prevention of stroke have been developed in research cohorts that included both diabetic and nondiabetic patients. Nevertheless, prevention in diabetes has some specific considerations. In this paper, we summarize evidence to guide the diagnosis and management of stroke in diabetic patients. We propose that diabetic stroke patients should have a robust risk assessment to target interventions, like other patients with cerebrovascular disease, but with special attention to glycemic control and lifestyle modification.

Preoperative assessment of adult patients for intracranial surgery

The preoperative assessment of the patient for neurosurgical and endovascular procedures involves the understanding of the neurological disease and its systemic presentation, and the requirements of the procedure. There is a wide spectrum of different neurosurgical disorders and procedures. This article provides an overview of the preoperative evaluation of these patients with respect to general principles of neuroanesthesia, and considerations for specific intracranial and vascular neurosurgical and interventional neuroradiological procedures.

Cardiovascular risk assessment of the diabetic patient undergoing major noncardiac surgery

Noncardiac surgery is associated with an increased risk for cardiovascular morbidity and mortality. It is important to stratify the risk of these patients for perioperative cardiac events. Diabetes, a presently rapidly expanding disease, is a major risk factor for cardiovascular morbidity and mortality. Importantly, silent ischemia is more common in diabetic patients than in the general population. When preoperative risk assessment identifies an increased risk, further cardiac testing is warranted. The most commonly used stress tests for detecting cardiac ischemia is treadmill or bicycle ergometry. However, patients undergoing noncardiac surgery frequently have limited exercise capacity due to co-morbidities. Pharmacologic testing, such as dobutamine stress echocardiography and dipyridamole myocardial perfusion scintigraphy can be performed in patients with limited exercise capacity. Non-invasive stress testing should be considered, especially in diabetic patients, to detect asymptomatic coronary artery disease. Furthermore, when an increased cardiac risk is assessed, two strategies could be used to reduce the incidence of perioperative cardiac events: 1) prophylactic coronary revascularization from which the value is still controversial, and 2) pharmacological treatment (with beta-blockers, statins and aspirin), associated with improved post-operative outcome.

Peripheral and cerebrovascular atherosclerotic disease in diabetes mellitus

Diabetes mellitus is frequently associated with atherosclerotic vascular disease involving the coronary, peripheral and cerebrovascular circulation. Compared with non-diabetic counterparts, peripheral arterial disease (PAD) in diabetic individuals is more diffuse and often involves the popliteal and below-knee arteries. The goal of treatment in diabetic patients with PAD, as in other patients with this condition, is to aggressively treat atherosclerotic risk factors to reduce future cardiovascular events as well as to improve symptoms of claudication and prevent limb amputation. Diabetes is also associated with a heightened risk of stroke which is a common cause of morbidity and mortality in diabetic individuals. Optimal blood pressure control is paramount in reducing the future risk of stroke in these patients. Clinicians need to be aware of the strong association between diabetes and non-coronary atherosclerosis and use appropriate medical and interventional treatments to reduce the associated disability and mortality in these patients.

Metabolic syndrome: A predictor of adverse outcomes after carotid revascularization

BACKGROUND

Metabolic syndrome (MetS) is rapidly increasing in prevalence and is associated with carotid plaque development and is a risk factor for stroke. The aim of this study is to describe the outcomes for patients with MetS after carotid revascularization (carotid endarterectomy [CEA] and carotid stenting [CAS]).

METHODS

A database of patients undergoing carotid revascularization for primary atherosclerotic lesions was queried from 1996 to 2006. MetS was defined as the presence of >or=3 of the following criteria: blood pressure >or=130 mm Hg/>or=90 mm Hg; Triglycerides >or=150 mg/dL; high-density lipoproteins (HDL) <or=50 mg/dL for women and <or=40 mg/dL for men; fasting blood glucose >or=110 mg/dL; or Body Mass Index (BMI) >or=30 kg/m(2). Multivariate and Kaplan-Meier analyses were performed to outcomes. The average follow-up period was 4.5 years. A major adverse event (MAE) was defined as the occurrence of stroke, myocardial infarction (MI), or death.

RESULTS

A total of 921 patients (mean age: 71 +/- 10 years; 64% male) underwent 750 CEAs and 171 CAS. Thirty-one percent were identified as having MetS, 48% were asymptomatic, 87% had hypertension, 27% had hyperlipidemia, 32% were considered diabetic, and 14% had chronic renal insufficiency. The morbidity and mortality rates for all patients were 16.9% and 1.1%, respectively. The 30-day combined stroke/death rate was 3.6%. The 30-day MAE rates were: 6.7% vs 3.3% for MetS vs No-MetS (P = .02). The 90-day MAE rates were 8.7% vs 4.9% for MetS vs No-MetS (P = .03). MetS patients were more likely to experience a complication than No-MetS patients (23% vs 14%, P = .001). By Kaplan-Meier analysis, there was no difference between MetS and No-MetS patients with respect to patency, restenosis, re-intervention, or survival, but a difference existed for freedom from stroke, MI, and MAE. The difference between stroke rates was maintained between MetS and No-MetS, when subgrouped by those with and without symptoms. For patients with diabetes mellitus (DM), those with MetS had a 68% and 410% higher risk of developing an MAE and MI, respectively. However, for patients without diabetes, MetS was not significantly associated with MAE, stroke, or MI. No factors were found to be significantly associated with risk of stroke in all cases (in all patients, patients with diabetes, and patients without diabetes).

CONCLUSION

MetS is prevalent among patients undergoing carotid revascularization. MetS patients are at a greater risk for perioperative morbidity as well as stroke, MI, and MAE during follow-up when compared to patients without MetS. Long-term stroke prevention is poor in the presence of MetS. MetS should be considered a significant risk factor for patients undergoing carotid revascularization.

Diabetes and asymptomatic carotid stenosis: does diabetic disease influence the outcome of carotid endarterectomy? A 10-year single center experience

BACKGROUND

Few studies have focused directly on carotid endarterectomy (CEA) in symptomatic and asymptomatic diabetic patients, reporting controversial outcome. We compared perioperative (30-day) and late outcomes in diabetic versus nondiabetic patients undergoing CEA for severe asymptomatic carotid disease.

METHODS

Over 10 years, data were prospectively collected for diabetic and nondiabetic patients undergoing CEA for asymptomatic severe carotid disease. All procedures were eversion CEA. All patients underwent concomitant neurologic follow-up and a duplex ultrasound scan at 1, 6, and 12 months, then yearly, after operation.

RESULTS

Of 391 CEAs performed on 374 patients, 112 (28.7%) were in diabetic patients. There were no perioperative deaths or strokes in either diabetic patients or nondiabetic patients. A significantly higher incidence of cardiac complications occurred in diabetic patients (P < .01). A complete follow-up (mean, 6.1 years) was obtained for 348 patients. No recurrent stenoses or late occlusions were diagnosed in diabetic or nondiabetic patients. At 10 years, the risk of death was up to 4.6 times higher in diabetic patients, with a significant prevalence of cardiac-related deaths (P < .01).

CONCLUSIONS

CEA can be performed with no perioperative stroke risk or mortality, for asymptomatic disease in both diabetic and nondiabetic patients. The absence of fatal strokes associated with a significantly higher risk of cardiac-related death in the long-term points to the need to improve prevention strategies for postoperative cardiac risk in diabetic patients.

Risk Estimates of Stroke After Coronary Artery Bypass Graft and Carotid Endarterectomy

Neurologic complications of cardiovascular surgeries are well documented in the literature. Neurologic deficits may be mild and reversible or may be associated with permanent neurologic deficit. The incidence and severity of such complications vary according to the type of surgical procedure and usually correlate with patients' preoperative general medical condition, duration of surgeries, and intraoperative complications.

Defining the high-risk patient for carotid endarterectomy: An analysis of the prospective National Surgical Quality Improvement Program database

BACKGROUND

Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector).

METHODS

National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated).

RESULTS

A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk reduction for stroke (17%), death (24%), cardiac event (33%), and the composite outcome (31%; odds ratio, 0.69; P = .008).

CONCLUSIONS

Carotid endarterectomy results across a spectrum of Veterans Affairs and private sector hospitals compare favorably to contemporary studies. These data will assist in selecting patients who are at an increased risk for adverse outcomes. Use of regional anesthetic significantly reduced perioperative complications in a risk-adjusted model, thus suggesting that it is the anesthetic of choice when CEA is performed in high-risk patients.

Diabetes mellitus and stroke

The aim of this article was to describe (i) the epidemiology and outcomes of stroke relating to diabetes; (ii) the pathophysiology of diabetes as a risk factor for stroke; (iii) the management of acute stroke in patients with diabetes; (iv) the evidence of primary and secondary prevention of stroke in patients with diabetes; and (v) the risk of new-onset diabetes using older antihypertensive agents. The combination of diabetes and stroke disease is a major cause of morbidity and mortality worldwide. Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target patients' cardiovascular (CV) risks in order to prevent the onset, recurrence and progression of acute stroke. Identification of at-risk patients with diabetes and metabolic syndrome has also allowed the delivery of early and effective intervention to reduce stroke risks, while active treatment during the acute phase of stroke will reduce long-term neurological and functional deficits. While the ongoing debate on the risk benefits of different antihypertensive, lipid-lowering and antiplatelet agents should not detract clinicians from pursuing aggressive CV risk reduction, the application of evidence-based medicine specifically in patients with diabetes will facilitate the use of appropriate agents to improve clinical outcomes. The overall management of patients with diabetes and acute stroke or at risk of secondary stroke should also include multifactorial intervention that not only targets patient's CV risk but also includes behavioural, lifestyle and, where appropriate, surgical intervention.

The safety of carotid endarterectomy in diabetic patients: clinical predictors of adverse outcome

OBJECTIVES

Patients with diabetes mellitus have been shown to have an increased incidence of complications after elective major vascular surgery. The objective of this study was to evaluate a large series of diabetic patients undergoing carotid endarterectomy (CEA) to determine if outcome differed from nondiabetic patients and to examine predisposing factors of poor outcome among diabetic patients.

METHODS

A retrospective review of a prospectively compiled database was performed. From 1992 through 2000, 2151 CEAs were performed at our institution. Of these, 507 were in diabetic patients (23.6%), and the remaining 1644 procedures were in nondiabetic patients (76.4%).

RESULTS

Diabetic patients were significantly more likely than nondiabetic patients to have hypertension (70.8% vs 64.5%, P = .01) and cardiac disease (54.6% vs 49.1%, P = .03). They were more likely than nondiabetic patients to be symptomatic before surgery (52.5% vs 47.1%, P = .04) and to have sustained a preoperative stroke (21.3% vs 17.7%, P = .07). No differences were noted in other recorded demographic factors or in intraoperative factors between diabetic and nondiabetic patients. Despite these differences, diabetic patients had similar perioperative outcomes compared with nondiabetic patients, including perioperative myocardial infarction (0.6% vs 0.4%, P = NS), perioperative death (0.8% vs 0.5%, P = NS), and perioperative neurologic events such as transient ischemic attack and stroke (3.2% vs 2.4%, P = NS). Among diabetic patients alone, cigarette smoking, general anesthesia, the use of a shunt, and the lack of clamp tolerance while under regional anesthesia predicted adverse perioperative neurologic outcome, and contralateral occlusion was associated with increased perioperative mortality.

CONCLUSIONS

Despite an increased prevalence of cardiac disease and preoperative neurologic symptoms among diabetic patients undergoing CEA, the rates of perioperative cardiac morbidity, mortality, and stroke were equal to nondiabetic patients. In contrast to nondiabetic patients, current cigarette smoking appeared to predict increased adverse neurologic outcomes among diabetic patients, and the presence of contralateral occlusion among diabetic patients appeared to predispose them towards increased perioperative mortality. The use of a general anesthetic appeared to increased perioperative neurologic risk among diabetic patients; however, this may be related to surgeon bias in the selection of anesthetic technique. Although diabetic patients may have an increase in complications after other major vascular surgical procedures, the presence of diabetes mellitus does not appear to significantly increase risk.

Review of prevalence and outcome of vascular disease in patients with diabetes mellitus

OBJECTIVES

Review the literature to determine the prevalence and outcome in patients with diabetes that undergo surgery to correct carotid artery stenosis, lower extremity arterial disease, and abdominal aortic aneurysm (AAA).

DESIGN AND MATERIALS

Studies were obtained from searches over the past 15 years on the National Library of Medicine's online search engine.

RESULTS

The review demonstrated an equivalent prevalence of carotid artery stenosis requiring surgery in patients with diabetes, it favored no increase risk of post-CEA stroke, and it was split on perioperative morbidity and mortality risk. There was an increase prevalence of lower extremity arterial disease requiring surgery in patients with diabetes, it favored equivalent patency and limb salvage rates, and it was split on the morbidity and mortality risk. The review demonstrated a decrease in AAA prevalence among patients with diabetes, it found an increase in the morbidity risk, and equivalent mortality risk.

CONCLUSIONS

Stroke, graft patency, and limb salvage rates in patients with diabetes after surgery are similar to patients without diabetes; however, their risk of complications is increased after surgery and the mortality risk may be higher after CEA.

Stroke in patients with diabetes and hypertension

Stroke is major public health problem leading to increased morbidity and mortality. Modifiable risk factors for stroke include hypertension, diabetes, atrial fibrillation, dyslipidemia, smoking, and alcohol abuse. Among these risk factors, diabetes and hypertension are rapidly growing epidemics leading to a substantial increase in cardiovascular disease and stroke. In this review, the authors discuss the risk factors for stroke with emphasis on the diabetic and hypertensive population, highlighting the interventions that have been shown to decrease stroke risk in this patient population.

Perioperative cardiovascular risk stratification of patients with diabetes who undergo elective major vascular surgery

BACKGROUND

The importance of diabetes mellitus (DM) as an independent risk factor for perioperative cardiac morbidity after vascular surgery is controversial. This study examined the impact of DM on perioperative outcomes and length of stay in patients who underwent major vascular surgery.

METHODS

Patients who underwent elective aortic reconstruction (n = 2792), lower extremity bypass (n = 3838), carotid endarterectomy (n = 5522), and major amputation (n = 3883) from 1997 to 1999 were identified in the National Surgical Quality Improvement Program database of the Department of Veterans Affairs. Outcomes assessed were death, cardiovascular complications (myocardial infarction, stroke, need for cardiopulmonary resuscitation), and length of stay. Multivariable logistic and linear regression models were used to control for patient demographics, procedure type, comorbidities, and diabetic complications.

RESULTS

Before adjustment for potential confounders, patients with diabetes had a higher incidence rate of perioperative death (3.9% versus 2.6%; P =.001) and cardiovascular complications (3.3% versus 2.6%; P =.01) when compared with patients without diabetes. After controlling for comorbid conditions, procedure type, and diabetic complications, only patients with DM who underwent treatment with insulin were at statistically increased risk for cardiovascular complications (odds ratio [OR], 1.48; 95% CI, 1.15 to 1.91). Neither DM treated with insulin (OR, 1.10; 95% CI, 0.85 to 1.41) nor DM treated with oral medications (OR, 0.96; 95% CI, 0.73-1.28) was an independent risk factor for death. Important independent risk factors for death included several conditions that are commonly associated with diabetes, including proteinuria, elevated creatinine level, history of congestive heart failure, and history of cerebrovascular accident. DM was also found to increase length of stay by as much as 38% even after adjustment for comorbidities.

CONCLUSION

Patients with diabetes have a higher incidence rate of death and cardiovascular complications. However, after controlling for specific comorbid conditions, the only independent association was between patients with insulin treatment and the risk of cardiovascular complications. DM does not appear to be an independent risk factor for postoperative mortality. All patients with diabetes, regardless of insulin use, have a prolonged length of stay after major vascular surgery.