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Vrsalovic M, Vucur K, Vrsalovic Presecki A, Fabijanic D, Milosevic M. Impact of diabetes on mortality in peripheral artery disease: a meta-analysis. Clin Cardiol 2016; 40:287-291. [PMID: 28026025 DOI: 10.1002/clc.22657] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/07/2016] [Accepted: 11/11/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND There are accumulating studies showing the association between diabetes and all-cause mortality in peripheral vascular disease. However, the results in these studies are conflicting regarding the impact of diabetes on outcome. HYPOTHESIS Diabetes is associated with increased risk of mortality in peripheral artery disease. METHODS Using MEDLINE and Scopus, we searched for studies published before January 2016. Additionally, studies were identified by manual search of references of original articles or review studies on this topic. Of the 1072 initially identified records, 21 studies with 15,857 patients were included in the final analysis. RESULTS Diabetes was associated with a statistically significant increased risk of all-cause mortality (odds ratio: 1.89, 95% confidence interval: 1.51-2.35, P < 0.001), without detected publication bias (Egger bias = 0.75, P = 0.631). The stronger effect on outcome was obtained in patients with critical limb ischemia (odds ratio: 2.38, 95% confidence interval: 1.22-4.63, P < 0.001) as the most severe form of peripheral vascular disease. CONCLUSIONS Diabetes is associated with an increased risk of mortality in peripheral vascular disease, and the effect is even more pronounced in patients with critical limb ischemia.
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Affiliation(s)
- Mislav Vrsalovic
- University of Zagreb, School of Medicine, Zagreb, Croatia.,Department of Vascular Medicine, Cardiovascular Center, Sisters of Charity University Hospital Center, Zagreb, Croatia
| | - Ksenija Vucur
- Department of Nephrology, University Hospital Merkur, Zagreb, Croatia
| | | | - Damir Fabijanic
- Department of Cardiology, University Hospital Centre Split, School of Medicine, University of Split, Split, Croatia
| | - Milan Milosevic
- University of Zagreb, School of Medicine, Zagreb, Croatia.,Andrija Stampar School of Public Health, Zagreb, Croatia
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2
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Ballotta E, Toniato A, Piatto G, Mazzalai F, Da Giau G. Lower extremity arterial reconstruction for critical limb ischemia in diabetes. J Vasc Surg 2014; 59:708-19. [DOI: 10.1016/j.jvs.2013.08.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 10/25/2022]
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3
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Tenna AS, Watson A, Stansby G. Revascularization for Critical Limb Ischemia in Diabetes. Angiology 2013; 65:272-3. [DOI: 10.1177/0003319713494465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Adriano Sala Tenna
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Alex Watson
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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4
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Oberhuber A, Benecke B, Orend KH, Hutschenreiter S, Muehling BM. The diabetic patient has a higher benefit from infrapopliteal revascularization than the non-diabetic patient: a 10-year retrospective study. Diab Vasc Dis Res 2013; 10:78-83. [PMID: 22505398 DOI: 10.1177/1479164112442076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of this article is to evaluate the limb salvage and patency rates after crural arterial revascularization, differences between graft material and co-morbidities. PATIENTS AND METHODS All patients with crural artery bypasses were analysed retrospectively in a single centre (Department of Vascular Surgery, Thüringen Kliniken Saalfeld, Rudolstadt, Germany) over a 10-year period (1996-2006); 157 patients with 170 consecutive arterial reconstructions could be included. RESULTS Follow-up time was 55 months (6-119). Median age of the 56 women and the 101 men at the time of operation was 70 years (45.6-93.6). The five-year secondary patency rates were 71.5 ± 6.22% (vein), 44.3 ± 10.8% (composite; p = 0.0011), 52.6 ± 13.4% (prosthetic graft with distal vein cuff/patch; p = 0.00953) and 42 ± 12% (prosthetic graft without distal vein cuff/patch; p = 0.00443). Limb salvage rates after five years were 79.5 ± 5.8%, 61.6 ± 10.3%, 77.9 ± 11.3% and 70.1 ± 14.7%, respectively. Cumulative limb salvage rate was significantly higher in diabetic patients (78.9 ± 4.9%), than in non-diabetic patients (66.6 ± 6.8); p = 0.023. CONCLUSION Crural reconstruction is a suitable method for peripheral arterial occlusive disease to prevent amputation, particularly in diabetics.
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Affiliation(s)
- Alexander Oberhuber
- Department of Vascular Surgery, University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
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5
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Mutirangura P, Ruangsetakit C, Wongwanit C, Sermsathanasawadi N, Chinsakchai K. Comparative study of the management of diabetic versus nondiabetic patients with atherosclerosis obliterans of the lower extremities. Vascular 2009; 16:333-9. [PMID: 19344591 DOI: 10.2310/6670.2008.00062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to identify the influence of diabetes mellitus on patients with atherosclerosis obliterans (ASO) of the lower extremities. A prospective study was designed to compare differences between ASO patients with and without diabetes mellitus in regard to clinical characteristics and outcomes of management. Two hundred fifty-three consecutive (61.1%) diabetic and 161 (38.9%) nondiabetic patients were included in this study. Crural artery occlusion occurred more frequently in diabetic patients (tibioperoneal segment 26.5% vs 14.3%; p = .003). Diabetic patients had higher comorbidities, such as ischemic heart disease, disabling stroke, and renal failure. Infection requiring urgent surgical intervention was higher in diabetic patients (39.1% vs 24.2%; p = .001). This required primary major amputation in limb-threatening ischemia superimposed with infection (27.6% vs 17.7%; p = .037). The feasibility (67.2% vs 69.8%; p = .651) and success (74.4% vs 79.0%; p = .481) of revascularization between the two groups were comparable. Diabetic patients often needed more distal revascularization for limb salvage (34.4% vs 18.5%; p = .019). The mortality rate after revascularization was higher in diabetic patients (13.3% vs 2.5%; p = .009). Diabetes mellitus per se has no direct impact on limb salvageability in limb-threatening ischemia. The parity of feasibility and success in revascularization between the two groups should encourage attempts at limb salvage revascularization in diabetic patients.
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Affiliation(s)
- Pramook Mutirangura
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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6
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Paraskevas KI, Baker DM, Pompella A, Mikhailidis DP. Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview. Ann Vasc Surg 2008; 22:481-91. [DOI: 10.1016/j.avsg.2007.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 12/26/2007] [Indexed: 10/21/2022]
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7
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Rivolta N, Piffaretti G, Tozzi M, Lomazzi C, Maida S, Riva F, Buscarini E, Castelli P. Two-stage treatment for diabetic foot: Surgical peripheral revascularization and minor amputation in day-surgery admission. Int J Surg 2008; 6 Suppl 1:S75-7. [DOI: 10.1016/j.ijsu.2008.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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8
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Fatourou EM, Paraskevas KI, Seifalian AM, Hamilton G, Mikhailidis DP. The role of established and emerging risk factors in peripheral vascular graft occlusion. Expert Opin Pharmacother 2007; 8:901-11. [PMID: 17472536 DOI: 10.1517/14656566.8.7.901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Several studies have evaluated the association between established as well as emerging vascular risk factors with peripheral graft occlusion. There is evidence for a link between the risk for graft occlusion and total serum cholesterol, low-density lipoprotein cholesterol and triglyceride levels. The overall effect of smoking shows a 2.35-fold increase in risk of graft failure. Studies involving diabetic patients undergoing peripheral bypass may have failed to detect higher occlusion rates, possibly due to increased morbidity and mortality as well as higher amputation rates even if the graft is patent. Both antiplatelet agents and anticoagulation seem to be effective in the prevention of graft occlusion. Unconvincing data have been published with regards to the effect of hypertension on graft patency. Emerging factors such as fibrinogen, lipoprotein (a), C-reactive protein and homocysteine levels should also be considered when assessing the risk of graft occlusion. More research is needed to prevent graft occlusion due to the obvious clinical relevance, quality of life and cost issues.
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Affiliation(s)
- E M Fatourou
- Department of Clinical Biochemistry, Royal Free Hospital and Royal Free University College Medical School, London, UK
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9
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Awad S, Karkos CD, Serrachino-Inglott F, Cooper NJ, Butterfield JS, Ashleigh R, Nasim A. The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia. Eur J Vasc Endovasc Surg 2006; 32:51-9. [PMID: 16488631 DOI: 10.1016/j.ejvs.2005.12.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 12/23/2005] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon. METHODS Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival. RESULTS Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% (p = ns in all). There were eight deaths (7%) within 30-days. At follow-up (1-44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p = 0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p = 0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p = 0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p = 0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p = 0.15). CONCLUSIONS In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.
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Affiliation(s)
- S Awad
- Department of Vascular and Endovascular Surgery, Leicester Royal Infirmary, University of Leicester, Leicester, UK
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10
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Zaragozá-García J, Plaza-Martínez A, Blanes-Mompó J, Briones-Estébanez J, Martínez-Parreño C, Gómez-Palonés F, Martínez-Perelló I, Crespo-Moreno I, Martínez-Meléndez S, Torres A, Ortiz-Monzón E. Influencia de la diabetes mellitus en la permeabilidad y tasa de salvamento de extremidad de los bypasses distales a arterias perimaleolares en la isquemia crítica de las extremidades inferiores. ANGIOLOGIA 2006. [DOI: 10.1016/s0003-3170(06)75006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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11
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Saucy F, Dischl B, Delachaux A, Feihl F, Liaudet L, Waeber B, Corpataux JM. Foot skin blood flow following infrainguinal revascularization for critical lower limb ischemia. Eur J Vasc Endovasc Surg 2005; 31:401-6. [PMID: 16359880 DOI: 10.1016/j.ejvs.2005.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 10/17/2005] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The aim of this study was to assess the blood flow in the feet before and after lower limb revascularization using laser Doppler imaging (LDI). METHODS Ten patients with critical lower limb ischemia were prospectively enrolled from June to October 2004. All patients underwent successful unilateral surgical interventions including above-knee bypass, distal bypass and endarterectomy. Skin blood flow (SBF) over the plantar surface of both forefeet and heels was measured by LDI 24h before and 10 days after revascularization, expressed in perfusion units (PU), and reported as mean+/-SD. RESULTS Measurements in the forefoot and heel were similar. Before revascularization mean SBF was significantly lower in the ischemic foot (130+/-71 PU) compared to the contralateral foot (212+/-68 PU), p<0.05. After revascularization a significant increase of the SBF in the forefoot (from 135+/-67 to 202+/-86 PU, p=0.001) and hindfoot (from 148+/-58 to 203+/-83, p=0.001) was observed on the treatment side. However, a large decrease of the SBF was seen in forefoot and hindfoot on the untreated side (from 250+/-123 PU to 176+/-83 and from 208+/-116 to 133+/-40, p=0.001, respectively). CONCLUSION This study confirms the benefits of revascularization in patients with nonhealing foot lesions due to critical limb ischemia. A significant increase of the SBF was observed on the treatment side. However, an unexpected decrease was observed on the untreated side.
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Affiliation(s)
- F Saucy
- Vascular and Thoracic Surgery Service, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne-CHUV, Switzerland.
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12
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Weiss JS, Sumpio BE. Review of prevalence and outcome of vascular disease in patients with diabetes mellitus. Eur J Vasc Endovasc Surg 2005; 31:143-50. [PMID: 16203161 DOI: 10.1016/j.ejvs.2005.08.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 08/27/2005] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- J S Weiss
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, CT 06520, USA
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13
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Georgopoulos S, Filis K, Vourliotakis G, Bakoyannis C, Papapetrou A, Klonaris C, Papalambros E, Bastounis E. Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile? ACTA ACUST UNITED AC 2004; 99:c37-41. [PMID: 15627791 DOI: 10.1159/000082865] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2003] [Accepted: 07/08/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. METHODS A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. RESULTS Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. CONCLUSION Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.
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Affiliation(s)
- S Georgopoulos
- Division of Vascular Surgery, First Department of Surgery, University of Athens Medical School, Athens, Greece
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Virkkunen J, Heikkinen M, Lepäntalo M, Metsänoja R, Salenius JP. Diabetes as an independent risk factor for early postoperative complications in critical limb ischemia. J Vasc Surg 2004; 40:761-7. [PMID: 15472606 DOI: 10.1016/j.jvs.2004.07.040] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the significance of diabetes mellitus as a risk factor for postoperative major morbidity and mortality after surgery for critical lower limb ischemia (CLI). SUBJECTS A national vascular registry (Finnvasc)-based survey included 5709 operations for CLI from 1991 through 1999. Of these operations, 2508 (44%) were performed on diabetics. Tissue loss was the indication for surgery in 77% of diabetics and in 52% of nondiabetics. The proportion of femorodistal bypasses was 43% in diabetics and 24% in nondiabetics, whereas the proportion of reconstructions for aortofemoral arterial occlusive disease was 16% in diabetics and 34% in nondiabetics. RESULTS Thirty-day mortality was 4.5% in diabetics and 3.4% in nondiabetics ( P = .05). The rate for early below-knee amputation was 6.5% in diabetics and 3.3% in nondiabetics ( P < .001). Independent factors for postoperative death were aortofemoral reconstruction (odds ratio [OR], 4.0), preoperative cardiac risk factor (OR, 3.1), primary surgery (OR, 2.0), renal insufficiency (OR, 1.9), urgent surgery (OR, 1.7), and age (OR, 1.3). Diabetes was an independent risk factor for postoperative below-knee amputation (OR, 1.7), cardiac complications (OR, 1.5), and superficial wound infection (OR, 1.3). There was an inverse association between diabetes and acute graft occlusion (OR, 0.8). Independent risk factors for early postoperative mortality in diabetes were aortofemoral reconstruction (OR, 2.5), urgent surgery (OR, 2.0), male gender (OR, 2.0), renal insufficiency (OR, 1.9), cardiac risk factor (OR, 1.7), and age (OR, 1.4). In nondiabetics independent risk factors for early postoperative mortality were aortofemoral reconstruction (OR, 4.5), cardiac risk factor (OR, 3.6), primary surgery (OR, 2.6), and extra-anatomic bypass (OR, 2.3). CONCLUSIONS Diabetes was not an independent risk factor for early postoperative mortality in CLI as there was an increased morbidity in diabetics associated with old age, male gender, known coronary artery disease, and renal insufficiency, as well as urgent surgery. As diabetics have increased proclivity for these factors, special attention needs to be paid to their preoperative assessments.
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Affiliation(s)
- Jyrki Virkkunen
- Department of Surgery, Central Hospital for Central Finland, Jyväskylä.
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Lazaris AM, Tsiamis AC, Fishwick G, Bolia A, Bell PRF. Clinical Outcome of Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients With Critical Lower Limb Ischemia. J Endovasc Ther 2004; 11:447-53. [PMID: 15298514 DOI: 10.1583/03-1159.1] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the clinical outcome of subintimal angioplasty in diabetic patients with critical limb ischemia (CLI) compared to nondiabetics irrespective of the patency status of the treated arteries. METHODS The records of 99 consecutive patients (53 men; median age 78.5 years, range 42-92) suffering from CLI who underwent primary infrainguinal subintimal angioplasty in 112 limbs within a 6-month period were studied retrospectively. A third of the patients (n=33) were diabetic. The technical success, perioperative morbidity/mortality, and clinical success were compared between the diabetic and nondiabetic patients. Kaplan-Meier life-table analysis was used to analyze clinical success, limb salvage, and survival for both groups. RESULTS The overall technical success was 89% (81% in diabetics, 93% in nondiabetics, p=0.05). Perioperative morbidity was 8% (16.7% in diabetics, 3.9% in nondiabetics, p=0.03). The perioperative mortality was zero. The clinical success at 12, 24, and 36 months was 74%, 72%, and 65% in nondiabetics and 69%, 63%, and 54% in diabetics, respectively (p=0.17). The limb salvage rate at 36 months was 88% overall (90% in nondiabetics, 82% among diabetics, p=0.20). The 36-month survival rate was 61% in nondiabetics and 57% in diabetics (p=0.29). CONCLUSIONS In terms of clinical outcome, infrainguinal subintimal angioplasty is almost equally effective in diabetics as in nondiabetics suffering from CLI.
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Affiliation(s)
- Andreas M Lazaris
- Department of Surgery, Leicester Royal Infirmary, Leicester, England, UK.
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AhChong AK, Chiu KM, Wong MWC, Hui HK, Yip AWC. Diabetes and the outcome of infrainguinal bypass for critical limb ischaemia. ANZ J Surg 2004; 74:129-33. [PMID: 14996159 DOI: 10.1046/j.1445-2197.2004.02915.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM To examine the influence of diabetes mellitus (DM) on the outcome of infrainguinal bypass operations performed for critical foot ischaemia in Chinese patients. METHODS A prospective audit of 265 consecutive infrainguinal bypass operations. RESULTS Diabetic patients suffered more frequently from ischaemic heart disease (48% vs 25%, P=0.001) and tissue loss (90% vs 79%, P=0.01) at presentation. Cigarette smoking was more prevalent in the non-diabetic (NDM) group (72% vs 51%, P=0.001). Arterial segments distal to the common femoral artery were more often used as inflow to bypass graft in DM patients (36% vs 22%, P=0.02). Operative mortality (seven DM vs one NDM, P=0.19). Early graft failure (7% in DM group vs 10% in NDM group, P=0.24), wound infection rate (24% in DM group vs 17% in NDM group, P=0.21), early limb loss (9% in DM group vs 6% in NDM group, P=0.66) were comparable. However, hospital mortality was higher in DM patients (8% vs 1%, P=0.04). DM patients more frequently required further surgical debridement postoperatively (20% vs 9%, P=0.04). Long-term, patient survival was inferior in the DM group (43% NDM vs 33% DM at 5 years, P=0.03). Primary graft patency (46% DM vs 34% NDM at 4 years P=0.19), secondary graft patency (57% DM vs 47% NDM at 4 years P=0.14) and limb salvage rate (78% vs 81% at 5 years, P=0.79) were comparable. CONCLUSION Diabetes mellitus adversely affects hospital mortality and long-term survival. Graft patency and limb salvage are not compromised by the presence of DM.
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Affiliation(s)
- Ah Kian AhChong
- Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong.
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17
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Wölfle KD, Bruijnen H, Loeprecht H, Rümenapf G, Schweiger H, Grabitz K, Sandmann W, Lauterjung L, Largiader J, Erasmi H, Kasprzak PM, Raithel D, Allenberg JR, Lauber A, Berlakovich GM, Kretschmer G, Hepp W, Becker HM, Schulz A. Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis. Eur J Vasc Endovasc Surg 2003; 25:229-34. [PMID: 12623334 DOI: 10.1053/ejvs.2002.1849] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.
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Affiliation(s)
- K D Wölfle
- Klinik für Gefäss-und Thoraxchirurgie, Klinikum Augsburg, Chirurgische Universitätsklinik, Düsseldorf, Germany
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18
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Maharaj D, Ozsvath KJ, Darling RC, Roddy SP, Paty PSK, Krelenberg PB, Chang BB, Lloyd WE, Shah DM. Durability of the dorsalis pedis artery reconstruction in diabetics and nondiabetics: is there a difference? Ann Vasc Surg 2002; 16:102-7. [PMID: 11904813 DOI: 10.1007/s10016-001-0132-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Originally thought to be a disadvantaged outflow source, the dorsalis pedis artery is associated with excellent patency and limb salvage in the diabetic population. The aim of this study was to demonstrate that the dorsalis pedis artery is as durable in nondiabetics as in their diabetic counterparts. During a 21-year period from 1979 to 1999, 299 long lower limb bypasses to the dorsalis pedis artery were performed at our institution. Patient data and outcomes were reviewed from the vascular registry. Statistical analysis and patency rates were compared using chi-squared and log-rank analysis. This study confirms that the dorsalis pedis can be used as an outflow source with durability that is comparable in both diabetics and nondiabetics. No significant difference exists in morbidity, mortality and patency rates. In the nondiabetic, when the dorsalis pedis is the only patent distal vessel, amputation can be avoided if one considers this a suitable option as an outflow source.
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Affiliation(s)
- Dale Maharaj
- Institute for Vascular Health and Disease, Albany Medical College, NY 12208, USA
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19
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Calle-Pascual AL, Durán A, Diaz A, Moñux G, Serrano FJ, de la Torre NG, Moraga I, Calle JR, Charro A, Marañes JP. Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study. Diabetes Res Clin Pract 2001; 53:129-36. [PMID: 11403862 DOI: 10.1016/s0168-8227(01)00254-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- A L Calle-Pascual
- Servicio de Endocrinologia y Nutrición, 1aS Hospital Clínico San Carlos, Martín Lagos s/n, E-28040, Madrid, Spain.
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