Document Detail

Open bypass and endoluminal therapy: complementary techniques for revascularization in diabetic patients with critical limb ischaemia.
MedLine Citation:
PMID:  18384110     Owner:  NLM     Status:  MEDLINE    
The use of endovascular therapy (EVT) for lower extremity atherosclerosis is markedly increasing while open surgical bypass is in decline. The results of EVT for critical limb ischaemia (CLI) are difficult to evaluate, especially for patients with diabetes. To date, only one randomized, prospective trial has been published comparing EVT with open bypass for CLI. Although early costs and outcomes were equivalent or superior for EVT, after 2 years, surgery was associated with a significantly reduced risk of future amputation and death.Approximately, 40-50% of diabetic patients with CLI can be initially treated with EVT. Patients with Trans-Atlantic Inter-Society Consensus (TASC) A and B lesions should be treated endoluminally. EVT should be used with caution in patients with TASC C and D lesions; however, in selected patients, particularly if vein conduit is lacking and life expectancy is short, EVT is not unreasonable. For low-to-moderate risk patients with TASC C or D lesions, extensive tibial disease, and suitable vein conduit, surgical bypass remains the best limb preservation option. The primary therapeutic goals are relief of rest pain, healing of ischaemic lesions, and maintenance of functional status. Haemodynamic assessment is critical following both open and EVT for CLI and aids in determining the need for further revascularization; additional interventions are required in 20-30% of CLI patients depending on the degree of ischaemia, anatomical disease extent, and mode of initial therapy. At the University of Arizona, we currently recommend that TASC A and B CLI patients undergo EVT first. TASC C and D patients should undergo bypass unless available conduit is poor, surgical risk is prohibitive, or life expectancy is limited. CLI is a serious end-of-life condition given the sobering realization that only 50-55% of CLI patients are alive with an intact limb 5 years after initial presentation.
Joseph L Mills
Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  Diabetes/metabolism research and reviews     Volume:  24 Suppl 1     ISSN:  1520-7552     ISO Abbreviation:  Diabetes Metab. Res. Rev.     Publication Date:    2008 May-Jun
Date Detail:
Created Date:  2008-05-05     Completed Date:  2008-08-07     Revised Date:  2009-11-03    
Medline Journal Info:
Nlm Unique ID:  100883450     Medline TA:  Diabetes Metab Res Rev     Country:  England    
Other Details:
Languages:  eng     Pagination:  S34-9     Citation Subset:  IM    
University of Arizona Health Sciences Center, Tucson, Arizona, USA.
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MeSH Terms
Diabetic Angiopathies / surgery*
Diabetic Neuropathies / complications
Ischemia / diagnosis,  surgery*
Leg / blood supply*
Vascular Surgical Procedures* / methods

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