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The influence of diabetes on short-term outcome following a prosthetic above-the-knee femoro-popliteal bypass.
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MedLine Citation:
PMID:  19575080     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVES: To assess the influence of diabetes mellitus on early morbidity and mortality following a femoro-popliteal bypass.
METHODS: Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass for atherothrombotic disease over a four-year period in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The patients were divided into two groups, diabetic and non-diabetic.
RESULTS: Two hundred and seventeen patient records were analysed; 102 (47%) patients were diabetic and 115 (53%) non-diabetic. The mean age in the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males and cigarette smokers in the non-diabetic group and hypertension among the diabetics. The prevalence of ischaemic heart disease in the two groups was not statistically significant. The majority of patients in both groups presented with critical limb ischaemia. Overall, 208 (96%) of the patients had their procedures performed using loco regional anaesthesia. The incidence of superficial wound infection between the two groups was not statistically significant. Deep infection, which necessitated removal of the graft, and cardiovascular complications were significantly higher in the diabetics. Four patients (3.9%) in the diabetic group and only one (0.9%) in the non-diabetic group died.
CONCLUSION: Diabetes mellitus significantly increases the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee femoro-popliteal bypass.
Authors:
T V Mulaudzi; J V Robbs; N Paruk; B Pillay; T E Madiba; V Govindsamy
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Cardiovascular journal of Africa     Volume:  20     ISSN:  1995-1892     ISO Abbreviation:  Cardiovasc J Afr     Publication Date:    2009 May-Jun
Date Detail:
Created Date:  2009-07-03     Completed Date:  2009-08-25     Revised Date:  2013-08-28    
Medline Journal Info:
Nlm Unique ID:  101313864     Medline TA:  Cardiovasc J Afr     Country:  South Africa    
Other Details:
Languages:  eng     Pagination:  170-2     Citation Subset:  IM    
Affiliation:
Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. mulaudzit@samedical.co.za
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MeSH Terms
Descriptor/Qualifier:
Aged
Blood Vessel Prosthesis Implantation / adverse effects*,  mortality
Cardiovascular Diseases / etiology
Databases as Topic
Diabetes Complications / etiology*,  mortality
Female
Femoral Artery / surgery*
Humans
Male
Middle Aged
Peripheral Vascular Diseases / complications,  mortality,  surgery*
Popliteal Artery / surgery*
Prosthesis-Related Infections / etiology
Reoperation
Retrospective Studies
South Africa / epidemiology
Surgical Wound Infection / etiology
Time Factors
Treatment Outcome
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-ta): Cardiovasc J Afr
Journal ID (iso-abbrev): Cardiovasc J Afr
Journal ID (publisher-id): TBC
ISSN: 1995-1892
ISSN: 1680-0745
Publisher: Clinics Cardive Publishing
Article Information
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www.cvja.co.zaCopyright © 2010 Clinics Cardive Publishing
open-access:
Received Day: 24 Month: 5 Year: 2008
Accepted Day: 6 Month: 10 Year: 2008
Print publication date: Month: 5 Year: 2009
Volume: 20 Issue: 3
First Page: 170 Last Page: 172
PubMed Id: 19575080
ID: 3721253

The influence of diabetes on short-term outcome following a prosthetic above-the-knee femoro-popliteal bypass
TV Mulaudzi, MB ChB, FCS (SA), Cert Vasc Surg (SA) Email: mulaudzit@samedical.co.za Affiliation: Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
JV Robbs, MB ChB, FRCS, FCS (SA) Affiliation: Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
N Paruk, MB ChB, FCS (SA), Cert Vasc Surg (SA) Affiliation: Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
B Pillay, MB ChB, FCS (SA), Cert Vasc Surg (SA) Affiliation: Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
TE Madiba, MB ChB, FCS (SA), MMed, PhD Affiliation: Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
V Govindsamy, MB ChB, FCS (SA) Affiliation: Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Summary

Patients with peripheral arterial disease (PAD) are at increased risk of having concomitant coronary artery disease (CAD), and the incidence is even higher in those who are diabetic.1-5 Myocardial disease is the commonest cause of morbidity and mortality in patients with PAD.6-13 Cardiovascular morbidity and mortality is proportional to the severity of the PAD.14 Some of these patients will have occult CAD. Non-invasive cardiac evaluation is able to identify most of these patients, but controversy still exists as to the type of cardiac evaluation to be performed before surgery.16,17

Antithrombotic medication has been shown to reduce the morbidity and mortality from myocardial complications in patient with PAD.12,13 Tight blood pressure control, and the use of β-blockers and statins have also been found to reduce the cardiac complication rate post peripheral bypass.4-7,11,12,17

There is a general perception that diabetic patients do not do as well as non-diabetics after a vascular procedure, but there is little evidence of this. Our study was performed to assess the influence of diabetes mellitus on the results of surgery in patients during the early postoperative phase following an above-the-knee prosthetic femoro-popliteal bypass.


Patients and methods

Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass over a four-year period (2001–2005) in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The study included only patients with atherothrombotic disease. In every case the distal anastamosis was made to the proximal popliteal artery above the knee joint.

The patients were divided into two groups, diabetic and nondiabetic. Patients who were known to be diabetic were already on treatment when referred to us and all other patients were evaluated for diabetes mellitus by means of blood tests.

Clinical information related to presenting symptoms, risk factors for atherothrombotic disease as well as co-morbidities were analysed. Thirty-day morbidity was analysed in terms of systemic and local complications as well as mortality in each group.

Statistical analysis was done using the Fishers exact test (two tailed). A p-value of < 0.05 was regarded as statistically significant.


Results

Two hundred and seventeen patient records were analysed; 102 (47%) were diabetic and 115 (53%) were non-diabetic. Table 1 shows the racial composition of the cohort. There was a significantly higher incidence of diabetes mellitus among Indian patients.

Table 2 summarises the patient profile and co-morbidities. The mean age between the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males (p = 0.005) in the non-diabetic group as well as a significantly higher proportion of cigarette smokers (p = 0.003) in this group. There was a higher prevalence of hypertension (p = 0.001) among diabetics. Even though ischaemic heart disease was more prevalent in diabetics, this was found not to be statistically significant (p = 0.064).

Clinical presentation is summarised in Table 3. The majority of patients in both groups (81% of diabetic patients and 73% of non-diabetics) presented with critical ischaemia, either with pain at rest or an ischaemic lesion such as an ulcer or gangrenous digits. Fifty-two (51%) of the diabetics had an infected ulcer or gangrene providing a septic focus, as opposed to 45 (39%) of the non-diabetics. This was not statistically significant (p = 0.100).

Overall, 208 (96%) of the patients had their procedures performed using loco regional anaesthesia. Table 4 summarises the complications occurring within 30 days of operation. Wound infection treated by systemic antibiotics and topical dressings occurred in six (5.8%) of the diabetics and 11 (9.6%) of the nondiabetics, but the difference was not significant (p = 0.60). There was no relationship between the incidence of wound infection and the presence of an infected foot lesion at presentation (p = 0.31).

Deep infection involving the graft occurred in six diabetics (5.8%) as opposed to one non-diabetic (0.9%), which was statistically significant (p = 0.05). This necessitated the removal of the graft in all patients. It should be noted that in only two of the total seven patients with graft sepsis was there an open, infected lesion on the foot at the time of the bypass. All patients were put on prophylactic antibiotics for 48 hours at the time of surgery.

The commonest systemic complication in the diabetic group involved the cardiovascular system (6.9%); myocardial infarction in five and stroke in two, as opposed to only one (0.9%) cardiovascular complication (myocardial infarction) in the non-diabetic group. This difference between the two groups was significant (p = 0.03). All those with cardiovascular complications were Indian patients and had presented with critical limb ischaemia. Four (3.9%) of these patients with cardiovascular complications in the diabetic group were hypertensive and the only patient in the non-diabetic group was also hypertensive. This was not statistically significant (p = 0.20). These patients had presented with asymptomatic coronary artery disease.

Four patients (3.9%) in the diabetic group died, two following a myocardial infarction, one following a stroke and one of renal failure. The single death (0.9%) in the non-diabetic group followed a myocardial infarction. This difference was not statistically significant (p = 0.19).


Discussion

There is little to be found in the literature that specifically addresses the influence of diabetes mellitus on peri-operative morbidity, which this study specifically attempts to address in relation to femoro-popliteal bypass. The operative procedure was standardised as far as possible by confining analysis to patients undergoing prosthetic grafting in the above-the-knee position. The overall co-morbidity profile in the two groups of patients was similar, although non-diabetics had a preponderance of males and a much higher incidence of cigarette smoking. There was a higher incidence of hypertension in the diabetics.

In general, diabetics are known to have an increased incidence of septic complications. The patients in this study with wound sepsis were managed with antibiotics and topical chemical debridement, with good results. There was no increased incidence of this type of sepsis in those patients who presented with tissue loss. In addition, the incidence of wound sepsis was not increased in those who were diabetic, whereas there was a significant difference in the incidence of deep sepsis affecting the graft in the diabetics. It is also of interest to note that there was no correlation between deep sepsis and the presence of preoperative tissue loss. As this was a retrospective study, there was a possibility of under reporting, with possibly different results.

Postoperative cardiovascular complications were significantly increased in those who were diabetic. This might have been influenced by the increased incidence of ischaemic heart disease among the diabetics, even though this was found not to be statistically significant. This concurs with the findings of several authors and was mainly due to the increased incidence of associated cardiovascular disease in those diabetics who presented with peripheral arterial occlusive disease.1-5 As the majority of the patients in this study had critical ischaemia, the incidence of cardiovascular disease would have been expected to be even higher, as its incidence is increased with the severity of peripheral arterial disease.14 Of interest is that all patients who had cardiovascular complications were Indians. This was probably due to the fact that there is a higher prevalence of diabetes in this population.

Overall in this series, those who developed myocardial infarction did not have symptomatic coronary artery disease. This calls into question how aggressive one needs to be in the pre-operative workup. There remains no consensus but most authors suggest that only those who have symptomatic coronary artery disease should be referred for cardiological assessment. Others have shown that routine extensive cardiac assessment for patients presenting with peripheral arterial disease does not reduce the morbidity and mortality rate.15,16

It is our practice to refer patients with symptomatic coronary artery disease for cardiological assessment. What we do not know is whether we should be more aggressive with our Indian diabetic patients as they have demonstrated a higher incidence of cardiovascular complications even though they had been asymptomatic at presentation. We are continuing the study of this subgroup of patients to determine how we can reduce the morbidity and mortality rate.

Strong evidence is emerging in support of beta-blockade and statin administration to reduce the incidence of peri-operative cardiovascular complications.4-8,11,12,17 Few patients in this study were on beta-blockers and statins when referred to us. Hopefully, the importance of this will be realised and more patients will be placed on this therapy.

Even though this was not statistically significant, all five patients who died had presented with critical ischaemia. Four of these patients died from cardiovascular-related complications and they were all diabetic. This confirms the increased incidence of cardiovascular complications in diabetics and in those with critical ischaemia.6-14 It is important then for these patients with PAD to have a proper clinical history and examination to identify those with suspected significant coronary artery disease. This group of patients will require further assessment by cardiologists.


Conclusion

Despite the relatively small patient number in this study, diabetes mellitus was shown to significantly increase the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee prosthetic bypass for femoro-popliteal occlusive disease.


References
1. Manson JAE,Colditz GA,Stampfer MJ,Willett WC,et al. A prospective study of maturity-onset diabetes mellitus and risk of coronary heart disease and stroke in women.Arch Intern MedYear: 1994121912918
2. Garcia MJ,McNamara PM,Gordon T,Kannell WB,Morbidity and mortality in diabetes in the Framingham population. Six-year follow-up.DiabetesYear: 1974231051114359625
3. Stamler J,Vaccaro O,Neaton JD,Wentworth D,Diabetes, other risk factors, and 12 year cardiovascular mortality formen screened in the multiple risk factor intervention trial.Diabetes CareYear: 1993164344448432214
4. et al. UK Prospective Diabetes Study 23: risk factors for coronary artery disease in non-insulin dependent diabetes.Br Med JYear: 19983168238289549452
5. Criqui MH,Fronek A,Barrett-Connor E,Klauber MR,et al. The prevalence of peripheral arterial disease in a defined population.CirculationYear: 1985715105153156006
6. et al. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.Br Med JYear: 19983177037139732337
7. Collins R,Macmahon S,Blood pressure, antihypertensive drug treatment and the risk of stroke and of coronary heart disease.Br Med BullYear: 1996502722988205459
8. et al. Mortality findings for stepped-care and referred-care in the Hypertension Detection and Follow-up Program, stratified by other risk factors.Prevent MedYear: 198514312335
9. Caro JJ,Migliaccio-Walle K,Ishak KJ,Proskorovsky I,The morbidity and mortality following a diagnosis of peripheral arterial disease: Longterm follow-up of a large database.BMC Cardiovasc DisYear: 2005514
10. Dormandy JA,Rutherford RB,et al. Management of peripheral arterial disease (PAD).J Vasc SurgYear: 200031S1S29610666287
11. Hirsch AT,Criqui MH,Treat-Jacobson D,et al. Peripheral arterial disease detection, awareness, and treatment in primary care.J Am Med AssocYear: 200128613171324
12. et al. Collaboration overview of randomized trials of antiplatelet therapy: Prevention of death, myocardial infarction, and stroke by prolonged anti-platelet therapy in various categories of patients.Br Med JYear: 1994308811068298418
13. Tomson J,Lip GHY,Peripheral arterial disease: A high-risk but neglected disease population.BMC Cardiovasc DisordYear: 20055263016150143
14. Criqui HM,Langer RD,Fronec A,Feigelson HS,et al. Mortality over a period of 10 years in patient with peripheral arterial disease.N Engl J MedYear: 19923263813861729621
15. Auerbach A,Goldman L,Assessing and reducing the cardiac risk of noncardiac surgery.CirculationYear: 20061131361137616534031
16. Eagle KA,Berger PB,Calkins H,et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).J Am Coll CardiolYear: 20023954255311823097
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Tables
[TableWrap ID: T1] Table 1  Racial Composition
Diabetics Non-diabetics
Total 102 115
Africans (%) 21 (21) 45 (39)
Indians (%) 68 (67) 40 (35)
Mixed races (%) 1 (1) 2 (2)
Caucasians (%) 12 (12) 28 (24)

[TableWrap ID: T2] Table 2  Patient Profile And Co-Morbidities
Diabetics Non-diabetics p-value
Total (%) 102 (47) 115 (53)
Male (%) 56 (55) 85 (74) 0.005
Female (%) 46 (45) 30 (26) 0.005
Age mean (years) 65 63
Hypertension (%) 54 (53) 35 (30) 0.001
Smokers (%) 68 (67) 101 (89) 0.0003
Hyperlipidaemia (%) 8 (8) 6 (5) 0.61
IHD (%) 23 (23) 14 (12) 0.064
COPD (%) 1 (0.9) 6 (5) 0.17
Lung carcinoma (%) 4 0 0.10

IHD: ischaemic heart disease, CABG: coronary artery bypass graft, COPD: chronic obstructive pulmonary disease.


[TableWrap ID: T3] Table 3  Clinical Presentation
Diabetics Non-diabetics p-value
Total 102 115
Disabling claudication (%) 19 (19) 31 (27) 0.20
Resting pain (%) 31 (30) 39 (34) 0.68
Ulcer (%) 33 (32) 15 (13) 0.001
Gangrene (%) 19 (19) 30 (26) 0.25

[TableWrap ID: T4] Table 4  Complications Within 30 Days Of Femoro-Popliteal Bypass
Diabetics Non-diabetics p-value
Total 102 115
Wound sepsis (%) 6 (5.8) 11 (9.7) 0.60
Graft sepsis (%) 6 (5.8) 1 (0.9) 0.05
Cardiovascular complications (%) 7 (6.9) 1 (0.9) 0.03
Died (%) 4 (3.9) 1 (0.9) 0.19


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