Mulaudzi TV, Robbs JV, Paruk N, Pillay B, Madiba TE, Govindsamy V. Effect of diabetes on short-term outcome after knee femoro-popliteal bypass surgery. I wrote this publication myself). 27 4A.IV Systemic early morbidity and mortality after aortic surgery 29 4A.V: Early local complications after aortic surgery 31 4B.I: Demographic data of patients who underwent peripheral bypass surgery 33 4B.II: Clinical picture of peripheral arterial disease 37 4B . III: Risk factors and comorbidity of peripheral bypass surgery 39 4B.IV: Morbidity after peripheral bypass surgery 41 4C.I: Demographics of patients for major amputation 43 4C.II: Clinical picture and disease rate in major amputation 46 4C. III: Risk factors and co-morbidities of major amputation 48. 4C.V: Morbidity and mortality after major amputation 52 4D.I: Demographics of patients with carotid disease 55 4D.II: Clinical picture of carotid disease 57 4D.III: Risk factors and co-morbidities carotid diseases 59 4D.IV: Contralateral carotid status, shunting and patching 61 4D.V: Morbidity and mortality after carotid endarterectomy 63.
These were open abdominal aortic surgery, peripheral bypass surgery, major lower extremity amputation and carotid endarterectomy. Diabetes mellitus significantly increased the incidence of graft sepsis in those who had undergone aorto-bifemoral bypass and peripheral bypass. The incidence of peri-operative cardiovascular morbidity was significantly increased in diabetics who had peripheral bypass procedures, open abdominal aortic surgery, and major lower extremity amputations.
Most patients with DM die from cardiovascular disease, which is the leading cause of death among diabetics in Western countries2-6. This has been reported to be mainly after aortic aneurysm repair and peripheral bypass surgery6 11-13. Peripheral bypass surgery consisted of either an above-the-knee femoro-popliteal bypass or an extra-anatomic femoro-femoral bypass.
Patients undergoing peripheral bypass surgery did not undergo the same extensive preoperative assessment as those undergoing aortic surgery.
RESULTS
The clinical presentation in terms of symptoms and signs for those with aortic disease did not differ significantly between the two groups. The second most common risk factor was hypertension (39%) also with no significant differences between the two groups (p=0.5891). The incidence of ischemic heart disease (IHD) was 18% and was significantly more prevalent in diabetics (p<0.00001).
Chronic obstructive airway disease (COAD) was present in 9% of patients with no significant differences between the two groups. Myocardial infarction (MI) after open abdominal aortic surgery was significantly more common (p=0.00001) in diabetics than non-diabetics. There were significantly more diabetic patients who died after aortic surgical procedures (p=0.0335) than non-diabetics.
For the AFBG transplant, sepsis was statistically significantly more common among diabetic patients (Table 4A.IV). There were no significant differences in the incidence of wound infection and graft thrombosis between the two groups.
VALUE
Discussion
The incidence of symptomatic ischemic heart disease among diabetics was significantly higher (p<0.0001), which was noted in earlier studies in groups of patients with atherosclerotic peripheral arterial disease33-35. Despite the increased incidence of ischemic heart disease and postoperative myocardial infarction among diabetic patients, congestive heart failure no longer occurred. Among patients undergoing abdominal aortic aneurysm repair, the incidence of graft sepsis was not significantly different between the two groups.
The incidence of graft sepsis was significantly higher (p<0.00001) in diabetic patients with aorto-bifemoral bypass, most likely due to the inguinal incision. There was a significantly higher mortality rate among diabetics (p=0.0335), which is partly due to the higher incidence of MI. Tight blood pressure, glycemic control and statins have been shown to reduce the incidence of postoperative cardiovascular complications35-37.
Overall, the comorbidity profiles were similar in both groups of patients, although non-diabetics had a male predominance and a much higher incidence of cigarette smoking. Strict aseptic technique during surgery and careful blood glucose control can help reduce the incidence of graft infection. This is in agreement with the findings of several authors and is mainly due to the increased incidence of associated cardiovascular disease in those diabetics who have peripheral arterial occlusive disease.
Strong evidence has emerged in support of beta blockade and statin administration to reduce the incidence of perioperative cardiovascular complications35-38,41-44. The high incidence of ischemic heart disease in this group of patients is a reflection of the fact that all had critical limb ischemia11. This would be expected as there is a higher incidence of coronary artery occlusive disease among patients with critical limb ischemia, which in turn is greater in diabetics11,32,33,35.
Particular attention should also be paid to foot care, as this will reduce the incidence of diabetic foot ulcers and thereby possibly reduce the need for amputation58. These patients with peripheral arterial disease should be given antiplatelet therapy to reduce the incidence of cardiovascular complications44,59. For those with carotid artery disease, carotid endarterectomy has been shown to effectively reduce the incidence of cerebrovascular events60–66.
5.E. Best medical therapy
CONCLUSION
Some patients may not have been included in the study and some of the information may have been lost. The numbers in this study are large and these limitations do not seem to have affected the outcome of this study. This study has shown that diabetes mellitus has a different impact on the early outcome after different vascular surgical procedures.
Diabetic patients who had open abdominal aortic surgery had a significantly increased incidence of myocardial infarction and mortality. For those who had peripheral bypass procedures, diabetes mellitus significantly increased the incidence of graft sepsis and that of cardiovascular morbidity. Diabetic patients who had major lower limb amputations had significantly increased incidence of myocardial infarction and mortality.
Diabetes mellitus did not influence the early outcome of those who underwent carotid endarterectomy.
Aortoiliac occlusive disease in different population groups - clinical pattern, risk profile and reconstruction outcomes. Prevalence and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, and Scott RA et al., The Multicenter Aneurysm Screening Study (MASS) on the effect of abdominal aortic aneurysm screening on mortality in men: a randomized controlled trial , Lancet 16 November ), p.
A prospective study of adult-onset diabetes mellitus and risk of coronary heart disease and stroke in women. UK Prospective Diabetes Study 23: Risk factors for coronary artery disease in non-insulin-dependent diabetes.
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