2nd Surgical Clinic, Vascular Surgery Group, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
2nd Surgical Clinic, Vascular Surgery Group, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
J Vasc Surg. 2014 Mar;59(3):708-19. doi: 10.1016/j.jvs.2013.08.103. Epub 2013 Dec 28.
The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with CLI over a 17-year period.
Details on all consecutive patients undergoing primary IAR at our institution were stored prospectively in a vascular registry from 1995 to 2011. Demographics, risk factors, indications for surgery, inflow sources and outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination, duplex scans, and ankle-brachial index measurements in all patients at discharge, 1 and 6 months after surgery, and every 6 months thereafter. End points were patency, limb salvage, survival, and amputation-free survival rates, and were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance.
Overall, 1407 IARs were performed in 1310 patients with CLI by the same surgeon, 705 (50.2%) in 643 diabetic patients and 702 in 667 nondiabetic patients. Autogenous vein conduits were used in 87% of the IARs. There were no perioperative deaths. Diabetic patients had significantly more major (16.7% vs 11.8%; P = .02) and minor complications (9.7% vs 6.5%; P = .02) than nondiabetic patients. At 5 and 10 years, there were no significant differences between diabetic and nondiabetic patients in the rates of primary patency (65% and 46% vs 69.5% and 57%; log-rank test, P = .09), secondary patency (76% and 60% vs 80% and 68%; log-rank test, P = .20), limb salvage (88% and 76% vs 91% and 83%; log-rank test, P = .12) survival (51% and 34% vs 57% and 38%; log-rank test, P = .41), or amputation-free survival (45.5% and 27% vs 51% and 29%; log-rank test, P = .19). The type of conduit did not affect patency or limb salvage rates in either group.
Diabetic patients receiving IAR for CLI can have the same survival and amputation-free survival rates as nondiabetic patients. Their comparable technical and clinical outcomes strongly demonstrate that diabetics with CLI can expect the same quantity and quality of life as nondiabetics with CLI, and aggressive attempts at limb salvage in patients with diabetes mellitus, including distal and foot level bypass grafting, should not be discouraged.
糖尿病对严重肢体缺血（CLI）患者的腔内动脉重建（IAR）的技术和临床结果的影响仍存在争议。本研究分析了 17 年来我院 CLI 患者 IAR 的结果。
从 1995 年到 2011 年，在我院机构中对所有连续进行 IAR 的患者，将其详细信息前瞻性地存储在血管登记册中。分析了人口统计学、危险因素、手术适应证、入流源和流出靶血管、移植物类型以及不良结果。所有患者在出院时、手术后 1 个月和 6 个月以及此后每 6 个月进行一次临床检查、双功超声检查和踝肱指数测量。终点是通畅率、肢体存活率、生存率和无截肢生存率，采用 Kaplan-Meier 生命表分析进行评估。使用卡方或 Fisher 确切检验、学生 t 检验和对数秩检验来确定统计学意义。
总体而言，同一位外科医生对 1310 例 CLI 患者进行了 1407 次 IAR，其中 643 例糖尿病患者中有 705 次，667 例非糖尿病患者中有 702 次。自体静脉移植物在 87%的 IAR 中使用。没有围手术期死亡。与非糖尿病患者相比，糖尿病患者有更多的主要（16.7%比 11.8%；P=0.02）和次要并发症（9.7%比 6.5%；P=0.02）。在 5 年和 10 年时，糖尿病患者和非糖尿病患者的初次通畅率（65%和 46%比 69.5%和 57%；对数秩检验，P=0.09）、次级通畅率（76%和 60%比 80%和 68%；对数秩检验，P=0.20）、肢体存活率（88%和 76%比 91%和 83%；对数秩检验，P=0.12）、生存率（51%和 34%比 57%和 38%；对数秩检验，P=0.41）和无截肢生存率（45.5%和 27%比 51%和 29%；对数秩检验，P=0.19）均无显著差异。在两组中，移植物类型均未影响通畅率或肢体存活率。
接受 IAR 治疗 CLI 的糖尿病患者与非糖尿病患者具有相同的生存率和无截肢生存率。他们可比的技术和临床结果强烈表明，CLI 糖尿病患者可以期望与 CLI 非糖尿病患者具有相同的生活质量和数量，并且不应该劝阻对糖尿病患者进行积极的肢体挽救尝试，包括远端和足部水平的旁路移植术。
