The impact of diabetes on arterial reconstructions for multilevel arterial occlusive disease

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Purpose: Critical limb ischemia due to multilevel arterial occlusive disease often may be treated with an inflow procedure alone; however, a subset patients require a subsequent infrainguinal revascularization for persistence of their symptoms. As diabetic patients typically exhibit a pattern of extensive distal arterial disease, we sought to determine if the presence of diabetes mellitus altered the need for an outflow procedure after inflow bypass. Methods: A total of 504 patients undergoing inflow bypass for occlusive disease and lower extremity ischemia between 1990 and 1998 were entered prospectively into a computerized vascular registry. Inflow bypass procedures performed were as follows: aortofemoral (370; 73%), axillofemoral (56; 11%), femorofemoral (81; 16%). Of these patients, 79 required subsequent outflow bypass for unresolved ischemic symptoms. Multiple logistic regression analysis was used to analyze the effects of diabetes and multiple other risk factors on the need for an additional outflow procedure. Results: The indications for surgery were limb salvage (78%) and disabling claudication (22%). Overall morbidity was 17.7% (hematoma, 3.8%; wound infection, 2.5%; graft occlusion, 1.3%; myocardial infarction, 2.5%; acute renal failure,1.3%; pulmonary failure, 2.5%; pneumonia, 3.8%). Overall mortality was 0%. Diabetic patients comprised a greater proportion of the total number of patients requiring inflow bypass (301 of 504) as well as a greater proportion of patients requiring inflow and outflow procedures (47 of 79). Diabetes was determined not to be an independent risk factor for the need for multiple revascularization procedures by multiple logistic regression analysis ( P >0.10). Conclusion: Although patients with diabetes are predisposed to the development of distal arterial occlusive disease, in this study the subgroup of diabetic patients who present with aortoiliac occlusive disease were no more likely than patients without diabetes to require multiple levels of revascularization. These findings provide little rationale for simultaneous inflow and outflow procedures based on the presence of diabetes alone.