Long-term outcomes of infrainguinal bypass surgery for patients with diabetes mellitus and tissue loss

PURPOSE: To determine the long-term outcomes of patients with diabetes mellitus (DM) and tissue loss who have undergone infrainguinal bypass surgery (IBS). METHODS: We retrospectively reviewed the medical records of 91 patients with DM and tissue loss who underwent IBS between July 2003 and December 2013. We determined the rates of overall survival (OS), amputation-free survival (AFS), limb salvage (LS), and graft patency (GP). In addition, we evaluated data to identify risk factors that affected long-term outcomes. RESULTS: The mean age of patients was 66 +/- 8 years, and 78 patients (85.7%) were men. The locations of tissue loss were toe on 76 limbs (71.6%), heel on 6 limbs (5.7%) and others on 24 limbs (22.6%). Single lesions were found in 81 limbs (76.4%). According to categorization by distal anastomosis artery, there were 57 popliteal (53.8%) and 49 infrapopliteal bypasses (46.2%). Among infrapopliteal bypasses, 5 cases (10.2%) were sequential bypasses. The OS at 1, 3, and 5 years was 90.5%, 70.9%, and 44.2%, respectively. At 1, 3, and 5 years, the LS was 92.1%, 88.9%, 88.9%, respectively; and AFS was 84.4%, 67.6%, 45.7%, respectively. At 1, 3, and 5 years, the GP was 84.8%, 74.5%, and 69.8%, respectively. Renal failure was a negative predictor for OS, and female gender was a negative predictor for GP. CONCLUSION: IBS for patients with DM and tissue loss led to acceptable OS, AFS, LS, and GP. Active revascularization for patients with DM and tissue loss can reduce the risk of major amputation.

The Outcome Analysis of Reintervention for the Infrainguinal Bypasses

Retrospective analysis of reinterventions for the failed or failing infrainguinal bypass grafts were carried out to observe the outcomes and to analyze the factors impacting the outcomes of the reinterventions. During the period of 5 years, 30(16.6%) reinterventions were performed at Department of Surgery, Kyungpook National University Hospital following 181 infrainguinal bypasses for 150 patients with chronic arterial occlusive disease. The indications for the reinterventions were recurrent claudication (23.3%), rest pain (60%), ulcer or gangrene (10%), and graft infection (3.3%). The angiographic findings were categorized as graft occlusion(16), stenosis of the bypass graft or anastomotic sites(8) and inflow or run-off artery occlusive lesion(5). The reintervention procedures were surgical in 27 limbs and percutaneous transluminal angioplasty(PTA) in 3 limbs. To observe the outcomes of reinterventions, the initial technical success, requirement of further interventions, and overall limb salvage rates were analyzed according to the time intervals between primary bypasses and reintervention, reintervention procedures and types of the lesions. The overall limb salvage rates after 30 reinterventions were 83.3% with mean follow-up of 28.6 months. We observed the limb salvage rate was lower after reintervention for the patients with total graft occlusion compared to stenotic lesion(75 % vs 100% p=0.26 ), prosthetic graft occlusion(75%), infrapopliteal bypass as a primary bypass, and patients who underwent early within 30 days reintervention after primary bypasses(60%). However, further investigation is required to get statistical acceptance.

Outcomes of Infrainguinal Arterial Bypasses for the Patients with Atherosclerotic Lower Extremity Arterial Occlusive Disease

Surgery has been a well accepted treatment modality for the advanced lower extremity arterial occlusive disease. From March 1993 through February 1997, 121 limbs with atherosclerosis obliterans (ASO) in 99 patients were treated with infrainguinal bypasses at Department of Surgery, Kyungpook National University Hospital. Indications for the infrainguinal bypasses were intermittent claudication in 66 limbs(54.5%) and limb threatening ischemia in 55 limbs(45.5%). Conduits used for the arterial bypasses were 92 autogenous veins(79 reversed saphenous veins, 7 in situ veins, 2 nonreversed translocated veins, and 4 spliced vein grafts), 21 PTFE grafts, and 8 composite grafts. The operations were performed as the primary procedure in 112 limbs(92.6%) and as redo bypasses in 9 limbs(7.4%). The levels of distal anastomosis were above-knee popliteal artery in 34, below-knee popliteal artery in 57, posterior tibial artery in 19, anterior tibial artery in 4, peronal artery in 5, and inframalleolar artery in 2 limbs. Associated inflow arterial procedures were performed in 45 limbs(37.2%), which included 17 aortofemoral, 24 femorofemoral, 3 axillofemoral bypasses and 1 iliac PTA. Assisted primary patency rates at 4 years after graft implantation were 82.8% in reversed vein grafts(including 4 spliced vein grafts) and 62.8% in prosthetic and composite grafts according to the life table method. Clinical outcomes categorized by the revised SVS/ISCVS standard showed better results in claudication group than in limb threatening ischemia group. Limb salvage rate in the patients with limb threatening ischemia (n=55) was 87.2% at 4 years after graft implantation and operative mortality was absent.