Diabetes Care for Patients with Peripheral Arterial Disease

The number of diabetics will increase almost 70% in developed countries during the next 20 years: peripheral arterial disease is a common and costly complication. The incidence of cardiovascular disease (mortality and morbidity) due to atherosclerosis, is higher among patients with diabetes than in those without diabetes. Intensive management of diabetes, including glycaemic control, treatment of hypertension and dyslipidemia, as well as nonpharmacological interventions, decreases both micro- and macrovascular complications. Aspirin and clopidogrel have less antiplatelet effect in patients with diabetes. Metformin therapy is considered a risk factor for lactic acidosis if not withdrawn 2 days before angiography, but this risk is extremely low in patients with normal renal function. Peri-operative hyperglycaemia and large fluctuations in plasma glucose increase postoperative mortality and morbidity and careful measures are required to minimise these effects

SUrgical versus PERcutaneous Bypass: SUPERB-trial; Heparin-bonded endoluminal versus surgical femoro-popliteal bypass: study protocol for a randomized controlled trial

Contains fulltext : 96315.pdf (publisher's version ) (Open Access)BACKGROUND: Endovascular treatment options for the superficial femoral artery are evolving rapidly. For long lesions, the venous femoropopliteal bypass considered to be superior above the prosthetic bypass. An endoluminal bypass, however, may provide equal patency rates compared to the prosthetic above knee bypass. The introduction of heparin-bonded endografts may further improve patency rates. The SUrgical versus PERcutaneous Bypass (SuperB) study is designed to assess whether a heparin-bonded endoluminal bypass provides equal patency rates compared to the venous bypass and to prove that it is associated with improved quality of life, related to a decreased complication rate, or not. METHODS/DESIGN: Two-hundred-twenty-two patients with peripheral arterial occlusive disease, category 3-6 according to Rutherford, will be randomized in two treatment arms; 1. the surgical femoro-popliteal bypass, venous whenever possible, and 2. the heparin-bonded endoluminal bypass. The power analysis was based on a non-inferiority principle, with an effect size of 90% and 10% margins (alpha 5%, power 80%). Patients will be recruited from 5 teaching hospitals in the Netherlands during a 2-year period. The primary endpoint is primary patency and quality of life evaluated by the RAND-36 questionnaire and the Walking Impairment Questionnaire. Secondary endpoints include secondary patency, freedom-from-TLR and complications. DISCUSSION: The SuperB trial is a multicentre randomized controlled trial designed to show non-inferiority in patency rates of the heparin-bonded endograft compared to the surgical bypass for treatment of long SFA lesions, and to prove a better quality of life using the heparin bonded-endograft compared to surgically treatment, related to a reduction in complications. TRIAL REGISTRATION: Clinicaltrials: NCT01220245

Does a Completely Accomplished Duplex-based Surveillance Prevent Vein-graft Failure?

AbstractObjectives: to assess the benefits of duplex-based vein-graft surveillance over clinical surveillance with distal pressure measurements. Design: prospective randomised comparative trial. Material and methods: three hundred and forty-four patients with 362 consecutive infrainguinal vein bypasses were prospectively randomised to a follow-up regime with or without duplex scanning (ABI group and DD group) at 1, 3, 6, 9, and 12 months postoperatively.Results: one hundred and eighty-three grafts were enrolled to the ABI group and 179 to the DD group. The primary assisted patency, secondary patency and limb salvage rates were 67%, 74%, 85% for the ABI group and 67%, 73%, 81% for the DD group. Ninety grafts in the ABI group and 57 in the DD group had surveillance that completely adhered to the protocol. The outcome was also similar for these groups at one year (77%, 87%, 94% and 77%, 83%, 93% respectively), although grafts were revised more frequently in the DD group.Conclusions: intensive surveillance with duplex scanning did not improve the results of any outcome criteria examined. To demonstrate any potential benefit of duplex scanning for vein-graft surveillance a multicentre study with a large number of patients to ensure sufficient power is needed

Angiographic Runoff Score as a Predictor of Outcome Following Femorocrural Bypass Surgery

AbstractObjective:to evaluate the efficacy of the revised ad hoc scoring system in predicting the outcome of femorocrural bypass surgery.Design:retrospective study.Materials and methods:seventy-seven infrainguinal bypass procedures to the crural arteries were performed in 69 patients with critical leg ischaemia. Preoperative angiographic findings were graded according to the revised ad hoc scoring system and other preoperative angiographic measures.Results:the revised ad hoc scores were valuable in predicting the outcome of these grafts. The status of the outflow artery throughout its length had a great impact on the long-term outcome in terms of secondary patency, leg salvage, patients alive with legs, and survival rates. In situ autogenous saphenous grafts achieved the best immediate and long-term results.Conclusions:the revised ad hoc angiographic scoring method is useful in predicting the outcome of patients undergoing femorocrural arterial reconstruction. Patients with an outflow artery completely open throughout its length had excellent long-term results

Blood Flow in a Pedal Bypass Combined with a Free Muscle Flap

AbstractObjective: to assess the haemodynamic effect of a free muscle flap on the midterm success of a pedal bypass. Design: prospective consecutive study. Materials: a pedal bypass (autogenous vein graft) combined with a free muscle flap was performed in 13 patients with critical leg ischaemia. The feeding artery of the flap was anastomosed end-to-side to the bypass. Methods: blood flow was measured in the bypass before and after transplanting the flap. Doppler was used postoperatively to assess the patency. Results: the bypass and flap pedicle were patent in 11 cases six months postoperatively. Two grafts were thrombosed and the legs amputated. In the successful group the median (range) blood flow in the bypass was 50 (10–100) ml/min. It increased (p<0.05) after transplantation to 64 (20–113) ml/min, being 44 (14–97) ml/min distributed to the foot. Blood flow through the flap was 20 (6–37) ml/min. The two failing grafts had a flow of 30 and 51 ml/min before and 48 and 52 ml/min after transplantation, respectively. Blood flow through the flap was 47 ml/min and 36 ml/min, respectively. In the failure group the free flap received most of the blood supply through the bypass. Conclusions: a free muscle flap connected to an infrapopliteal bypass increases the distal outflow bed and thus decreases the outflow resistance and increases graft flow

The Impact of Adjuvant Av-fistula on Cuffed Femorocrural PTFE Bypass Grafting: Flow and Pressure Response

AbstractObjectiveThe aim of the present study was to assess the effect of an adjuvant av-fistula on prosthetic bypass grafting and whether intraoperative flow measurements could predict patency and adverse events of cuffed femorocrural PTFE bypass with or without an av-fistula.MethodsA total of 50 patients in need of vascular reconstruction for critical limb ischaemia (CLI) but with no suitable venous conduit were included.ResultsThe flow values in patients with av-fistula were significantly higher (p=0.009) than in the group without the fistula but the higher flow values did not result in improved patency. The maximum flow velocity (Vmax) in the av-fistula group was significantly higher in the immediate postoperative period (p=0.04), but there was no difference in patency. When a flow value of 50ml/min was used as a cut-off point, patients with a higher flow had significantly better immediate patency (p=0.025).ConclusionThe adjuvant av-fistula neither caused any adverse effects nor had any effect on patency