RESUMEN
The case reports of 100 consecutive patients receiving aortic bifurcation grafts strictly for occlusive disease were reviewed. Fifty-seven diabetics and 43 nondiabetics constituted the study group. Mean age and preoperative risk factors were otherwise comparable. Sixty-eight percent of operations in diabetics were for limb salvage as compared with 47% in the nondiabetic group. All 100 patients survived the operation and left the hospital with open grafts. The complication rate was similar in both groups. Mean follow-up was 48 months in the diabetic group vs 58 months in the nondiabetic group. Thirty-three percent of the diabetics were dead at four years, a survival rate one half of that of the nondiabetics. Nine percent of patients in each group suffered late limb graft occlusions, a cumulative graft patency of 94% at five years. Limb loss and subsequent distal reconstruction were comparatively low although higher in the diabetic group. This suggests more and progressive distal arterial disease in the diabetics and not an unsuccessful inflow procedure. We conclude that aortic reconstruction can be safely carried out in diabetics with high graft patency and limb salvage rates.
Asunto(s)
Aorta/cirugía , Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/cirugía , Complicaciones de la Diabetes , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
This study of 100 consecutive below-knee amputations in 98 diabetic patients was undertaken to review our results and to compare them with a similar report of 20 years ago. Ninety-three limbs were ischemic, and 79% of the patients had significant infection. This finding was similar to that in our previous study group. Twenty-one percent of the patients had previous arterial reconstruction, 11% had had a toe or metatarsal amputation, and 17% required a guillotine (open) amputation to control sepsis. The below- to above-knee amputation ratio was 2.3/1. The selection of level was made on clinical grounds. None of the 100 amputations required revision to above-knee amputation. The mortality rate was 3% and the wound complication rate was 18%. Eighty-three percent of the patients were ambulatory at the time of discharge, which occurred at an average of 35 days. There has been a significant improvement in the number of successful below-knee amputations performed since our previous study. We attribute these results to aggressive surgical control of infection and to close follow-up with early recognition and treatment of healing problems.
Asunto(s)
Amputación Quirúrgica , Angiopatías Diabéticas/complicaciones , Isquemia/cirugía , Pierna/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Pie/cirugía , Humanos , Isquemia/etiología , Rodilla , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Infección de la Herida QuirúrgicaRESUMEN
We present a retrospective study of 191 carotid artery operations in which a large population of diabetic patients is compared with a smaller nondiabetic group of patients. Of the patients who were studied, 62.3% were diabetic and 37.6% were nondiabetic. The patients with a juvenile-onset diabetes fared poorly, with few of them living long enough to develop carotid artery disease. The patients with adult-onset diabetes differed from the nondiabetic patients only in the increased incidence of associated peripheral vascular disease. The incidence of symptomatic heart disease preoperatively, and the perioperative morbidity from heart disease was the same for both groups. The perioperative stroke rate was 2.6% and 0%, respectively, for asymptomatic patients. Long-term follow-up demonstrated the effectiveness of the procedure, with only two of the patients with transient ischemic attacks developing strokes later. There was, however, a highly significant increased death rate from myocardial infarction among the diabetic patients (55%), compared with the nondiabetic patients (25%).
Asunto(s)
Enfermedades de las Arterias Carótidas/cirugía , Complicaciones de la Diabetes , Enfermedades de las Arterias Carótidas/complicaciones , Trastornos Cerebrovasculares/etiología , HumanosRESUMEN
With better survival and extended indications for renal transplantation, it is anticipated that the problem of aortoiliac disease in the posttransplant patient will be seen with increasing frequency. Two patients requiring aortoiliac reconstruction were successfully managed with improvement in graft function after surgery. One patient manifested atheroembolism resulting from aortoiliac occlusive disease; the other had a 2 cm rupture in an aortic aneurysm, which resulted in a large retroperitoneal hematoma, but without frank shock. Perfusion of the transplanted kidney was maintained by the use of a temporary axillofemoral graft, which was removed following aortoiliac repair. The use of this technique involves minimal physiologic disturbance to the patient and the renal graft and allows conventional aortoiliac reconstruction.
Asunto(s)
Aneurisma de la Aorta/cirugía , Enfermedades de la Aorta/cirugía , Arteriosclerosis/cirugía , Arteria Ilíaca/cirugía , Trasplante de Riñón , Complicaciones Posoperatorias/cirugía , Aorta Abdominal/cirugía , Prótesis Vascular , Femenino , Humanos , Cuidados Intraoperatorios , Riñón/irrigación sanguínea , Masculino , Persona de Mediana EdadRESUMEN
Noninvasive laboratory testing was used to predict successful amputation levels in 150 diabetic patients. The cases of 100 patients undergoing forefoot amputation and 50 patients undergoing below-knee amputation were evaluated using segmental systolic pressures and pulse volume recordings (PVRs). The decision for and the level of amputation were based solely on clinical judgment. In patients undergoing forefoot amputation, segmental systolic pressures were falsely high or predicted incorrectly in over half the cases. Segment PVRs were correctly predictive in only half of the cases. In patients undergoing below-knee amputation, segment systolic pressures were falsely high or predicted incorrectly in over one third of cases. Segmental PVRs were correctly predictive in less than one third of the cases. In the diabetic patient, clinical judgment continues to provide the most accurate and reliable information by which the type of amputation and likelihood of its success can be judged.
Asunto(s)
Amputación Quirúrgica , Angiopatías Diabéticas/cirugía , Pierna/cirugía , Pulso Arterial , Adulto , Anciano , Presión Sanguínea , Femenino , Humanos , Pierna/irrigación sanguínea , Úlcera de la Pierna/cirugía , Masculino , Persona de Mediana Edad , Pronóstico , Sístole , Cicatrización de HeridasRESUMEN
Sixty-six diabetic patients underwent needed forefoot amputations when clinical assessment indicated a reasonable chance of healing. All patients underwent noninvasive testing consisting of segmental systolic pressure measurements and pulse volume recordings (PVRs) taken at the thigh, calf, ankle, and forefoot levels. Segmental systolic pressures were falsely high (greater than 200 mm Hg) and therefore not useful in 56%. Ankle systolic pressures predicted failure in 36% of patients who healed and success in 64% who failed to heal. Segmental PVRs were sequentially predictive in only 50%. Forefoot PVR traces predicted failure in 50% of patients whose amputations healed. No patient should be denied a forefoot amputation solely on the basis of unfavorable results of noninvasive tests. Favorable clinical signs and a strongly positive forefoot PVR trace are the best predictors of successful forefoot amputations in diabetic patients.