Lower Extremity Revascularisation in Patients with Diabetes

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Open surgical reconstructions for lower limb ischaemia are divided into supra- and infrainguinal reconstructions. Suprainguinal vascular reconstructions in the form of aorta-bifemoral bypass with Dacron grafts often achieve high patency rates in the presence of a patent superficial femoral artery. The standard procedure for infrainguinal occlusive disease is femoral-popliteal bypass or bypass to the crural arteries. The latter may be preferred for patients with diabetes since arterial occlusion in this group is often located more distally.

Outcomes of percutaneous revascularisation procedures depend on various factors, including the location and length of the lesion, stenosis and the presence of a collateral circulation (Beckman etal., 2002). Patients with diabetes tend to have more severe arterial occlusive disease below the knee, and with reduced distal collateral supply. The results of percutaneous interventions in patients with diabetes may be worse than in non-diabetics. Iliac artery stenting in patients with diabetes achieves a 90% patency rate at 1-year (Dormandy and Rutherford, 2000), although some groups have shown lower patency rates. The 1-year patency rates after femoral artery interventions range from 29% to 80%, with diabetes associated with a less favourable outcome (Stokes etal., 1990). This may be due to poor collateral circulation in patients with diabetes, because in those with good collaterals the patency rates were comparable to that of non-diabetic patients. For infrainguinal ischaemia, the outcomes of surgical revascularisation in diabetes are similar to those without diabetes in terms of limb salvage (Panneton etal., 2000). Overall, it appears that in patients with severe claudication or critical limb ischaemia, surgery seems to be superior to percutaneous revascularisation procedures in the femoral, popliteal and infrapopliteal vessels, but with higher risks of cardiovascular morbidity and mortality (Dormandy and Rutherford, 2000).

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