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      The influence of diabetes on short-term outcome following a prosthetic above-the-knee femoro-popliteal bypass

      , MB ChB, FCS (SA), Cert Vasc Surg (SA) , MB ChB, FRCS, FCS (SA) , MB ChB, FCS (SA), Cert Vasc Surg (SA) , MB ChB, FCS (SA), Cert Vasc Surg (SA) , MB ChB, FCS (SA), MMed, PhD , MB ChB, FCS (SA)

      Cardiovascular Journal of Africa

      Clinics Cardive Publishing

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          Abstract

          Objectives

          To assess the influence of diabetes mellitus on early morbidity and mortality following a femoro-popliteal bypass.

          Methods

          Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass for atherothrombotic disease over a four-year period in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The patients were divided into two groups, diabetic and non-diabetic.

          Results

          Two hundred and seventeen patient records were analysed; 102 (47%) patients were diabetic and 115 (53%) non-diabetic. The mean age in the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males and cigarette smokers in the non-diabetic group and hypertension among the diabetics. The prevalence of ischaemic heart disease in the two groups was not statistically significant. The majority of patients in both groups presented with critical limb ischaemia.

          Overall, 208 (96%) of the patients had their procedures performed using loco regional anaesthesia. The incidence of superficial wound infection between the two groups was not statistically significant. Deep infection, which necessitated removal of the graft, and cardiovascular complications were significantly higher in the diabetics. Four patients (3.9%) in the diabetic group and only one (0.9%) in the non-diabetic group died.

          Conclusion

          Diabetes mellitus significantly increases the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee femoro-popliteal bypass.

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          Most cited references 12

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          Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial.

          To assess predictors of CVD mortality among men with and without diabetes and to assess the independent effect of diabetes on the risk of CVD death. Participants in this cohort study were screened from 1973 to 1975; vital status has been ascertained over an average of 12 yr of follow-up (range 11-13 yr). Participants were 347,978 men aged 35-57 yr, screened in 20 centers for MRFIT. The outcome measure was CVD mortality. Among 5163 men who reported taking medication for diabetes, 1092 deaths (603 CVD deaths) occurred in an average of 12 yr of follow-up. Among 342,815 men not taking medication for diabetes, 20,867 deaths were identified, 8965 ascribed to CVD. Absolute risk of CVD death was much higher for diabetic than nondiabetic men of every age stratum, ethnic background, and risk factor level--overall three times higher, with adjustment for age, race, income, serum cholesterol level, sBP, and reported number of cigarettes/day (P < 0.0001). For men both with and without diabetes, serum cholesterol level, sBP, and cigarette smoking were significant predictors of CVD mortality. For diabetic men with higher values for each risk factor and their combinations, absolute risk of CVD death increased more steeply than for nondiabetic men, so that absolute excess risk for diabetic men was progressively greater than for nondiabetic men with higher risk factor levels. These findings emphasize the importance of rigorous sustained intervention in people with diabetes to control blood pressure, lower serum cholesterol, and abolish cigarette smoking, and the importance of considering nutritional-hygienic approaches on a mass scale to prevent diabetes.
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            Peripheral arterial disease detection, awareness, and treatment in primary care.

             Alan Hirsch (2001)
            Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis that is common and is associated with an increased risk of death and ischemic events, yet may be underdiagnosed in primary care practice. To assess the feasibility of detecting PAD in primary care clinics, patient and physician awareness of PAD, and intensity of risk factor treatment and use of antiplatelet therapies in primary care clinics. The PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program, a multicenter, cross-sectional study conducted at 27 sites in 25 cities and 350 primary care practices throughout the United States in June-October 1999. A total of 6979 patients aged 70 years or older or aged 50 through 69 years with history of cigarette smoking or diabetes were evaluated by history and by measurement of the ankle-brachial index (ABI). PAD was considered present if the ABI was 0.90 or less, if it was documented in the medical record, or if there was a history of limb revascularization. Cardiovascular disease (CVD) was defined as a history of atherosclerotic coronary, cerebral, or abdominal aortic aneurysmal disease. Frequency of detection of PAD; physician and patient awareness of PAD diagnosis; treatment intensity in PAD patients compared with treatment of other forms of CVD and with patients without clinical evidence of atherosclerosis. PAD was detected in 1865 patients (29%); 825 of these (44%) had PAD only, without evidence of CVD. Overall, 13% had PAD only, 16% had PAD and CVD, 24% had CVD only, and 47% had neither PAD nor CVD (the reference group). There were 457 patients (55%) with newly diagnosed PAD only and 366 (35%) with PAD and CVD who were newly diagnosed during the survey. Eighty-three percent of patients with prior PAD were aware of their diagnosis, but only 49% of physicians were aware of this diagnosis. Among patients with PAD, classic claudication was distinctly uncommon (11%). Patients with PAD had similar atherosclerosis risk factor profiles compared with those who had CVD. Smoking behavior was more frequently treated in patients with new (53%) and prior PAD (51%) only than in those with CVD only (35%; P <.001). Hypertension was treated less frequently in new (84%) and prior PAD (88%) only vs CVD only (95%; P <.001) and hyperlipidemia was treated less frequently in new (44%) and prior PAD (56%) only vs CVD only (73%, P<.001). Antiplatelet medications were prescribed less often in patients with new (33%) and prior PAD (54%) only vs CVD only (71%, P<.001). Treatment intensity for diabetes and use of hormone replacement therapy in women were similar across all groups. Prevalence of PAD in primary care practices is high, yet physician awareness of the PAD diagnosis is relatively low. A simple ABI measurement identified a large number of patients with previously unrecognized PAD. Atherosclerosis risk factors were very prevalent in PAD patients, but these patients received less intensive treatment for lipid disorders and hypertension and were prescribed antiplatelet therapy less frequently than were patients with CVD. These results demonstrate that underdiagnosis of PAD in primary care practice may be a barrier to effective secondary prevention of the high ischemic cardiovascular risk associated with PAD.
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              Mortality over a period of 10 years in patients with peripheral arterial disease.

              Previous investigators have observed a doubling of the mortality rate among patients with intermittent claudication, and we have reported a fourfold increase in the overall mortality rate among subjects with large-vessel peripheral arterial disease, as diagnosed by noninvasive testing. In this study, we investigated the association of large-vessel peripheral arterial disease with rates of mortality from all cardiovascular diseases and from coronary heart disease. We examined 565 men and women (average age, 66 years) for the presence of large-vessel peripheral arterial disease by means of two noninvasive techniques--measurement of segmental blood pressure and determination of flow velocity by Doppler ultrasound. We identified 67 subjects with the disease (11.9 percent), whom we followed prospectively for 10 years. Twenty-one of the 34 men (61.8 percent) and 11 of the 33 women (33.3 percent) with large-vessel peripheral arterial disease died during follow-up, as compared with 31 of the 183 men (16.9 percent) and 26 of the 225 women (11.6 percent) without evidence of peripheral arterial disease. After multivariate adjustment for age, sex, and other risk factors for cardiovascular disease, the relative risk of dying among subjects with large-vessel peripheral arterial disease as compared with those with no evidence of such disease was 3.1 (95 percent confidence interval, 1.9 to 4.9) for deaths from all causes, 5.9 (95 percent confidence interval, 3.0 to 11.4) for all deaths from cardiovascular disease, and 6.6 (95 percent confidence interval, 2.9 to 14.9) for deaths from coronary heart disease. The relative risk of death from causes other than cardiovascular disease was not significantly increased among the subjects with large-vessel peripheral arterial disease. After the exclusion of subjects who had a history of cardiovascular disease at base line, the relative risks among those with large-vessel peripheral arterial disease remained significantly elevated. Additional analyses revealed a 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease that was both severe and symptomatic. Patients with large-vessel peripheral arterial disease have a high risk of death from cardiovascular causes.
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                Author and article information

                Contributors
                Journal
                Cardiovasc J Afr
                Cardiovasc J Afr
                TBC
                Cardiovascular Journal of Africa
                Clinics Cardive Publishing
                1995-1892
                1680-0745
                May 2009
                : 20
                : 3
                : 170-172
                Affiliations
                Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Durban Metropolitan Vascular Service and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
                Article
                3721253
                19575080
                Copyright © 2010 Clinics Cardive Publishing

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Cardiovascular Topics

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