Diabetes and Old Age Could Affect Long-Term Patency of Paramalleolar Distal Bypass for Peripheral Arterial Disease in Japanese Patients

Abstract

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp istal bypass has been established as the most effective treatment for critical limb ischemia of peripheral arterial disease (PAD). In particular, bypass to the paramalleolar arteries is considered to enable complete revascularization through the pedal lesion. It is still a challenging procedure, however, because the long-term patency rate is not satisfactory, despite recent progress in surgical techniques and postoperative management. Early graft failure might be due to poor anastomotic technique, presence of inadequate run-off vessels, or marked calcification of the target artery and/or poor quality of the conduit vein. Although many papers have been published concerning the long-term patency of distal bypass, 1-3 the factors subsequently affecting the patency rate have not yet been elucidated. In the present report, data were reviewed and the factors affecting long-term patency were investigated. Patient background profile and technical factors involved in the distal bypass operation to the paramalleolar tibial artery were considerably similar in each patient due to the presence of similar risk factors of atherosclerosis and coexistent atherosclerotic vascular diseases. The extent of the disease was similar, variation in surgical techniques was limited, and surgical procedures and postoperative care were uniform in general. Thus, we believe that it would be beneficial to analyze the results of paramalleolar distal bypass to elucidate the risk factors of graft failure. In particular, Japanese subjects are very homogeneous genetically, 4,5 which favors determination of the substantial factors involved in graft failure. MethodsWe retrospectively studied 65 legs of 60 consecutively treated Japanese patients (49 men, 11 women; age range, 42-87 years; average, 70.5 years) with PAD who underwent distal bypass to the paramalleolar tibial artery (artery supplying the distal third of the calf) 6 for critical limb ischemia (Table 1). All the patients had lower extremity ischemic ulcer or necrosis. Ankle brachial pressure index, skin perfusion pressure and angiography showed the lesions to be of ischemic origin, and they met the criteria for critical limb ischemia in the Trans-Atlantic Inter-Society Consensus (TASC) guidelines. Comorbidity factors consisted of diabetes in 43 patients (66%), hypertension in 42 (65%), dyslipidemia in 12 (18%), chronic renal failure Background: The results of paramalleolar distal bypass for critical limb ischemia in patients with peripheral arterial disease were reviewed to determine the factors affecting the long-term patency of this procedure in Japanese subjects.

Comparison of Clinical Outcome of Infrapopliteal Angioplasty Between Korean Diabetic and Non-Diabetic Patients With Critical Limb Ischemia

“…21 In addition, as previously mentioned, diabetic patients are more likely to develop CLI and its serious complications including gangrene, and to have higher morbidity and mortality; 6,7 also, diabetes mellitus is the possible determinant factor of graft failure in patients with CLI. 22 For these reasons, infrapopliteal angioplasty is currently proposed as the primary treatment for CLI in diabetic patients. 5,8,12-14 Infrapopliteal angioplasty, however, has been criticized because of the small diameter and length of the treated vessel, both of which have a tendency towards a high restenosis rate; furthermore, it is not clear whether the clinical success of infrapopliteal angioplasty is due solely to technical success.…”

Comparison of Clinical outcomes of Infragenicular Angioplasty between diabetic and non-diabetic patients with Peripheral Arterial Occlusive Disease

“…Moreover, diabetes is the potential ascertained factor of failure of graft failure in CLI patients [23].…”

Prospective Study of Sarpogrelate Hydrochloride on Patients with Arterioscler osis Obliterans

“…Most patients with ASO require medical treatment, and only less than one third of patients are indicated for surgery, those patients included approximately 10% patients with painless walking distance <100 meter or rest pain with ulceration or gangrene, the surgical outcomes have been dismay, because postoperative restenosis of atherosclerotic artery was approximately 30%. 4,5,10) Therefore, the cardinal management is medical therapy using anticoagulants, thrombolysis, antiplatelet agents, consecutive alternative biological pressure, etc. 11,12) The mechanism of those medications is dilation of blood vessels, anticoagulation, alteration of blood viscosity, improving the collateral circulation.…”

“…There are no definitive treatments for ASO. The efficacy of surgical treatment, particularly the long-term patency rate of bypass grafts, is not satisfactory, medication is required to maintain the postoperative vascular patency 2,4,5) The primary approaches of therapy for ASO are control of risk factors of ASO, such as prohibition of smoking, keeping fit through physical exercise, aggressive management of hyperlipidemia, diabetes and hypertension, etc. 1,6) A variety of medications have been used for the treatment of ASO.…”