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Surgical Treatment of Infrainguinal Occlusive Disease in Diabetes

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Diabetes and Peripheral Vascular Disease

Part of the book series: Contemporary Diabetes ((CDI))

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Abstract

Diabetes is a ubiquitous disease process that initiates and accelerates the progression of atherosclerosis in all vascular territories, and remains the leading cause of limb loss in the United States. Diabetes and smoking are the two strongest risk factors for peripheral artery disease (PAD), and when present in combination they portend a high risk for progression to critical limb ischemia (CLI). The severity of the clinical presentation can be broad, ranging from symptoms of intermittent claudication (IC) to CLI with extensive gangrene. Importantly, many patients with diabetes present with CLI without an antecedent history of IC due to the common anatomic pattern of diffuse infrapopliteal disease with proximal sparing. The goal of surgical intervention for advanced PAD is to preserve a functional limb—through relief of pain, clearance of infection, and promotion of wound healing. Four types of treatment options exist: medical management, open surgical revascularization, endovascular intervention, or primary amputation. Although patients with diabetes tend to have unique clinical presentations and anatomic patterns of disease compared to nondiabetics, the vascular treatment algorithms for advanced PAD are broadly similar. Therapeutic decisions are individualized for each patient, factoring in estimated life expectancy, current functional status, comorbid conditions, severity of ischemia, and the underlying vascular anatomy. Diabetic patients with CLI are a high risk group, underscoring the importance of making the correct decision about which intervention to apply, and executing a quality revascularization in a timely fashion. Although patency outcomes of infrainguinal vein grafts are no different in diabetes, limb loss and mortality rates tend to be higher in this overall population. Aggressive management of the ischemic–neuropathic diabetic foot is the critical component to successful limb salvage, and requires multidisciplinary expertise.

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Authors and Affiliations

  1. Department of Surgery, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143, USA

    Shant M. Vartanian M.D. & Michael S. Conte M.D.

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  1. Shant M. Vartanian M.D.
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  2. Michael S. Conte M.D.
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Correspondence to Michael S. Conte M.D. .

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Editors and Affiliations

  1. Columbia University College of Physician, Division of Vascular Surgery, New York Presbyterian Hospital, 72 East 93rd Street, Apt 2 AB, New York, 10128, New York, USA

    Gautam V. Shrikhande

  2. Columbia University College of Physician, Division of Vascular Surgery, New York Presbyterian Hospital, 161 Fort Washington Ave. Suite 535, New York, 10032, New York, USA

    James F. McKinsey

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Vartanian, S.M., Conte, M.S. (2012). Surgical Treatment of Infrainguinal Occlusive Disease in Diabetes. In: Shrikhande, G., McKinsey, J. (eds) Diabetes and Peripheral Vascular Disease. Contemporary Diabetes. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-62703-158-5_10

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  • DOI: https://doi.org/10.1007/978-1-62703-158-5_10

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  • Publisher Name: Humana Press, Totowa, NJ

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  • Online ISBN: 978-1-62703-158-5

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