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The Effect Of Diabetes On Suprainguinal Bypass
Daniel Colome, BS, Mikayla Kricfalusi, BS, Elisa Caron, MD, Sai Divya Yadaelli, Mohit Manchella, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
ABSTRACT:Background: Existing research suggests that diabetes mellitus (DM) negatively affects vascular surgery outcomes, but specific data on suprainguinal bypass (SIB) are lacking. This study examines the association between DM management and SIB outcomes.
Methods: We performed a retrospective cohort study of all patients undergoing SIB for chronic limb-threatening ischemia (CLTI) in the Vascular Quality Initiative from 2009-2023, divided into nondiabetic (NDM), diet-controlled diabetic (DCDM), non-insulin-dependent diabetic (NIDDM), and insulin-dependent diabetic (IDDM). Baseline and intraoperative characteristics were reported for all groups. Modified Poisson regression analyzed perioperative mortality, postoperative complications, graft occlusion at discharge, major amputations, Major Adverse Limb Events (MALE), and Major Adverse Cardiac Events (MACE), with ND as the reference group.
Results: There were 4,760 NDM patients (70.2%), 274 DCD patients (4.0%), 878 NIDDM patients (12.9%), and 832 IDDM patients (12.9%). On adjusted analysis, perioperative mortality was not significantly associated with DM management type (DCD: RR 1.27 [0.73-2.21], p=0.40; NIDDM: RR 0.95 [0.65-1.41], p=0.80; IDDM: RR 1.30 [0.89-1.89], p=0.20). DCD was associated with a higher risk of complications (RR 1.32 [1.09-1.60], p=0.005), as was IDDM (RR 1.27 [1.12-1.44], p<0.001). DCD was associated with graft occlusion (RR 3.28 [1.18-9.13], p=0.023), while NIDDM (RR 0.42 [0.10-1.76], p=0.24) and IDDM (RR 1.48 [0.59-3.70], p=0.40) were not. Major amputation was significantly associated with all DM management types compared to NDM (DCD: RR 1.94 [1.32-2.85], p<0.001; NIDDM: RR 2.00 [1.56-2.55], p<0.001; IDDM: RR 2.22 [1.73-2.84], p<0.001). NIDDM (RR 1.39 [1.17-1.65], p<0.001) and IDDM (RR 1.55 [1.31-1.83], p<0.001) were associated with higher odds of MALE. There was no significant association between MACE and DM management.
Conclusions: CLTI DM patients undergoing suprainguinal bypass have similar perioperative mortality rates compared to NDM. DM is associated with higher rates of postoperative complications, major amputations, and MALE. The data suggest diet-controlled diabetics may benefit from preoperative medical management. Patients with diabetes and CLTI may require preoperative optimization and increased monitoring post-surgery due to higher complication and major amputation risks.
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| Outcomes | Cohort | Incidence | Unadjusted Risk Ratio (95% CI, P-value) | Adjusted Risk Ratio (95% CI, P-value) |
| Perioperative Death | NDM | 164 (3.4%) | - | - |
| DCD | 13 (4.7%) | 1.39 (0.80, 2.41), 0.23 | 1.27 (0.73, 2.21), 0.40 |
| NIDDM | 31 (3.5%) | 1.03 (0.71, 1.51), 0.89 | 0.95 (0.65, 1.41), 0.80 |
| IDDM | 37 (4.4%) | 1.30 (0.92, 1.84), 0.14 | 1.30 (0.89, 1.89), 0.20 |
| Any Complications | NDM | 1,063 (22.2%) | - | - |
| DCD | 82 (29.9%) | 1.35 (1.12, 1.63), 0.002 | 1.32 (1.09, 1.60), 0.005 |
| NIDDM | 230 (26.2%) | 1.18 (1.04, 1.34), 0.013 | 1.16 (1.02, 1.32), 0.025 |
| IDDM | 238 (28.6%) | 1.29 (1.15, 1.46), <0.001 | 1.27 (1.12, 1.44), <0.001 |
| Graft Patency | NDM | 27 (0.6%) | - | - |
| DCD | 5 (1.8%) | 3.27 (1.27, 8.43), 0.014 | 3.28 (1.18, 9.13), 0.023 |
| NIDDM | 2 (0.2%) | 0.40 (0.10, 1.70), 0.2 | 0.42 (0.10, 1.76), 0.24 |
| IDDM | 8 (1.0%) | 1.72 (0.78, 3.76), 0.2 | 1.48 (0.59, 3.70), 0.40 |
| Major Amputations | NDM | 235 (4.9%) | - | - |
| DCD | 29 (10.6%) | 2.16 (1.50, 3.12), <0.001 | 1.94 (1.32, 2.85), <0.001 |
| NIDDM | 86 (9.8%) | 2.00 (1.58, 2.53), <0.001 | 2.00 (1.56, 2.55), <0.001 |
| IDDM | 88 (10.6%) | 2.15 (1.70, 2.72), <0.001 | 2.22 (1.73, 2.84), <0.001 |
| MALE | NDM | 589 (12.3%) | - | - |
| DCD | 46 (16.8%) | 1.37 (1.04, 1.80), 0.03 | 1.29 (0.97, 1.72), 0.084 |
| NIDDM | 150 (17.1%) | 1.39 (1.18, 1.64), <0.001 | 1.39 (1.17, 1.65), <0.001 |
| IDDM | 159 (19.1%) | 1.55 (1.32, 1.82), <0.001 | 1.55 (1.31, 1.83), <0.001 |
| MACE | NDM | 285 (5.9%) | - | - |
| DCD | 21 (7.7%) | 1.29 (0.84, 1.97), 0.24 | 1.19 (0.78, 1.83), 0.40 |
| NIDDM | 67 (7.6%) | 1.28 (0.99, 1.66), 0.06 | 1.19 (0.91, 1.55), 0.22 |
| IDDM | 62 (7.5%) | 1.26 (0.96, 1.64), 0.09 | 1.20 (0.91, 1.59), 0.20 |
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