K. Nagarsheth1, T. Dinitto1, J. Schor1, K. Singh1, J. Deitch1 1Staten Island University Hospital,Vascular And Endovascular Surgery,Staten Island, NY, USA
Introduction:
Diabetic patients are known to suffer from peripheral vascular disease. We sought to compare outcomes after femoral-to-popliteal artery bypass (FPB) in diabetic patients based on the use of oral medications (PO) versus insulin (INS) for glycemic control.
Methods:
The National Surgical Quality Improvement Program (NSQIP) database was searched, from the years 2005 to 2011, to identify diabetic patients who underwent FPB. There were a total of 5523 FPB procedures performed on diabetic patients. The patients were divided into groups based on what was used primarily to manage their diabetes, PO or INS. The search for FPB was performed using the following CPT codes; 35556, 35583 and 35656. Patient demographics, comorbidities, perioperative data, and outcomes were compared.
Results:
There were 13631 FPB identified in this database. Of those, 5523 were performed on diabetic patients. There were 2545 patients taking PO and 2978 who were treated with INS. The INS group had a higher incidence of pre-existing coronary artery disease, such as CHF (4.7% v. 2%, p<0.01), recent MI (2.6% v. 1.7%, p=0.01) and prior CABG (31.2 % v. 24.9%, p<0.01). The INS group also presented with critical limb ischemia more frequently than the PO group (42.9% v. 36.2%, p<0.01). Intraoperatively, the INS group had a higher rate of cardiac arrest (0.2% v. 0.1%, p<0.01) and needed blood transfusions more frequently (10.4% v. 8.6%, p=0.02). Post-operatively, the INS group had a higher incidence of respiratory failure (2.6% v. 1.6%, p=0.01), cardiac arrest requiring CPR (1.6% v. 0.7%, p<0.01) and needed more blood transfusions (0.7% v. 0.3%, p=0.025). The INS group also had a higher incidence of postoperative complications like UTI (2.6% v. 1.3%, p<0.01) and deep SSI (4.1% v. 2.3%, p<0.01). The INS group also had a higher rate of 30 day mortality (2.7% v. 1.8%, p=0.03) than the PO group. There were no differences in operative time or hospital length of stay between these two groups.
Conclusion:
Patients who used insulin to manage their diabetes had more evidence of pre-existing heart disease, more post-operative complications and a higher 30 day mortality. Based on this data, when performing a FPB on an INS dependent diabetic patient, we advocate close peri-operative monitoring and pre-operative optimization, as they are more likely to have intra-operative and post-operative morbidity and mortality.