for Diabetes Care Clinicians
Pinjala Ramakrishna MS FRCS FICS
Chief of Vascular Endovascular Surgery at
Nizam's Institute of Medical Sciences, Hyderabad,
Editor, Vascular Endovascular Interventions and Surgery Update,
Tutor for the Royal College of Surgeons, Edinburgh UK
bypass grafts for preventing the
leg amputation in Diabetes
R K showing long synthetic bypass graft used for
Intermittent claudication (calf pain), wasting of the calf muscles, rest pain, non-healing ulceration, dry gangrene and wet gangrene are common manifestations peripheral vascular disease. Middle aged men who are stressed in their profession and smoking heavily are high risk of developing vascular problems in their body if, in addition they are found to have diabetes and hypertension. In diabetics macro and micro vascular angiopathy can lead to ischemic complications in the legs. The vessel changes occur over period of time and they slowly thicken and stiffen. The intima, inner layer of vessel may show ulcers exposing the core of the atherosclerotic plaques filled with hypercoagulable substances. That would result in precipitation of sudden thrombosis, which may completely occlude the narrowed vessels.
The treatment for such damaged blood vessels would be based up on the findings duplex scan and angiogram. If thrombus is the major component responsible for the obstruction then thrombolytic drugs would be able solve the problems. That is more common in excessively smoking individuals. If there is stenosis or short segment total occlusion then one can consider the endovascular therapies such as angioplasty, stenting or stent grafts. If there is a long segment superficial femoral artery occlusion of more than 30 cm a bypass operation would be required to save the leg. Usually long saphenous vein is harvested from the leg and it is used for bypassing the occluded artery. But in nearly 30% of the patients in our practice this vein is either small or not suitable for the leg bypass operations in such cases one has go for the alternate synthetic (plastic) blood vessels. There different types of artificial blood vessels available in the market. There are some benefits with each type. There are many attempting to make them as good as the natural blood vessels. Even these artificial blood vessels are prone for the diseases, infections and re-occlusions. It is felt that infection is more in diabetic patients with non-healing infected ulcers even after treating them with powerful antibiotics in some cases. If once the body accepts them then 50-70% of them would remain patent for the next 2-5 years depending the type of bypass and disease status. The cost of these synthetic grafts is also high and it is between Rs.15,000-40,000. The quality of the life and limb salvage can be improved with leg bypass operation with synthetic grafts along adequate care of the diabetes; other associated cardiac, brain and kidney problems. It was found to be more cost effective in people aged between 50-65 years of age with satisfactory risk benefit ratio.
go to index page in www.diabetes.org.in