The effect of arterial reconstruction on the natural history of diabetic neuropathy
C. M. Akbari, G. W. Gibbons, G. M. Habershaw, F. W. LoGerfo and A. Veves
Deaconess-Joslin Foot Center, Division of Vascular Surgery, Deaconess Hospital, Boston, Mass, USA.
OBJECTIVE: To determine whether reversal of hypoxia slows the progression
of neuropathy. DESIGN: Cohort study with a mean follow-up of 19.2 months.
SETTING: Institutional and private hospital. PATIENTS: A volunteer sample
of 55 patients with diabetes (mean age, 62 years; range, 30-74 years; mean
duration of diabetes, 21 years; range, 1-57 years) requiring
lower-extremity arterial bypass. Twenty-one successfully treated patients
were reexamined at the conclusion of the study. Neuropathy and hypoxia were
assessed the day before the operation and during the follow-up visit.
INTERVENTION: Lower-extremity arterial reconstruction. MAIN OUTCOME
MEASURES: Peroneal nerve conduction velocity and transcutaneous oxygen
tension. RESULTS: In the leg operated on, the peroneal nerve conduction
velocity remained unchanged during the follow-up period (preoperative, mean
[+/- SD] 35.79 +/- 6.02 vs postoperative 35.33 +/- 7.51 m/s; P > .05),
but deteriorated in the leg not operated on (36.68 +/- 6.22 vs 33.64 +/-
7.30 m/s; P < .05, Wilcoxon signed rank test). Transcutaneous oxygen
tension increased in the revascularized extremity (mean [+/- SD] 40.62 +/-
24.76 vs 66.73 +/- 14.89 mm Hg) but remained unchanged in the leg not
operated on (56.76 +/- 17.07 vs 62.00 +/- 15.66 mm Hg; P > .05). Of the
entire cohort, 5 patients died during the study period. Graft occlusion
occurred in 10 (17%) of 59 extremities. Subset analysis disclosed that the
preoperative transcutaneous oxygen tension was significantly higher in the
successfully revascularized extremities (41.98 +/- 23.58 vs 24.10 +/- 21.50
mm Hg; P < .001). CONCLUSIONS: Reversal of hypoxia halts the progression
of diabetic neuropathy, lending further support to the role of hypoxia in
the pathogenesis of nerve destruction in diabetes mellitus. Preoperative
transcutaneous oxygen tension is lower in patients with bypass failure, but
the severity of neuropathy does not affect the outcome of the operation.