CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 AFRICA 239 One hundred and eighty-one DM patients (64.9%) were using oral antidiabetics and 98 (35.1%) were on insulin. Total postoperative complications occurred in 25.4% of patients on oral antidiabetics and in 8.2% of patients on insulin (χ2 = 12.122; p < 0.001). Post-operative complications occurred in patients on oral antidiabetics considerably more frequently than in those using insulin (Table 4). The stratification of patients with diabetes according to their levels of glycosylated haemoglobin (HbA1c) has shown that the group with HbA1c levels > 7.6 % had a higher total morbidity and mortality rate (Table 5). The median value of HbA1c in patients without post-operative complications was 7.6 ± 1.2, whereas the median value of HbA1c in patients with post-operative complications was 8.4 ± 0.9 (t = 5.010; p < 0.001). Patients with post-operative complications had significantly higher values of HbA1c. The multiple logistic regression model, with post-operative complications as a dependent variable, was supplemented with those predictors of post-operative complications that were statistically significant in the simple logistic regression model, the significance level being 0.05. Statistically significant predictors of early post-operative complications in the multiple logistic regression model were: age (B = 0.069; p < 0.001) with odds ratio (OR) = 1.07, and it demonstrates that with increase in age of one year there is a 7% greater risk for patients to develop early post-operative complications. Diabetes (B = 0.854; p = 0.001) had an OR of 2.35, showing that diabetic patients were, with all other factors in the model controlled, at 2.35 times greater risk of the development of early post-operative complications. Concomitant coronary artery disease patients (B = 0.844; p = 0.001), (OR = 2.33) were at 2.33 times greater risk of the development of post-operative complications, with all other factors in the model controlled. With logistic regression, the factors identified to increase the odds of death and post-operative complications were: hyperlipoproteinaemia (p = 0.021), more persistent coronary artery disease (p = 0.001) and a higher frequency of peripheral arterial disease (p < 0.001). The factors determined to increase the odds of death and total morbidity were: higher levels of HbA1c (p < 0.001) and oral antidiabetics for controlling glucose levels (p < 0.001), which is shown in Tables 4 and 5. Discussion Although previous studies evaluated the connection between diabetes and a greater operative risk during CEA, there are various conflicting results in many studies. Most studies introduce CEA as a well-known and permanent procedure for the prevention of TIA and cerebrovascular infarction in patients with significant stenosis of the carotid artery.15 In previous studies, which included patients operated on for stenotic occlusive disease of the carotid arteries, the percentage of diabetics in most cases ranged from 13 to 23.6%.6,15 Our series included 37.7% of patients with diabetes, which is considerably higher compared to the study done by Ahari et al., which had 13% diabetic patients.5 Dorigo et al. report that the percentage of DM patients was 20.05%, whereas the study by Rockman et al. reports 23.5%.6,9 The study done by Jeong et al. reports on a high percentage of diabetics in Asia, up to 39%.16 The high percentage of diabetics in our study can be explained by the fact that DM has been reaching epidemic proportions in the general population over the last two decades, and especially in the group of patients with atherosclerotic disease. Our study shows that pre-operative factors believed to increase the risk of death and stroke in diabetics include higher low-density lipoprotein values, coronary artery disease and peripheral arterial disease. A prompt diagnosis of these co-morbidities and the use of statins should reduce mortality and stroke rates after CEA. Dorigo and co-workers state that patients with diabetes were predominantly women, who suffered from coronary artery disease, peripheral arterial disease and hyperlipidaemia.6 Other authors claim that pre-CEA diagnosed risk factors such as atherosclerosis and diabetes had an effect on 30-day mortality rate and stroke, but they did not record a significant influence from dyslipidaemia.17 Our research, however, has identified most frequent postoperative complications, such as post-operative MI, coronary insufficiency, TIA, CVI, respiratory insufficiency, post-operative bleeding and wound infection. All these complications were significantly more prevalent in patients with DM. Post-operative TIA was present in 0.9% of patients without DM and in 3.6% of patients with DM (p = 0.009), while postoperative CVI was 1.3 versus 3.2%, respectively (p = 0.072). Patients with DM suffer significantly more often from early post-operative TIA and CVI. The greater risk of cerebrovascular infarction in patients with DM was reported in the recent review by Hussain et al., wherein they determined that DM was associated with a 1.5-times greater risk of stroke after CEA.18 Contrary to these statements, Ballota et al. suggest that there is no important difference in the frequency of these post-operative complications between diabetics and non-diabetics.10 Post-operative cardiological complications, including MI, occurred in 1.1% of patients without DM and in 3.6% of Table 3. Total mortality and morbidity rates in patients with diabetes and without diabetes who underwent CEA Structure of patients Group A: diabetics Group B: non-diabetics Total p-value Fatal cardiac event, n (%) 4 (1.4) 3 (0.7) 7 (0.9) 0.435 Fatal neurological event, n (%) 3 (1.1) 1 (0.2) 4 (0.5) 0.153 Total mortality, n (%) 7 (2.5) 4 (0.9) 11 (1.5) 0.113 Total morbidity, n (%) 51 (18.3) 39 (8.5) 90 (12.2) < 0.01 Table 4. Distribution of patients depending on diabetes therapy, in relation to post-operative complications Oral antidiabetics Insulin therapy Total Post-operative complications n % n % n % Not present 135 74.6 90 91.8 225 80.6 Present 46 25.4 8 8.2 54 19.4 Total 181 100.0 98 100.0 279 100.0 Table 5. HbA1c level in examined patients HbA1c level Number % SD Median Minimum Maximum Without post-operative complications 225 7.6 1.2 8.0 6.0 9.8 With post-operative complications 54 8.4 0.9 8.5 6.0 9.5 Total 279 7.8 1.2 8.0 6.0 9.8
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