Ubbink D T, Spincemaille G H, Prins M H, Reneman R S, Jacobs M J
Department of Vascular Surgery, Academic Medical Center, Amsterdam, The Netherlands.
J Vasc Surg. 1999 Aug;30(2):236-44. doi: 10.1016/s0741-5214(99)70133-3.
Patients with non-reconstructable critical limb ischemia generally undergo medical treatment only to prevent or postpone amputation. There is some evidence that spinal cord stimulation (SCS) stimulates ischemic wound healing. Thus, this could benefit limb survival through improved skin perfusion. We investigated the effect of SCS versus conservative treatment on skin microcirculation in relation to treatment outcome in patients with non-reconstructable critical limb ischemia.
Standard medical treatment plus SCS was compared with only standard medical treatment in a multicenter randomized controlled trial comprised of 120 patients with surgically non-reconstructable chronic rest pain or ulceration. We investigated skin microcirculation by means of capillary microscopy, laser Doppler perfusion, and transcutaneous oxygen measurements in the foot. The microcirculatory status just before treatment was classified in three categories (poor, intermediate, and good) and was related to limb survival after a minimum follow-up period of 18 months.
Clinical parameters, peripheral blood pressures, and limb survival rates showed no significant differences between the SCS and standard groups during the follow-up period. In both treatment groups, amputation frequency after 18 months was high in patients with an initially poor microcirculatory skin perfusion (SCS 80% vs standard treatment 71%; NS) and low in those with a good skin perfusion (29% vs 11 %, respectively; NS). In patients with an intermediate skin microcirculation amputation, frequency was twice as low in patients additionally treated with SCS as in the standard treatment group (48% vs 24%; P =.08). In these patients, microcirculatory reactive hyperemia during the follow-up period reduced in the standard group but not in the SCS group (P <.01).
Selection on the basis of the initial microcirculatory skin perfusion identifies patients in whom SCS can improve local skin perfusion and limb survival.
患有不可重建的严重肢体缺血的患者通常仅接受药物治疗以预防或推迟截肢。有证据表明脊髓刺激（SCS）可刺激缺血性伤口愈合。因此，这可能通过改善皮肤灌注而有利于肢体存活。我们研究了SCS与保守治疗对不可重建的严重肢体缺血患者皮肤微循环的影响及其与治疗结果的关系。
在一项多中心随机对照试验中，将标准药物治疗加SCS与仅标准药物治疗进行比较，该试验纳入了120例手术不可重建的慢性静息痛或溃疡患者。我们通过毛细血管显微镜检查、激光多普勒灌注测量和足部经皮氧测量来研究皮肤微循环。治疗前的微循环状态分为三类（差、中等和良好），并与至少18个月的随访期后的肢体存活情况相关。
随访期间，SCS组和标准治疗组的临床参数、外周血压和肢体存活率无显著差异。在两个治疗组中，最初皮肤微循环灌注差的患者18个月后的截肢频率较高（SCS组为80%，标准治疗组为71%；无统计学差异），而皮肤灌注良好的患者截肢频率较低（分别为29%和11%；无统计学差异）。在皮肤微循环中等的患者中，接受SCS额外治疗的患者截肢频率比标准治疗组低一半（48%对24%；P = 0.08）。在这些患者中，随访期间标准治疗组的微循环反应性充血减少，而SCS组未减少（P < 0.01）。
根据初始皮肤微循环灌注进行选择可识别出SCS可改善局部皮肤灌注和肢体存活的患者。
