Seeger J M, Pretus H A, Carlton L C, Flynn T C, Ozaki C K, Huber T S
Section of Vascular Surgery, Department of Surgery, University of Florida College of Medicine, Naples, USA.
J Vasc Surg. 1999 Sep;30(3):427-35. doi: 10.1016/s0741-5214(99)70069-8.
Aggressive attempts at limb salvage in patients with ischemic tissue loss are justified by favorable initial results in most patients. The identification of patients whose conditions will not benefit from attempted revascularization remains difficult.
This study was designed as a retrospective review of prospectively collected clinical data. The subjects were 210 consecutive patients who underwent infrainguinal vein bypass grafting for ischemic tissue loss in the setting of an academic medical center. Bypass grafting was to the popliteal artery in 56 patients, to the infrapopliteal arteries in 131 patients, and to the pedal arteries in 23 patients. The follow-up examination was complete in 209 of 210 patients. One hundred twenty-five patients underwent blinded review of duplex scan venous mapping and arteriography to determine simplified vein and run-off scores. The outcome measures were the influence of risk factors, venous conduit, and runoff on mortality, limb loss, and graft failure at the 6-month follow-up examination.
One hundred seventy patients (81%) were alive and had limb salvage. Nineteen patients (9.1%) died, with need for a simultaneous inflow procedure and end-stage renal disease being most commonly associated with mortality. Thirty-three patients (15.8%) had undergone amputation: 18 after graft failure, and 15 for progressive tissue loss despite a patent graft. Amputation was significantly more common in patients with diabetes (P =.05) and with poor runoff scores (poor runoff, 44.4% vs good runoff, 7.4%; P <.01). Amputation despite a patent graft also correlated with runoff (poor runoff, 41.7% vs good runoff, 4.3%; P <.01). Twenty-five patients had graft failure without amputation, so that only 145 patients (69.4%) were alive, had limb salvage, and had a patent graft. Run-off score was the strongest predictor of outcome, with 70% of patients with poor run-off scores having death, amputation, or graft failure.
Aggressive use of infrainguinal vein bypass grafting in patients with ischemic tissue loss results in a high rate of initial limb salvage but significant morbidity and mortality. Arteriographically determined runoff scores appear to potentially identify patients at high risk for a poor initial outcome and may provide a method of selecting patients for primary amputation.
大多数患者肢体挽救的积极尝试因初期结果良好而合理。识别那些病情无法从血管再通尝试中获益的患者仍然困难。
本研究设计为对前瞻性收集的临床数据进行回顾性分析。研究对象为在一所学术医疗中心因缺血性组织缺失接受股动脉以下静脉搭桥术的210例连续患者。56例患者搭桥至腘动脉，131例患者搭桥至腘动脉以下动脉，23例患者搭桥至足部动脉。210例患者中有209例完成随访检查。125例患者接受了双功扫描静脉造影和动脉造影的盲法评估，以确定简化的静脉和流出道评分。观察指标为6个月随访时危险因素、静脉管道和流出道对死亡率、肢体缺失和移植物失败的影响。
170例患者（81%）存活且肢体得以挽救。19例患者（9.1%）死亡，最常与死亡率相关的因素是需要同时进行流入道手术和终末期肾病。33例患者（15.8%）接受了截肢：18例在移植物失败后，15例尽管移植物通畅但因组织进行性缺失而截肢。截肢在糖尿病患者（P = 0.05）和流出道评分差的患者中更为常见（流出道差，44.4% vs 流出道好，7.4%；P < 0.01）。尽管移植物通畅仍进行截肢也与流出道相关（流出道差，41.7% vs 流出道好，4.3%；P < 0.01）。25例患者移植物失败但未截肢，因此只有145例患者（69.4%）存活、肢体得以挽救且移植物通畅。流出道评分是结果的最强预测因素，70%流出道评分差的患者出现死亡、截肢或移植物失败。
对缺血性组织缺失患者积极应用股动脉以下静脉搭桥术可使初期肢体挽救率较高，但发病率和死亡率显著。动脉造影确定的流出道评分似乎有可能识别出初期结果不佳的高危患者，并可能提供一种选择患者进行一期截肢的方法。
