Ciervo A, Dardik H, Qin F, Silvestri F, Wolodiger F, Hastings B, Lee S, Pangilinan A, Wengerter K
Vascular Surgical Service of Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
J Vasc Surg. 2000 Mar;31(3):436-42.
The purpose of this study was to evaluate the role and efficacy of the tourniquet in lower limb revascularization.
During a 3-year period, 195 patients underwent 205 infrainguinal reconstruction operations in the lower extremity. These patients underwent bypass with a tourniquet and inflow occlusion (group 1) or bypass without a tourniquet (group 2). The type of infrainguinal reconstruction, tourniquet ischemia time, blood loss, and complications related to tourniquet use were recorded. A subset of patients underwent serial muscle biopsies. Specimens from calf muscle were taken just (1) before application of the tourniquet, (2) before tourniquet release, and (3) once wound closure was initiated. These biopsy specimens were studied by histochemical staining and also analyzed for phosphorylase enzyme, a marker for subcellular ischemia.
One hundred eleven patients underwent 117 infrainguinal reconstruction procedures in which the tourniquet and inflow occlusion were used. These patients were matched against 84 patients who underwent 88 infrainguinal reconstructions without the use of the tourniquet. Complete hemostatic control in group 1 was obtained in 108 of the procedures (92%). Eight percent of the procedures required minor additional techniques to obtain complete hemostasis; in two instances, the tourniquet was removed because it did not provide hemostasis. Mean tourniquet time was less than 1 hour for all reconstruction groups. There were no instances of neurologic deficit, thrombosis of distal vessels, or vascular injury that was related to the use of a tourniquet. A comparison of the two groups revealed no differences with regard to overall blood loss (P =.63) or duration of operation (P = 0.60), observations that reflect the complexity of the cases rather than the use or nonuse of a tourniquet. When tourniquet control was used, we noted a definite decrease in the time for the distal dissection, because total vascular control with extensive dissection was unnecessary. Histochemical analysis with phosphorylase revealed a conversion of tissue with active enzyme activity to a low level with tourniquet use (P <.05).
The use of a tourniquet for lower limb revascularization is safe and effective and improves visualization of the operative field. Less dissection of the target vessels is required. With a combination of the nonuse of clamps and other occluding devices, we project a decrease in host hyperplastic response that will, in turn, impact favorably on patency rates. The possibility exists that early failure may be prevented by avoiding the application of traumatic forces to diseased and brittle or calcified arteries. In this study, tourniquet time had no impact on overall operative procedural time, although certain phases of the operation were clearly shortened and facilitated, particularly in complex and difficult reconstructions. Histochemical changes found in muscle biopsy specimens did not adversely impact patients clinically, but further investigation is required to elucidate subcellular events.
本研究旨在评估止血带在下肢血管重建中的作用及疗效。
在3年期间，195例患者接受了205次下肢腹股沟下重建手术。这些患者接受了使用止血带和流入道阻断的旁路手术（第1组）或不使用止血带的旁路手术（第2组）。记录腹股沟下重建的类型、止血带缺血时间、失血量以及与止血带使用相关的并发症。一部分患者接受了系列肌肉活检。从小腿肌肉获取标本的时间分别为：（1）在应用止血带前，（2）在松开止血带前，（3）在开始伤口缝合时。这些活检标本通过组织化学染色进行研究，并分析磷酸化酶，这是亚细胞缺血的标志物。
111例患者接受了117次腹股沟下重建手术，术中使用了止血带和流入道阻断。这些患者与84例接受88次未使用止血带的腹股沟下重建手术的患者进行匹配。第1组在108例手术（92%）中实现了完全止血控制。8%的手术需要一些额外的小技巧来实现完全止血；有2例，因止血带未能提供止血而被移除。所有重建组的平均止血带时间均少于1小时。没有与止血带使用相关的神经功能缺损、远端血管血栓形成或血管损伤的情况。两组之间在总体失血量（P = 0.63）或手术持续时间（P = 0.60）方面没有差异，这些观察结果反映了病例的复杂性，而非止血带的使用与否。当使用止血带控制时，我们注意到远端解剖时间明显缩短，因为无需进行广泛解剖来实现完全血管控制。磷酸化酶的组织化学分析显示，使用止血带后组织中活性酶活性从高水平转变为低水平（P < 0.05）。
在下肢血管重建中使用止血带是安全有效的，可改善手术视野的清晰度。所需的目标血管解剖较少。结合不使用夹子和其他阻断装置，我们预计宿主增生反应会减少，这反过来将对通畅率产生有利影响。通过避免对病变、脆弱或钙化的动脉施加创伤性力量，有可能预防早期失败。在本研究中，尽管手术的某些阶段明显缩短且更便利，尤其是在复杂和困难的重建中，但止血带时间对总体手术操作时间没有影响。在肌肉活检标本中发现的组织化学变化在临床上对患者没有不利影响，但需要进一步研究以阐明亚细胞事件。
