长期结果证明自体股腘动脉旁路移植术对终末期肾衰竭患者是合理的。

Meyerson S L, Skelly C L, Curi M A, Desai T R, Katz D, Bassiouny H S, McKinsey J F, Gewertz B L, Schwartz L B

Department of Surgery, Section of Vascular Surgery, University of Chicago, Ill., USA.

J Vasc Surg. 2001 Jul;34(1):27-33. doi: 10.1067/mva.2001.116350.

INTRODUCTION

Infrainguinal bypass grafting for limb-threatening ischemia in patients with end-stage renal disease is generally thought to be associated with increased operative risk and poor long-term outcome. This retrospective study was undertaken to examine the modern-era, long-term results of infrainguinal bypass grafting in dialysis-dependent patients.

METHODS

Over the past 5 years in a single institution, 425 lower extremities (368 consecutive patients) were revascularized for the indication of limb salvage. Sixty-four patients (82 limbs) were dialysis-dependent at the time of revascularization, and this group was analyzed separately. They exhibited statistically significant higher incidences of diabetes (83% vs 56%; P <.001), hypertension (91% vs 74%; P <.001), and more distal vascular disease, which required a greater proportion of proximal anastomoses at the popliteal level (24% vs 11%; P <.01) and distal anastomoses at the infrapopliteal level (75% vs 65%; P <.05).

RESULTS

Despite the higher prevalence of comorbid conditions and distal disease in patients with renal failure, their perioperative 30-day mortality rate remained low (4.9%) and was not significantly different from that in patients with functioning kidneys (2.9%; P = not significant). After a median follow-up of 11 months (range, 0-60 months), the 3-year autogenous conduit secondary graft patency in patients with renal failure was no different than in patients with functioning kidneys (67% +/- 9% vs 64% +/- 5%; P = not significant). Nonautogenous conduits in dialysis-dependent patients exhibited a significantly poorer outcome with only 27% +/- 12% remaining secondarily patent at 2 years. As expected, both limb salvage and patient survival were significantly less in patients with renal faiture, although both exceeded 50% at 3 years (limb salvage 59% +/- 8% vs 68% +/- 5%; P <.05; patient survival 60% +/- 8% vs 86% +/- 4%; P <.001). The often-quoted phenomenon of limb loss, despite a patent bypass graft, occurred infrequently in this study (n = 3 of 82 limbs).

CONCLUSION

Infrainguinal revascularization can be performed in dialysis-dependent patients with acceptable perioperative and long-term results, especially in patients in whom adequate autologous conduit is available.

引言

对于终末期肾病患者，下肢旁路移植术治疗肢体威胁性缺血通常被认为手术风险增加且长期预后较差。本回顾性研究旨在探讨透析依赖患者下肢旁路移植术的现代长期结果。

方法

在过去5年中，在单一机构对425条下肢（368例连续患者）进行了血管重建以挽救肢体。64例患者（82条肢体）在血管重建时依赖透析，对该组进行单独分析。他们在糖尿病（83%对56%；P<.001）、高血压（91%对74%；P<.001）方面的发生率具有统计学意义的更高，并且远端血管疾病更多，这需要在腘动脉水平进行更高比例的近端吻合（24%对11%；P<.01）以及在腘动脉以下水平进行更高比例的远端吻合（75%对65%；P<.05）。

结果

尽管肾衰竭患者合并症和远端疾病的患病率较高，但其围手术期30天死亡率仍然较低（4.9%），与肾功能正常的患者相比无显著差异（2.9%；P=无显著差异）。在中位随访11个月（范围0 - 60个月）后，肾衰竭患者3年自体血管移植物二次通畅率与肾功能正常的患者无差异（67%±9%对64%±5%；P=无显著差异）。依赖透析患者的非自体血管移植物结果明显较差，2年时仅有27%±12%仍保持二次通畅。正如预期的那样，肾衰竭患者的肢体挽救率和患者生存率均显著较低，尽管3年时两者均超过50%（肢体挽救率59%±8%对68%±5%；P<.）。在本研究中，尽管旁路移植血管通畅，但经常提到的肢体丢失现象很少发生（82条肢体中有3例）。