Landry Gregory J, Moneta Gregory L, Taylor Lloyd M, Edwards James M, Yeager Richard A, Porter John M
Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97201, USA.
J Vasc Surg. 2002 Jan;35(1):56-62; discussion 62-3.
Reversed lower-extremity vein grafts (LEVGs) frequently require operative revisions to maintain patency. Identifying grafts that are at risk, however, requires an intensive duplex scanning-based surveillance program. Excellent 5-year graft patency and limb-salvage rates have previously been reported in patients undergoing graft revisions, but results beyond 5 years are essentially unknown, a factor that is of importance in an increasingly aging population. This study was performed to determine the results of surgical revisions of LEVGs after a follow-up as long as 10 years.
All patients undergoing placement of a LEVG were observed in a program of duplex scanning-based surveillance as long as the patient remained a candidate for graft revision. Grafts were considered for revision on the basis of the presence of focal areas of increased velocity, a prestenotic to intrastenotic velocity ratio more than 3.0, or uniformly low velocities throughout the graft. All lesions were confirmed with preoperative arteriography before revision. Assisted primary patency, limb-salvage, and survival rates were determined by means of Kaplan-Meier analysis in all patients who underwent LEVG revision from January 1990 to December 2000.
A total of 1498 LEVG procedures were performed during the study period. A total of 330 surgical graft revisions were performed on 259 extremities in 245 patients. The median follow-up period was 38 months. The assisted primary patency rate of all grafts, the limb-salvage rate for patients undergoing surgery for limb-salvage indications, and the survival rate of all patients were 87.4%, 88.7%, and 72.4%, respectively, 5 years after the original bypass grafting procedure, 85.7%, 83.4%, and 67.8%, respectively, 7 years after the original bypass grafting procedure, and 80.4%, 75.4%, and 53.4%, respectively, 10 years after the original bypass grafting procedure. A total of 180 revisions (55%) were performed during the first year, 110 (33%) between the first year and the fifth year, and 40 revisions (12%) were performed on grafts older than 5 years. LEVGs revised within the first year after bypass grafting had lesions within the graft in 78%, in the native arterial inflow in 10%, and in the native arterial outflow in 12%. This differed significantly from the location of lesions in revisions performed between 1 and 5 years and after 5 years (graft, 63% and 62%; inflow, 20% and 19%; outflow, 17% and 19%; P >.05, Chi-square).
Excellent assisted primary patency and limb-salvage rates can be achieved for as long as 10 years in LEVGs that require revision, with only a 7% drop in overall patency and limb-salvage rates between the fifth and 10th years. Although most revisions were required within the first year, 34% were performed between the first year and the fifth year, and 11% after 5 years. These data support the growing body of evidence that favors an aggressive regimen of duplex scanning surveillance of LEVGs for the life of the graft. Revised grafts have excellent patency through 10 years.
下肢静脉移植血管反转术（LEVGs）常常需要进行手术修正以维持血管通畅。然而，识别有风险的移植血管需要基于双功超声扫描的密集监测方案。此前已有报道接受移植血管修正术患者的5年移植血管通畅率和肢体挽救率良好，但5年以上的结果基本未知，而这一因素在人口老龄化日益严重的情况下至关重要。本研究旨在确定随访长达10年的LEVGs手术修正结果。
对所有接受LEVG植入的患者进行基于双功超声扫描的监测，只要患者仍有移植血管修正的指征。根据是否存在血流速度增加的局灶区域、狭窄前与狭窄内血流速度比大于3.0或整个移植血管血流速度均较低来考虑对移植血管进行修正。所有病变在修正术前均通过术前动脉造影得以证实。采用Kaplan-Meier分析确定1990年1月至2000年12月期间所有接受LEVG修正术患者的辅助原发性通畅率、肢体挽救率和生存率。
在研究期间共进行了1498例LEVG手术。对245例患者的259条肢体共进行了330次手术移植血管修正。中位随访期为38个月。在最初的旁路移植手术后5年，所有移植血管的辅助原发性通畅率、因肢体挽救指征接受手术患者的肢体挽救率以及所有患者的生存率分别为87.4%、88.7%和72.4%；在最初的旁路移植手术后7年，分别为85.7%、83.4%和67.8%；在最初的旁路移植手术后10年，分别为80.4%、75.4%和53.4%。共有180次修正（55%）在第一年进行，110次（33%）在第一年至第五年之间进行，40次修正（12%）在移植血管使用超过5年后进行。旁路移植术后第一年内修正的LEVGs，78%的病变位于移植血管内，10%位于自体动脉流入端，12%位于自体动脉流出端。这与1至5年之间以及5年之后进行修正时病变的位置有显著差异（移植血管内，分别为63%和62%；流入端，分别为20%和19%；流出端分别为17%和19%；P>.05，卡方检验）。
对于需要修正的LEVGs，长达10年可实现良好的辅助原发性通畅率和肢体挽救率，在第五年至第十年之间总体通畅率和肢体挽救率仅下降7%。虽然大多数修正需要在第一年内进行，但34%在第一年至第五年之间进行了修正，11%在5年后进行了修正。这些数据支持了越来越多的证据，即支持对LEVGs进行终身双功超声扫描监测的积极方案。修正后的移植血管10年内通畅率良好。
