Dardik Herbert, Wengerter Kurt, Qin Feng, Pangilinan Audwin, Silvestri Fred, Wolodiger Fred, Kahn Mark, Sussman Barry, Ibrahim Ibrahim M
Section of Vascular Surgery, Heart and Vascular Institute of New Jersey, Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631, USA.
J Vasc Surg. 2002 Jan;35(1):64-71.
Biological material has been used as an alternative to autogenous vein since the first lower extremity revascularization procedures were performed. Our experience with glutaraldehyde-tanned human umbilical cord vein graft (UVg), which spanned a period of 28 years, forms the basis of this report, with an emphasis on comparative results between the two decades from 1975 to 1985 and from 1990 to 2000.
Between 1990 and 2000, 283 lower extremity bypass grafting procedures were performed in 230 patients (264 limbs), with UVg used as the predominant, or sole, graft material. Our experience with 907 reconstructions in the decade from 1975 to 1985 has been previously documented and now serves as a baseline comparison with the past decade of experience with UVg. Each reconstruction was classified on the basis of the distal anastomotic site with or without distal arteriovenous fistulas (dAVFs). The primary and secondary graft patency rates were determined for each category as was cumulative palliation, which combines the end points of graft failure, amputation, and death.
The results from the second decade (1990 to 2000) showed a continuation of improving patency rates for UVg grafts in lower extremity revascularization. Comparison results of complications showed no changes in the low incidence rates of infection, stenosis, dissection, and pseudoaneurysm. The original series results showed a 2.9% requirement for aneurysm surgery, with an incidence rate of biodegradation of 57% (36% aneurysms, 21% dilation), whereas the current series results have shown no aneurysms to date. The comparative 6-year secondary patency rates for past and current popliteal and crural bypass grafts (with or without dAVF) were: popliteal, 53% versus 67%, P <.05; and crural, 26% without dAVF versus 47% with dAVF, P <.05. The limb salvage rates for the two series at 6 years showed no significant changes between the decades and the types of bypass grafts. Thrombolysis was performed during the decade from 1990 to 2000 in 27 UVg cases, with lysis achieved in 23 cases (85%) and limb salvage achieved in 20 cases (74%). Since 1996, associated endovascular procedures (fluoroscopy, angioplasty) have assumed increasing importance in the reduction of perioperative graft closure and in the enhancement of patency.
Our continuing experience with UVg confirms that favorable results can be obtained with this biologic alternative to autologous vein for lower limb revascularization. Concern regarding biodegradation and aneurysm formation even after 5 years are unfounded at this time. Improved patency and limb salvage rates can be achieved in concert with lower nonthrombotic failure rates, increasing performance of associated endovascular procedures, use of tourniquets, and the addition of dAVF for crural bypass grafting. Prospective randomized studies are still necessary for the assessment of the comparative role of all graft materials, a project that continues to evade our specialty.
自首次进行下肢血管重建手术以来，生物材料一直被用作自体静脉的替代物。我们使用戊二醛鞣制的人脐静脉移植物（UVg）的经验跨越了28年，为本报告奠定了基础，重点是1975年至1985年以及1990年至2000年这两个十年间的比较结果。
1990年至2000年期间，对230例患者（264条肢体）进行了283例下肢旁路移植手术，主要或唯一使用UVg作为移植物材料。我们在1975年至1985年这十年间进行907例重建手术的经验先前已有记录，现在作为与过去十年使用UVg的经验的基线比较。每次重建根据有无远端动静脉瘘（dAVF）的远端吻合部位进行分类。确定了每类的初级和次级移植物通畅率以及累积缓解率，累积缓解率综合了移植物失败、截肢和死亡的终点。
第二个十年（1990年至2000年）的结果表明，在下肢血管重建中，UVg移植物的通畅率持续提高。并发症的比较结果显示，感染、狭窄、夹层和假性动脉瘤的低发生率没有变化。最初系列的结果显示，动脉瘤手术的需求率为2.9%，生物降解发生率为57%（36%为动脉瘤，21%为扩张），而目前系列的结果迄今未显示有动脉瘤。过去和当前腘动脉及小腿旁路移植（有或无dAVF）的6年比较次级通畅率分别为：腘动脉，53%对67%，P<.05；小腿，无dAVF为26%对有dAVF为47%，P<.05。两个系列在6年时的肢体挽救率在不同十年和不同类型的旁路移植之间没有显著变化。1990年至2000年这十年间，对27例UVg病例进行了溶栓治疗，23例（85%）实现了溶栓，20例（74%）实现了肢体挽救。自1996年以来，相关的血管内手术（荧光透视、血管成形术）在减少围手术期移植物闭塞和提高通畅率方面的重要性日益增加。
我们对UVg的持续经验证实，这种生物替代自体静脉用于下肢血管重建可获得良好结果。目前，对即使5年后的生物降解和动脉瘤形成的担忧是没有根据的。通过降低非血栓性失败率、增加相关血管内手术的实施、使用止血带以及在小腿旁路移植中添加dAVF，可提高通畅率和肢体挽救率。对于评估所有移植物材料的比较作用，仍需要进行前瞻性随机研究，这一项目仍在困扰我们这个专业领域。
