血清学证实为高凝状态患者的股腘动脉旁路移植术的长期预后

Curi Michael A, Skelly Christopher L, Baldwin Zachary K, Woo David H, Baron Joseph M, Desai Tina R, Katz Daniel, McKinsey James F, Bassiouny Hisham S, Gewertz Bruce L, Schwartz Lewis B

Section of Vascular Surgery, Department of Surgery, University of Chicago, IL 60637, USA.

J Vasc Surg. 2003 Feb;37(2):301-6. doi: 10.1067/mva.2003.114.

OBJECTIVE

The purpose of this study was to test the hypothesis that the long-term outcome of infrainguinal bypass grafting in patients with congenital or acquired hypercoagulability is inferior to the results in patients without documented clotting disorders.

METHODS

The study was a retrospective analysis of consecutive patients from January 1994 to January 2001.

RESULTS

Five hundred eighty-two infrainguinal bypass grafts were created in 456 patients. Indication for surgery was limb-threatening ischemia in 84%; prosthetic conduits were implanted in 38%. Seventy-four grafts were created in 57 patients with one or more serologically proven hypercoagulable states, including heparin-induced platelet aggregation (n = 37), anticardiolipin antibodies (n = 11), lupus anticoagulant (n = 8), protein C or S deficiency (n = 7), antithrombin III deficiency (n = 3), and factor V Leiden mutation (n = 1). Patients with hypercoagulability were younger (63 +/- 2 years versus 69 +/- 1 years; P =.007), more likely to have undergone prior revascularization attempts (38% versus 21%; P =.003), and more likely to have chronic anticoagulation therapy after surgery (46% versus 25%; P =.001). After 5 years (median follow-up, 19 months), patients with hypercoagulability had poorer primary patency (28% +/- 7% versus 35% +/- 5%; P =.004), primary assisted patency (37% +/- 7% versus 45% +/- 6%; P =.0001), secondary patency (41% +/- 7% versus 53% +/- 6%; P =.0001), limb salvage (55% +/- 8% versus 67% +/- 6%; P =.009), and survival (61% +/- 8% versus 74% +/- 4%; P =.02) rates. Multivariate analysis identified only prosthetic conduit choice (P =.0001), hypercoagulability (P =.0003), and limb salvage indication (P =.01) as independent predictors of graft failure.

CONCLUSION

Patients with serologically proven hypercoagulability have inferior long-term patency, limb salvage, and survival rates after infrainguinal bypass. The high prevalence rate (13%) of diverse hypercoagulable states in this patient population supports serologic screening, especially in referral practices.

目的

本研究旨在验证以下假设，即先天性或后天性高凝状态患者的股下旁路移植术长期疗效低于无凝血功能障碍记录患者的疗效。

方法

本研究是对1994年1月至2001年1月连续收治患者的回顾性分析。

结果

456例患者共进行了582次股下旁路移植术。手术指征为肢体威胁性缺血的患者占84%；38%的患者植入了人工血管。57例患有一种或多种血清学证实的高凝状态的患者共进行了74次移植术，这些高凝状态包括肝素诱导的血小板聚集（n = 37）、抗心磷脂抗体（n = 11）、狼疮抗凝物（n = 8）、蛋白C或S缺乏（n = 7）、抗凝血酶III缺乏（n = 3）和因子V莱顿突变（n = 1）。高凝状态患者更年轻（63±2岁对69±1岁；P = 0.007），更有可能曾尝试过血管重建（38%对21%；P = 0.003），术后更有可能接受长期抗凝治疗（46%对25%；P = 0.001）。5年后（中位随访时间为19个月），高凝状态患者的初次通畅率（28%±7%对35%±5%；P = 0.004）、初次辅助通畅率（37%±7%对45%±6%；P = 0.0001）、二次通畅率（41%±7%对53%±6%；P = 0.0001）、肢体挽救率（55%±8%对67%±6%；P = 0.009）和生存率（61%±8%对74%±4%；P = 0.02）均较差。多因素分析仅确定人工血管选择（P = 0.0001）、高凝状态（P = 0.0003）和肢体挽救指征（P = 0.01）是移植失败的独立预测因素。