Pomposelli Frank B, Kansal Nikhil, Hamdan Alan D, Belfield Alana, Sheahan Malachi, Campbell David R, Skillman John J, Logerfo Frank W
Division of Vascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, MA 02215, USA.
J Vasc Surg. 2003 Feb;37(2):307-15. doi: 10.1067/mva.2003.125.
The purpose of this study was to review our experience over the last decade with the dorsalis pedis bypass for ischemic limb salvage in patients with diabetes mellitus.
The study was a retrospective analysis of a computerized vascular registry and chart review. From January 10, 1990 to January 11, 2000, 1032 bypasses to the dorsalis pedis artery were performed in 865 patients (27.6% of the 3731 lower extremity arterial bypass procedures performed in that time period). Five hundred ninety-seven patients (69%) were male, with a mean age of 66.8 years. Ninety-two percent had diabetes mellitus. All procedures were done for limb salvage. Conduits included 317 nonreversed saphenous vein (30.7%), 273 in situ (26.4%), 235 reversed vein (22.8%), 170 arm vein (16.5%), 35 other vein (3.4%), and two polytetrafluoroethylene (0.2%) grafts. The inflow arteries were as follows: 294 common femoral (28.5%), 550 popliteal (53.2%), 114 superficial femoral (11%), and 74 other (7.2%).
The mortality rate within 1 month of surgery was 0.9%, and 42 grafts (4.2%) failed in the same interval, although 13 were successfully revised. In a follow-up period that ranged from 1 to 120 months (mean, 23.6 months), primary patency, secondary patency, limb salvage, and patient survival rates were 56.8%, 62.7%, 78.2%, and 48.6%, respectively at 5 years and 37.7%, 41.7%, 57.7%, and 23.8% at 10 years. Both polytetrafluoroethylene grafts failed in less than 1 year. Primary graft patency was worse in female patients (46.5% female versus 61.6% male at 5 years; P <.009) but better in patients with diabetes (65.9% diabetes mellitus versus 56.3% non-diabetes mellitus at 4 years; P <.04). Saphenous vein grafts performed better than all other conduits with a secondary patency rate of 67.6% versus 46.3% at 5 years (P <.0001). Multivariate analysis showed that length of stay greater than 10 days and dorsalis pedis bypass for the surgical indication of previous graft occlusion were independently predictive of worse graft patency at 1 year and use of saphenous vein as conduit was predictive of better patency.
Dorsalis pedis bypass is durable with a high likelihood of ischemic foot salvage over many years. Saphenous vein is the preferred conduit when available. Short vein grafts from distal inflow sites are possible in more than 50% of cases. These results justify the routine use of pedal arterial reconstruction for patients with diabetes with ischemic foot complications.
本研究旨在回顾我们在过去十年中对糖尿病患者行足背动脉搭桥术挽救缺血肢体的经验。
本研究是对计算机化血管登记资料和病历回顾进行的回顾性分析。从1990年1月10日至2000年1月11日，对865例患者进行了1032次足背动脉搭桥术（占该时间段内3731例下肢动脉搭桥手术的27.6%）。597例（69%）为男性，平均年龄66.8岁。92%患有糖尿病。所有手术均为挽救肢体。血管移植物包括317条非翻转大隐静脉（30.7%）、273条原位大隐静脉（26.4%）、235条翻转静脉（22.8%）、170条上肢静脉（16.5%）、35条其他静脉（3.4%）和2条聚四氟乙烯移植物（0.2%）。流入动脉如下：294条股总动脉（28.5%）、550条腘动脉（53.2%）、114条股浅动脉（11%）和74条其他动脉（7.2%）。
术后1个月内死亡率为0.9%，同期有42条移植物（4.2%）失败，不过其中13条成功修复。在1至120个月（平均23.6个月）的随访期内，5年时原发性通畅率、继发性通畅率、肢体挽救率和患者生存率分别为56.8%、62.7%、78.2%和48.6%，10年时分别为37.7%、41.7%、57.7%和23.8%。两条聚四氟乙烯移植物均在不到1年内失败。女性患者原发性移植物通畅率较差（5年时女性为46.5%，男性为61.6%；P<.009），但糖尿病患者的原发性移植物通畅率较好（4年时糖尿病患者为65.9%，非糖尿病患者为56.3%；P<.04）。大隐静脉移植物的表现优于所有其他血管移植物，5年时继发性通畅率为67.6%，而其他血管移植物为46.3%（P<.0001）。多因素分析显示，住院时间超过10天以及因既往移植物闭塞而行手术指征的足背动脉搭桥术独立预测1年时移植物通畅情况较差，而使用大隐静脉作为血管移植物预测通畅情况较好。
足背动脉搭桥术效果持久，多年来挽救缺血足的可能性很高。如有可能，大隐静脉是首选的血管移植物。超过50%的病例可以采用来自远端流入部位的短静脉移植物。这些结果证明对有缺血足并发症的糖尿病患者常规进行足部动脉重建是合理的。
