Dougherty Matthew J, Young Laurence P, Calligaro Keith D
Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA 19106, USA.
J Vasc Surg. 2003 Feb;37(2):316-22. doi: 10.1067/mva.2003.116.
Although the results of staged endovascular and open surgical reconstructions have been well documented, the safety and efficacy of concomitant procedures in the operating room are less well defined. Suboptimal performance of endovascular procedures in an operative setting, or inappropriate reliance on endovascular techniques, might theoretically compromise graft patency. We questioned whether late graft thrombosis is frequently attributable to failure at the endovascularly treated site in this setting.
Between May 1, 1993, and June 30, 2001, we performed 125 concomitant endovascular and open arterial reconstructions (73 primary reconstructions, 52 graft revisions) in 106 patients. Endovascular techniques were used to treat inflow lesions in 72 cases, outflow lesions in 14 cases, both in four cases, and the graft itself in 35 cases. Fifty-five iliac, 18 femoral, 13 popliteal, six tibial, and 35 graft lesions were treated. For primary bypasses, 33 were to the popliteal level (21 prosthetic, 12 autogenous), 19 were to the tibial or pedal arteries (16 autogenous, three prosthetic or composite), and 12 were to the femoral arteries (one autogenous, 11 prosthetic). Nine patch angioplasties (eight femoral, one popliteal) were performed. For graft revisions, endovascular intervention was for inflow in 13 cases, outflow in three cases, both in one case, and of the graft itself in 35 cases. Surgical revisions involved segmental grafts in 33 cases, patch angioplasty in 18 cases, and both in one case.
In the primary group, the initial technical success rate of the endovascular procedure was 93% (68/73), with five patients needing open conversion. The 30-day mortality rate was 1.4%, and the morbidity rate was 11.0%. Of the 19 grafts in the primary group that occluded during the follow-up period (mean, 11.9 months), five thromboses could possibly be attributed to failure at the endovascular site. In the revision group, the initial technical success rate of the endovascular procedure was 88% (46/52), with six patients undergoing conversion to open procedure. The 30-day mortality rate was 0%, and the morbidity rate was 15.4%. Of 22 late graft occlusions in the revision group, only three were attributed to failure at the endovascular site.
This largest report to date of concomitant lower extremity endovascular and open revascularization procedures shows the approach to be safe. Few late graft occlusions were attributable to failure at the endovascularly treated site. The concomitant approach offers the efficiency and convenience of single stage therapy and allows immediate treatment for inadequate endovascular results or their complications and potential cost savings.
尽管分期血管腔内修复术和开放手术重建术的结果已有详尽记录，但手术室中联合手术的安全性和有效性尚不明确。在手术环境中血管腔内手术操作欠佳，或对血管腔内技术过度依赖，理论上可能会影响移植物通畅率。我们质疑在此种情况下晚期移植物血栓形成是否常归因于血管腔内治疗部位的失败。
在1993年5月1日至2001年6月30日期间，我们对106例患者进行了125例血管腔内与开放动脉重建联合手术（73例初次重建，52例移植物翻修）。血管腔内技术用于治疗72例流入道病变、14例流出道病变、4例两者均有的病变以及35例移植物本身病变。共治疗了55例髂动脉、18例股动脉、13例腘动脉、6例胫动脉和35例移植物病变。对于初次旁路移植术，33例至腘动脉水平（21例人工血管，12例自体血管），19例至胫动脉或足部动脉（16例自体血管，3例人工血管或复合血管），12例至股动脉（1例自体血管，11例人工血管）。进行了9例补片血管成形术（8例股动脉，1例腘动脉）。对于移植物翻修术，血管腔内介入治疗流入道病变13例、流出道病变3例、两者均有的病变１例以及移植物本身病变35例。手术翻修包括33例节段性移植物、18例补片血管成形术和1例两者均有的情况。
在初次手术组中，血管腔内手术的初始技术成功率为93%（68/73），5例患者需要转为开放手术。30天死亡率为1.4%，发病率为11.0%。在初次手术组随访期间闭塞的19例移植物中（平均11.9个月），5例血栓形成可能归因于血管腔内部位的失败。在翻修手术组中，血管腔内手术的初始技术成功率为88%（46/52），6例患者转为开放手术。30天死亡率为0%，发病率为15.4%。在翻修手术组的22例晚期移植物闭塞中，仅3例归因于血管腔内部位的失败。
这份关于下肢血管腔内与开放血运重建联合手术的迄今最大规模报告表明该方法是安全的。很少有晚期移植物闭塞归因于血管腔内治疗部位的失败。联合手术方法具有单阶段治疗的效率和便利性，并允许对血管腔内治疗效果不佳或其并发症进行即时治疗，还可能节省成本。
