Timaran Carlos H, Prault Trent L, Stevens Scott L, Freeman Michael B, Goldman Mitchell H
Division of Vascular Surgery, Department of Surgery and Graduate School of Medicine, University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920-6999, USA.
J Vasc Surg. 2003 Aug;38(2):272-8. doi: 10.1016/s0741-5214(03)00411-7.
The TransAtlantic Inter-Society Consensus (TASC) document did not define the best treatment for moderately severe iliac artery lesions, ie, TASC type B and type C iliac lesions, because of insufficient solid evidence to make firm recommendations. The purpose of this study was to evaluate the influence of risk factors on outcome of iliac stenting and operative procedures used to treat TASC type B and type C lesions.
Over the 5 years from 1996 to 2001, 188 endovascular and direct aortoiliac surgical reconstruction procedures were performed in 87 women and 101 men with TASC type B and type C iliac lesions and chronic limb ischemia. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) were followed to define variables. Both univariate analysis (Kaplan-Meier method) and multivariate analysis (Cox proportional hazards model) were used to determine the association between variables, cumulative patency rate, limb salvage, and survival.
Indications for revascularization were disabling claudication (73%), limb salvage (25%), and blue toe syndrome (2%). Patients in the surgery group (n = 52) had significantly higher primary patency rates compared with patients in the stent group (n = 136) at univariate analysis (Kaplan-Meier method, log-rank test; P =.015). Primary patency rates at 1, 3, and 5 years were 85%, 72%, and 64% after iliac stenting, and 89%, 86%, and 86% after surgical reconstruction, respectively. Univariate and multivariate Cox regression analysis enabled identification of poor runoff (ie, runoff score >5 for unilateral procedures or >2.5 for bilateral outflow procedures; relative risk, 2.5; 95% confidence interval [CI], 1.4-4.2; P =.001) as the only independent predictor of decreased primary patency in all patients. However, stratified analysis including only patients with poor runoff revealed that patients undergoing iliac stenting had significantly lower primary patency rates compared with those undergoing surgical reconstruction (Kaplan-Meier method, log-rank test; P =.05). External iliac artery disease and female gender were also identified as independent predictors of decreased primary stent patency.
Poor infrainguinal runoff is the main risk factor for decreased primary patency after surgical reconstruction and iliac stenting to treat TASC type B and type C iliac lesions. However, primary patency is less affected by poor runoff in patients undergoing surgical procedures. The presence of poor runoff, external iliac artery disease, and female gender are independent predictors of poor outcome after iliac stenting, and therefore these risk factors should determine the need for surgical reconstruction.
跨大西洋跨学会共识（TASC）文件未明确针对中度严重髂动脉病变（即TASC B型和C型髂病变）的最佳治疗方法，因为缺乏确凿证据来做出坚定的推荐。本研究的目的是评估风险因素对用于治疗TASC B型和C型病变的髂动脉支架置入术及手术操作结果的影响。
在1996年至2001年的5年期间，对87名女性和101名男性患有TASC B型和C型髂病变及慢性肢体缺血的患者进行了188例血管腔内和直接主动脉髂动脉重建手术。遵循报告标准特设委员会（血管外科学会/国际心血管外科学会[SVS/ISCVS]）制定的标准来定义变量。采用单因素分析（Kaplan-Meier法）和多因素分析（Cox比例风险模型）来确定变量、累积通畅率、肢体挽救率和生存率之间的关联。
血管重建的指征为致残性间歇性跛行（73%）、肢体挽救（25%）和蓝趾综合征（2%）。在单因素分析（Kaplan-Meier法，对数秩检验；P = 0.015）中，手术组（n = 52）患者的初始通畅率显著高于支架组（n = 136）患者。髂动脉支架置入术后1年、3年和5年的初始通畅率分别为85%、72%和64%，手术重建后分别为89%、86%和86%。单因素和多因素Cox回归分析确定，不良流出道（即单侧手术流出道评分>5或双侧流出道手术评分>2.5；相对风险，2.5；95%置信区间[CI]，1.4 - 4.2；P = 0.001）是所有患者初始通畅率降低的唯一独立预测因素。然而，仅包括流出道不良患者的分层分析显示，与接受手术重建的患者相比，接受髂动脉支架置入术的患者初始通畅率显著较低（Kaplan-Meier法，对数秩检验；P = 0.05）。髂外动脉疾病和女性性别也被确定为初始支架通畅率降低的独立预测因素。
下肢流出道不良是治疗TASC B型和C型髂病变的手术重建和髂动脉支架置入术后初始通畅率降低的主要风险因素。然而，手术患者的初始通畅率受流出道不良的影响较小。流出道不良、髂外动脉疾病和女性性别是髂动脉支架置入术后预后不良的独立预测因素，因此这些风险因素应决定是否需要进行手术重建。
