Mills J L, Fujitani R M, Taylor S M
Section of Vascular Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas.
Am J Surg. 1992 Nov;164(5):506-10; discussion 510-1. doi: 10.1016/s0002-9610(05)81190-0.
To determine the clinical utility of routine intraoperative completion arteriography, we prospectively evaluated 214 consecutive infrainguinal bypass grafts (209 reversed-vein and 5 polytetrafluoroethylene grafts) performed from July 1987 to August 1991. Visual inspection, pulse palpation, and continuous-wave Doppler examination were performed in all cases. At least 1 completion arteriogram was obtained in 213 cases (99%). The bypasses were to the popliteal artery in 130 cases and to the tibial or pedal arteries in 84 cases. Graft patency was confirmed at 30 days in all patients by ankle-brachial index determinations (greater than 0.2 increase) and duplex scan-derived peak-systolic flow velocities (greater than 45 cm/s). Significant technical problems requiring revision were identified in 18 grafts (8%), including 6% of popliteal grafts and 12% of tibial/pedal grafts. Only three of these problems were suspected by pulse palpation or continuous-wave Doppler examination. The intraoperative angiographic findings leading to revision included distal anastomotic stenoses (n = 6), distal arterial disease requiring sequential bypass (n = 4), mid-graft valvular or branch ligature stenoses (n = 4), distal arterial thrombosis (n = 2), and graft kink or twist (n = 2). Thirty-day primary patency was 99% (129 of 130) for femoropopliteal grafts and 93% (78 of 84) for femorodistal grafts. Secondary patency was 100% (130 of 130) and 96% (81 of 84), respectively. Primary patency was 89% (16 of 18) for those grafts that required intraoperative revision based on arteriographic findings. We conclude that routine completion arteriography is an excellent method of ensuring the intraoperative technical adequacy of infrainguinal bypass. The test is easy to perform, reproducible, and should be considered the "gold standard" for intraoperative bypass assessment. Prior to adopting angioscopy or duplex scanning for intraoperative surveillance, randomized, controlled validation studies against angiography should be performed.
为确定术中常规完成动脉造影的临床应用价值，我们前瞻性评估了1987年7月至1991年8月连续进行的214例股腘以下旁路移植术（209例静脉翻转移植术和5例聚四氟乙烯移植术）。所有病例均进行了肉眼检查、脉搏触诊和连续波多普勒检查。213例（99%）至少获得了1次完成动脉造影。130例旁路移植至腘动脉，84例旁路移植至胫动脉或足背动脉。通过踝肱指数测定（增加大于0.2）和双功超声扫描得出的收缩期峰值流速（大于45 cm/s）在所有患者中于30天时确认移植通畅。18例移植（8%）发现了需要修正的重大技术问题，包括6%的腘动脉移植和12%的胫动脉/足背动脉移植。这些问题中只有3例通过脉搏触诊或连续波多普勒检查被怀疑。导致修正的术中血管造影结果包括远端吻合口狭窄（n = 6）、需要序贯旁路的远端动脉疾病（n = 4）、移植血管中段瓣膜或分支结扎处狭窄（n = 4）、远端动脉血栓形成（n = 2）以及移植血管扭结或扭曲（n = 2）。股腘动脉移植的30天原发性通畅率为99%（130例中的129例），股腘以下动脉移植的为93%（84例中的78例）。继发性通畅率分别为100%（130例中的130例）和96%（84例中的81例）。基于血管造影结果需要术中修正的那些移植的原发性通畅率为89%（18例中的16例）。我们得出结论，常规完成动脉造影是确保股腘以下旁路移植术中技术充分性的极佳方法。该检查易于实施、可重复，应被视为术中旁路评估的“金标准”。在采用血管内镜或双功超声扫描进行术中监测之前，应针对血管造影进行随机对照验证研究。
