Modrall J Gregory, Sadjadi Javid, Ali Ahsan T, Anthony Thomas, Welborn M Burress, Valentine R James, Hynan Linda S, Clagett G Patrick
Department of Surgery, University of Texas Southwestern Medical Center and Dallas Veterans Affairs Medical Center, Dallas, TX 75390-9157, USA.
J Vasc Surg. 2004 Feb;39(2):387-94. doi: 10.1016/j.jvs.2003.10.021.
Deep thigh veins, including the superficial femoral, superficial femoropopliteal, and profunda femoris veins, are versatile autogenous conduits for arterial reconstruction. Although late venous complications are unusual, deep vein harvest may induce severe venous hypertension and predispose the limb to acute compartment syndrome. The purpose of this study was to define the frequency of fasciotomy in patients undergoing deep vein harvest and to identify clinical predictors of the need for fasciotomy after deep vein harvest.
Over 9 years, 162 patients underwent arterial reconstruction with deep vein harvested from 264 limbs. Indications for deep vein harvest included aortofemoral reconstruction in 127 patients, brachiocephalic arterial reconstruction in 22 patients, and visceral arterial reconstruction in 13 patients.
Fasciotomy was performed in 47 of 264 limbs (17.8%) after deep vein harvest. The prevalence of fasciotomy after deep vein harvest was 20.6% for patients requiring aortofemoral reconstruction, whereas no patients underwent fasciotomy after deep vein harvest for mesenteric or brachiocephalic arterial reconstruction (P =.0068). Fasciotomy was performed in 20.7% of limbs after complete deep vein harvest to a level below the adductor hiatus, but no fasciotomies were performed in patients undergoing subtotal deep vein harvest, ending above the adductor hiatus (P =.0023). The mean preoperative ankle-brachial index (ABI) was significantly lower in limbs requiring fasciotomy (ABI, 0.39 +/- 0.05), compared with patients who did not require fasciotomy (ABI, 0.79 +/- 0.02; P <.0001). Fasciotomy was performed in 76.0% of limbs undergoing concurrent ipsilateral greater saphenous vein (GSV) and deep vein harvest, compared with 11.7% of patients undergoing deep vein harvest alone (P <.0001). The mean volume of intraoperative fluid administered to patients requiring fasciotomy was almost 50% higher than the fluid resuscitation received by patients who did not require fasciotomy (9.6 +/- 1.2 L vs 6.5 +/- 0.6 L; P <.0001). Logistic regression analysis determined that lower preoperative ABI (odds ratio [OR], 60.1; 95% confidence interval [CI], 12.5-289.3; P <.0001) and concurrent harvest of the ipsilateral GSV (OR, 9.9; 95% CI, 3.1-31.3; P <.0001) were predictors of the need for fasciotomy.
One in four patients undergoing deep vein harvest for aortofemoral reconstruction may be expected to develop acute compartment syndrome and require fasciotomy. The risk appears to be greatest in patients with severe lower extremity ischemia and in patients undergoing simultaneous GSV and deep vein harvest. Prophylactic fasciotomy may be appropriate in patients with both risk factors, but vigilance for the development of compartment syndrome after deep vein harvest is required in all patients undergoing deep vein harvest for aortofemoral reconstruction.
大腿深部静脉，包括股浅静脉、股浅腘静脉和股深静脉，是用于动脉重建的多功能自体管道。尽管晚期静脉并发症并不常见，但采集深部静脉可能会引发严重的静脉高压，并使肢体易患急性骨筋膜室综合征。本研究的目的是确定接受深部静脉采集患者中筋膜切开术的发生率，并识别深部静脉采集后需要进行筋膜切开术的临床预测因素。
在9年多的时间里，162例患者接受了取自264条肢体的深部静脉进行动脉重建。深部静脉采集的适应证包括127例患者的主-股动脉重建、22例患者的头臂动脉重建和13例患者的内脏动脉重建。
264条肢体中有47条（17.8%）在深部静脉采集后进行了筋膜切开术。对于需要主-股动脉重建的患者，深部静脉采集后筋膜切开术的发生率为20.6%，而接受肠系膜或头臂动脉重建的患者在深部静脉采集后未进行筋膜切开术（P = 0.0068）。在完全采集深部静脉至收肌裂孔以下水平后，20.7%的肢体进行了筋膜切开术，但在仅采集至收肌裂孔以上水平的次全深部静脉采集患者中未进行筋膜切开术（P = 0.0023）。需要进行筋膜切开术的肢体术前平均踝肱指数（ABI）显著低于不需要进行筋膜切开术的患者（ABI为0.39±0.05），后者的ABI为0.79±0.02（P < 0.0001）。在同期进行同侧大隐静脉（GSV）和深部静脉采集的肢体中有76.0%进行了筋膜切开术，而仅进行深部静脉采集的患者中这一比例为11.7%（P < 0.0001）。需要进行筋膜切开术的患者术中平均补液量比不需要进行筋膜切开术的患者接受的液体复苏量高出近50%（9.6±1.2 L对6.5±0.6 L；P < 0.0001）。逻辑回归分析确定，术前ABI较低（优势比[OR]，60.1；95%置信区间[CI]，12.5 - 289.3；P < 0.0001）和同期采集同侧GSV（OR，9.9；95% CI，3.1 - 31.3；P < 0.0001）是需要进行筋膜切开术的预测因素。
接受取深部静脉进行主-股动脉重建的患者中，预计有四分之一可能会发生急性骨筋膜室综合征并需要进行筋膜切开术。在严重下肢缺血患者以及同时进行GSV和深部静脉采集的患者中，这种风险似乎最大。对于具有这两种危险因素的患者，预防性筋膜切开术可能是合适的，但对于所有因主-股动脉重建而接受深部静脉采集手术的患者，都需要警惕术后骨筋膜室综合征的发生。
