O'Hare Ann M, Sidawy Anton N, Feinglass Joe, Merine Kendra Magee, Daley Jennifer, Khuri Shukri, Henderson William G, Johansen Kirsten L
Department of Medicine, Veterans Affairs Medical Center and University of California, San Francisco 94121, USA. Ann.O'
J Vasc Surg. 2004 Apr;39(4):709-16. doi: 10.1016/j.jvs.2003.11.038.
Limb loss after lower extremity surgical revascularization occurs relatively frequently in patients receiving dialysis. The goal of the present study was to determine whether patients with milder degrees of renal insufficiency are also at risk for this complication.
This cohort study was carried out at the Department of Veterans Affairs (VA). The study sample consisted of 9932 patients undergoing an initial surgical revascularization procedure between October 1, 1995, and September 30, 2000, recorded by the VA National Surgical Quality Improvement Program (NSQIP). We examined the occurrence of major amputation within 1 year of lower extremity surgical revascularization by level of renal function.
Eleven percent of study patients underwent major lower extremity amputation within 1 year of NSQIP-documented lower extremity revascularization surgery: 10% (739 of 7335) of patients with normal renal function, 11% (251 of 2210) of patients with moderately reduced renal function, 12% (24 of 205) of patients with severe renal insufficiency, and 29% (53 of 182) of patients receiving dialysis. After adjustment for demographic characteristics and comorbid conditions, only patients receiving dialysis were at significantly increased risk for amputation, compared with patients with normal renal function (odds ratio, 2.46; 95% confidence interval, 1.74-3.47; P<.001). Compared with all other veterans undergoing bypass procedures, patients receiving dialysis were more likely to have a wound infection; a diagnostic code for lower extremity gangrene, infection, or ischemic ulceration; an elevated white blood cell count; and preoperative sepsis at the time of initial revascularization. In addition, they were more likely to have a preoperative hospital stay longer than 1 week, undergo concurrent minor amputation, and undergo an outflow (vs inflow) procedure.
Only patients receiving dialysis, and not patients with milder degrees of renal insufficiency, appear to be at higher risk for limb loss after revascularization, compared with patients with normal renal function. Further studies are needed to determine why patients receiving dialysis are at a singularly increased risk for limb loss after lower extremity revascularization and whether their more frequent presentation with limb-threatening infection at the time of revascularization reflects late presentation for surgery or a more rapid course of peripheral arterial disease in this patient group.
接受透析的患者在下肢外科血管重建术后肢体缺失相对常见。本研究的目的是确定肾功能不全程度较轻的患者是否也有发生这种并发症的风险。
本队列研究在退伍军人事务部（VA）进行。研究样本包括1995年10月1日至2000年9月30日期间由VA国家外科质量改进计划（NSQIP）记录的9932例行初次外科血管重建手术的患者。我们根据肾功能水平检查了下肢外科血管重建术后1年内大截肢的发生情况。
11%的研究患者在NSQIP记录的下肢血管重建手术后1年内接受了下肢大截肢：肾功能正常的患者中10%（7335例中的739例），肾功能中度降低的患者中11%（2210例中的251例），严重肾功能不全的患者中12%（205例中的24例），接受透析的患者中29%（182例中的53例）。在对人口统计学特征和合并症进行调整后，与肾功能正常的患者相比，只有接受透析的患者截肢风险显著增加（比值比，2.46；95%置信区间，1.74 - 3.47；P <.001）。与所有其他接受搭桥手术的退伍军人相比，接受透析的患者更有可能发生伤口感染；下肢坏疽、感染或缺血性溃疡的诊断代码；白细胞计数升高；以及初次血管重建时的术前败血症。此外，他们更有可能术前住院时间超过1周，同时接受小截肢手术，并接受流出（而非流入）手术。
与肾功能正常的患者相比，只有接受透析的患者，而非肾功能不全程度较轻的患者，在血管重建术后肢体缺失风险更高。需要进一步研究以确定为什么接受透析的患者在下肢血管重建术后肢体缺失风险特别增加，以及他们在血管重建时更频繁出现威胁肢体的感染是否反映了手术延迟或该患者群体外周动脉疾病进展更快。
