Eagleton Matthew J, Erez Orry, Srivastava Sunita D, Henke Peter K, Upchurch Gilbert R, Stanley James C, Wakefield Thomas W
Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, 48109, USA.
Vasc Endovascular Surg. 2006 Jan-Feb;40(1):11-22. doi: 10.1177/153857440604000102.
The objective of this study was to compare the outcomes of percutaneous transluminal angioplasty (PTA) versus open surgical repair of anastomotic strictures affecting infrainguinal bypasses. Anastomotic strictures affecting 39 bypasses in 36 patients were identified among 593 consecutive infrainguinal arterial reconstructions performed between 1994 and 2004. The mean age of affected patients was 65 +/- 2 years (range: 61 to 101 years). The original bypasses, with vein grafts outnumbering prosthetic grafts 2 to 1, were performed for acute (5%) and chronic (54%) limb-threatening ischemia, disabling claudication (28%), or popliteal aneurysms (13%). Anastomotic strictures were first recognized an average of 16 +/- 3 months (range 2 to 92 months) postoperatively. Strictures affected the distal anastomosis in 62% of cases and the proximal anastomosis in 38%. Primary patency, assisted primary patency, secondary patency, and limb salvage were assessed following PTA or open surgical repair of the strictures. Anastomotic strictures were detected following acute (41%) and chronic (18%) limb-threatening ischemia, claudication (13%), or during routine graft surveillance (28%) in asymptomatic patients. Graft thrombosis, occurring in 51% of patients at the time of presentation, was not affected by the site of anastomotic stricture, although prosthetic grafts were affected more than vein grafts (92% vs 31%). Interventions included PTA (67%) and conventional open procedures (33%). The latter included vein patch angioplasty, short interposition grafts, and redo bypasses. The stricture site and bypass material used in the original revascularization did not affect reintervention patency rates. Sixteen (62%) of the endovascular procedures were performed on a graft presenting with thrombosis, while only 4 (31%) were initially treated with operative therapy. Treatment of thrombosed grafts resulted in an 18-month patency of 32% compared to an 80% patency in treating grafts that were not occluded at the time of presentation (p < 0.05). No anastomotic stricture repaired operatively required reintervention, whereas 42% of those treated by PTA required a mean of 1.3 additional reinterventions (p < 0.03). Anastomotic strictures affecting infrainguinal bypass grafts contribute to low patency rates. Outcomes can be significantly improved if these strictures are identified before graft thrombosis. Open surgical repair, compared to PTA, provides improved graft function as evident by fewer subsequent interventions required to maintain graft patency.
本研究的目的是比较经皮腔内血管成形术（PTA）与开放性手术修复影响股腘以下旁路移植血管的吻合口狭窄的疗效。在1994年至2004年期间进行的593例连续股腘以下动脉重建手术中，确定了36例患者的39处旁路移植血管出现吻合口狭窄。受影响患者的平均年龄为65±2岁（范围：61至101岁）。最初的旁路移植手术，静脉移植物与人工血管移植物的比例为2比1，手术原因包括急性（5%）和慢性（54%）肢体威胁性缺血、致残性跛行（28%）或腘动脉瘤（13%）。吻合口狭窄首次被发现的平均时间为术后16±3个月（范围2至92个月）。62%的病例狭窄影响远端吻合口，38%影响近端吻合口。在对狭窄进行PTA或开放性手术修复后，评估了原发性通畅率、辅助原发性通畅率、继发性通畅率和肢体挽救情况。吻合口狭窄在急性（41%）和慢性（18%）肢体威胁性缺血、跛行（13%）患者中被检测到，或在无症状患者的常规移植物监测期间（28%）被发现。移植物血栓形成在就诊时发生于51%的患者中，不受吻合口狭窄部位的影响，尽管人工血管移植物比静脉移植物受影响更严重（92%对31%）。干预措施包括PTA（67%）和传统开放性手术（33%）。后者包括静脉补片血管成形术、短段移植血管置换和再次旁路移植手术。原始血管重建中使用的狭窄部位和旁路材料不影响再次干预后的通畅率。16例（62%）血管腔内手术是针对出现血栓形成的移植物进行的，而最初仅4例（31%）接受了手术治疗。与治疗就诊时未闭塞的移植物相比，治疗血栓形成的移植物18个月的通畅率为32%，而未闭塞移植物的通畅率为80%（p<0.05）。接受手术修复的吻合口狭窄无需再次干预，而接受PTA治疗的患者中有42%平均需要额外进行1.3次再次干预（p<0.03）。影响股腘以下旁路移植血管的吻合口狭窄导致通畅率较低。如果在移植物血栓形成之前识别出这些狭窄，疗效可显著改善。与PTA相比，开放性手术修复可改善移植物功能，这一点从维持移植物通畅所需的后续干预较少可以明显看出。
