Townley W A, Carrell T W G, Jenkins M P, Wolfe J H N, Cheshire N J W
St. Mary's Hospital, London, UK.
Vasc Endovascular Surg. 2006 Oct-Nov;40(5):362-6. doi: 10.1177/1538574406293739.
The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.
严重肢体缺血与终末期肾衰竭（即依赖透析的肾衰竭，ESRF）并存代表着严重的全身性动脉粥样硬化，且与中期生存率极低相关。许多肾病学家和外科医生主张一期截肢。我们研究了本单位近期的经验，以确定在这些患者中行股动脉以下旁路移植术是否合理。对1996年1月至2003年5月期间在某地区血管和肾脏科接受手术的所有严重肢体缺血合并ESRF患者进行回顾性研究。42例ESRF患者（中位年龄65岁）因严重肢体缺血前来就诊。17例患者接受了24次（7例双侧）股动脉以下旁路移植术（17例使用自体静脉，7例使用聚四氟乙烯[PTFE]导管；24例中有21例出现组织缺失，占88%），25例患者对32条肢体进行了一期大截肢。5条移植物发生早期闭塞（21%，5条均为PTFE导管）。旁路移植组的住院死亡率为13%，截肢组为24%。旁路移植组的中位住院时间为59天，截肢组为46天。旁路移植组的30天、1年和2年生存率分别为88%、50%和33%；截肢组分别为83%、39%和35%。1年时肢体挽救率为66%。在随访（中位时间18个月）或死亡时，75%（18/24）的手术肢体（静脉移植物的15/17）避免了大截肢。严重肢体缺血与终末期肾衰竭并存，无论一期截肢还是手术血运重建，中期生存率都很低。然而，在选择的病例中使用静脉导管进行股动脉以下旁路移植术，可以使大多数此类患者避免大肢体截肢。
