Jaquinandi Vincent, Picquet Jean, Bouyé Philippe, Saumet Jean-Louis, Leftheriotis Georges, Abraham Pierre
Department of Vascular Investigations, University Hospital of Angers, Angers, France.
J Vasc Surg. 2007 Feb;45(2):312-8. doi: 10.1016/j.jvs.2006.09.050.
Proximal (ie, buttock, hip) claudication can result from impaired perfusion in the hypogastric area after aortobifemoral bypass (ABF) despite normal femorodistal blood flow provided by the patent bypass. The proportion of patients that experience proximal claudication after ABF is unknown, and arguments for the vascular origin of symptoms specifically at the proximal level have never been reported.
This was a prospective study set in an institutional practice of ambulatory patients referred for a systematic survey of their previous ABF bypass. Among the 131 eligible patients, 10 refused to participate and 16 were unable to walk on a treadmill. The 105 studied patients (94 men, 11 women) were a mean age of 63 +/- 10 years, and the median delay from surgery was 2 years (range, 4 months to 26 years). We used a modified version of the San Diego Claudication Questionnaire administered both at rest before the treadmill study and again after the treadmill test. Transcutaneous oxygen pressure (TcPO2) at the buttock level was used to evaluate blood flow impairment during exercise at the proximal level, with blood flow impairment defined as buttock minus chest TcPO2 decrease in excess of -15 mm Hg.
Thirty patients reported proximal exercise-related pain consistent with vascular criteria by history before exercise. However, 59 patients (56%) reported symptoms compatible with proximal claudication, and TcPO2 values were abnormal on one or both sides in 52. The persistence of at least one (prograde or retrograde) pathway to the hypogastric circulation, determined by review of operative details from the aortobifemoral bypass and angiography, did not significantly decrease the proportion of patients reporting proximal claudication by history (26%) or on treadmill (55%) compared with those with bilateral hypogastric occlusion (33% by history, P = .51 compared with at least one prograde hypogastric pathway and 61% based on treadmill test, P = .65 compared with at least one prograde hypogastric pathway).
The present study shows that (1) the proportion of ABF patients with a median bypass age of 2 years that report proximal claudication is high (28%), (2) this proportion is significantly higher when claudication is detected by treadmill exercise tests, (3) a vascular origin (or at least contribution) is likely 88% of the proximal symptoms observed on treadmill, (4) the presence of proximal claudication with associated abnormal TcPO(2) results increases the risk of walking impairment in affected patients, and (5) preservation of at least one internal iliac artery to allow prograde or retrograde flow to the hypogastric vascular bed does not decrease the risk of proximal claudication after ABF surgery. A vascular origin of (or at least contribution to) most of the proximal exercise-related symptoms should always be discussed in patients with patent ABF bypass.
尽管主动脉双股动脉旁路移植术（ABF）后股腘动脉血流正常，但腹下区域灌注受损仍可导致近端（即臀部、髋部）跛行。ABF术后出现近端跛行的患者比例尚不清楚，且从未有关于症状特别是近端层面血管源性的相关报道。
这是一项前瞻性研究，纳入了前来接受系统性既往ABF旁路移植术评估的门诊患者。在131例符合条件的患者中，10例拒绝参与，16例无法在跑步机上行走。105例纳入研究的患者（94例男性，11例女性）平均年龄为63±10岁，手术至研究的中位间隔时间为2年（范围4个月至26年）。我们使用了改良版的圣地亚哥跛行问卷，在跑步机研究前静息时以及跑步机测试后再次进行评估。使用臀部水平的经皮氧分压（TcPO2）评估近端运动时的血流受损情况，血流受损定义为臀部TcPO2减去胸部TcPO2的降低超过-15 mmHg。
30例患者在运动前根据病史报告了符合血管标准的近端运动相关疼痛。然而，59例患者（56%）报告了符合近端跛行的症状，52例患者一侧或双侧的TcPO2值异常。通过回顾主动脉双股动脉旁路移植术的手术细节和血管造影确定，至少存在一条（顺行或逆行）通向腹下循环的通路，与双侧腹下动脉闭塞患者相比，通过病史报告近端跛行的患者比例（26%）或跑步机检查时报告近端跛行的患者比例（55%）并未显著降低（病史报告时，与至少一条顺行腹下动脉通路相比，P = 0.51；基于跑步机测试，与至少一条顺行腹下动脉通路相比，P = 0.65）。
本研究表明，（1）中位旁路移植术年龄为2年的ABF患者中报告近端跛行的比例较高（28%），（2）通过跑步机运动试验检测到跛行时，这一比例显著更高，（3）在跑步机上观察到的近端症状中，88%可能源于血管（或至少与血管有关），（4）存在近端跛行及相关异常TcPO2结果会增加受影响患者行走障碍的风险，（5）保留至少一条髂内动脉以允许向腹下血管床的顺行或逆行血流，并不会降低ABF手术后近端跛行的风险。对于ABF旁路移植术通畅的患者，应始终讨论大多数近端运动相关症状的血管源性（或至少与血管有关）。
