Ballotta Enzo, Da Giau Giuseppe, Piccoli Antonio
Vascular Surgery Section, Institute of Geriatric Surgery, Department of Surgical and Gastroenterological Sciences, School of Medicine, University of Padua, Padua - Italy.
J Nephrol. 2007 Jan-Feb;20(1):80-7.
This study was undertaken to ascertain whether infrapopliteal arterial revascularization (IAR) for limb-threatening ischemia is worthwhile in patients with severe chronic kidney disease (CKD).
With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with CKD who underwent IAR between January 1, 1990, and December 31, 2002. Primary, assisted primary and secondary patency rates, limb salvage, patient survival and amputation-free survival were assessed using Kaplan-Meier analysis. Factors influencing the outcome were evaluated with univariate and multivariate analyses.
Eighty-seven consecutive patients underwent 93 IARs; more than half (53%) of the patients were diabetic and nearly all (84%) had foot tissue loss. No patients died during the perioperative (30-day) period. At 1 and 5 years, primary patency rates were 92.3% and 77.2% in the series as a whole, 89.5% and 71.4% for diabetics vs. 95.3% and 83.4% for nondiabetics (p=0.164), and 78.9% and 49.1% for patients on dialysis vs. 95.7% and 85.3% for those not on dialysis (p=0.006). At 1 and 5 years, the secondary patency rates were 93.4% and 85.6% in the series as a whole, 91.7% and 82.1% for diabetics vs. 95.3% and 88.7% for nondiabetics (p=0.381), and 84.2% and 68% for patients on dialysis vs. 95.7% and 90.1% for those not on dialysis (p=0.002). At 1 and 5 years, the limb salvage rates were 96.8% and 80.6% in the series as a whole, 98% and 71.4% for diabetics vs. 100% and 88.7% for nondiabetics (p=0.104), and 94.7% and 61.7% for patients on dialysis vs 97.3% and 85.9% for those not on dialysis (p=0.020). There were 31 late deaths in the series as a whole, with a 5-year survival rate of 62.5%. At 1 and 5 years, the amputation-free survival probabilities were 93.4% and 54.4% in the series as a whole, 91.7% and 38.6% for diabetics vs. 95.2% and 70.2% for nondiabetics (p=0.011), and 89.5% and 39% for patients on dialysis vs. 94.4% and 58.8% for those not on dialysis (p=0.097). The dialysis treatment was the only predictor of primary patency failure (p=0.04).
Although the overall outcome was poorer in patients on dialysis, IARs for limb-threatening ischemia in patients with CKD can achieve satisfactory results in terms of graft patency, limb salvage and amputation-free survival, especially if the tissue loss is manageable and an adequate autologous conduit is available.
本研究旨在确定对于患有严重慢性肾脏病（CKD）且肢体存在威胁性缺血的患者，腘下动脉血管重建术（IAR）是否值得实施。
利用一家大学教学医院血管登记处前瞻性录入的数据，我们回顾了1990年1月1日至2002年12月31日期间所有接受IAR的CKD患者的记录。使用Kaplan-Meier分析评估原发性、辅助原发性和继发性通畅率、肢体挽救情况、患者生存率和无截肢生存率。通过单因素和多因素分析评估影响结果的因素。
87例连续患者接受了93次IAR；超过一半（53%）的患者患有糖尿病，几乎所有患者（84%）存在足部组织缺失。围手术期（30天）内无患者死亡。在1年和5年时，整个系列的原发性通畅率分别为92.3%和77.2%，糖尿病患者分别为89.5%和71.4%，非糖尿病患者分别为95.3%和83.4%（p = 0.164）；透析患者分别为78.9%和49.1%，未透析患者分别为95.7%和85.3%（p = 0.006）。在1年和5年时，整个系列的继发性通畅率分别为93.4%和85.6%，糖尿病患者分别为91.7%和82.1%，非糖尿病患者分别为95.3%和88.7%（p = 0.381）；透析患者分别为84.2%和68%，未透析患者分别为95.7%和90.1%（p = 0.002）。在1年和5年时，整个系列的肢体挽救率分别为96.8%和80.6%，糖尿病患者分别为98%和71.4%，非糖尿病患者分别为100%和88.7%（p = 0.104）；透析患者分别为94.7%和61.7%，未透析患者分别为97.3%和85.9%（p = 0.020）。整个系列中有31例晚期死亡，5年生存率为62.5%。在1年和5年时，整个系列的无截肢生存概率分别为93.4%和54.4%，糖尿病患者分别为91.7%和38.6%，非糖尿病患者分别为95.2%和70.2%（p = 0.011）；透析患者分别为89.5%和39%，未透析患者分别为94.4%和58.8%（p = 0.097）。透析治疗是原发性通畅失败的唯一预测因素（p = 0.04）。
尽管透析患者的总体结果较差，但对于CKD且肢体存在威胁性缺血的患者，IAR在移植物通畅率、肢体挽救和无截肢生存率方面可取得满意结果，尤其是在组织缺失可控且有足够自体血管可用的情况下。
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