Hertzer Norman R, Bena James F, Karafa Mathew T
Cleveland Clinic Foundation, Department of Vascular Surgery, Cleveland, Ohio 44195, USA.
J Vasc Surg. 2007 Aug;46(2):271-279. doi: 10.1016/j.jvs.2007.03.050. Epub 2007 Jun 27.
To investigate the influence of diabetes mellitus and other factors on the outcome of all infrainguinal bypass grafts performed for occlusive disease by a single surgeon at a tertiary referral center.
The series includes 650 operations in 412 men and 238 women with median ages of 65 and 69 years, respectively. Critical ischemia was the indication for most procedures (n = 553, 85%), but 97 (15%) were done for claudication alone. Nearly half (n = 312, 48%) of the patients were diabetic, and 195 (30%) required insulin. All-autogenous vein was used for 389 grafts (60%). Synthetic or composite materials were employed for the remaining 261 grafts, 91 (35%) of which were entirely above the knee. Perioperative data were recorded contemporaneously and were supplemented by reviewing 558 of the 565 medical records and the Social Security Death Index. Survival, graft patency, and limb salvage were analyzed using logistic regression, Kaplan-Meier estimates and proportional hazards models.
Diabetics were more likely to have critical preoperative limb ischemia (P < .001), elevated serum creatinine (P = .003) or a history of previous coronary intervention (P = .015), lower extremity revascularization (P < .001) or minor amputations (P = .002). The operative mortality rate was 4.8%, and there were 81 graft occlusions (12%) and 49 major amputations (7.5%) during the index hospital admission. Patency was immediately restored in 46 of the 81 occluded grafts, but their secondary patency rates were only 62 +/- 16% at 1 year and 26 +/- 18% at 5 years. Insulin-dependent diabetes was associated with a higher incidence of early amputation (odds ratio, 2.6; 95% confidence interval [CI], 1.4-4.8; P = .004). Overall survival was 52 +/- 4% at 5 years and 25 +/- 5% at 10 years, and there were 175 late graft occlusions (27%), a total of 198 related reoperations and 107 late amputations (16%). The risks for further occlusion and/or major amputation after three or more graft revisions were 65% and 71%, respectively. Insulin-dependent diabetes also was associated with higher late mortality (hazard ratio [HR], 1.5; 95% CI, 1.2-1.8; P = .001) and amputation rates (HR, 1.5; 95% CI, 1.0-2.1; P = .026), but other independent variables like age, elevated serum creatinine, critical preoperative ischemia, synthetic conduits, and previous ipsilateral bypass had at least as much influence as diabetes on survival, graft failure or limb loss.
Diabetes was one of several factors influencing survival and limb preservation, but it did not adversely affect graft patency. The number of graft revisions was an important predictor of further occlusion or amputation.
研究糖尿病及其他因素对一名外科医生在三级转诊中心为闭塞性疾病施行的所有股下旁路移植术预后的影响。
该系列研究包括650例手术，其中男性412例，女性238例，年龄中位数分别为65岁和69岁。大多数手术（n = 553，85%）的指征为严重缺血，但97例（15%）仅因间歇性跛行而进行手术。近一半（n = 312，48%）的患者患有糖尿病，195例（30%）需要胰岛素治疗。389例移植（60%）使用了全自体静脉。其余261例移植使用了合成材料或复合材料，其中91例（35%）完全位于膝上。同期记录围手术期数据，并通过查阅565份病历中的558份及社会保障死亡指数进行补充。使用逻辑回归、Kaplan-Meier估计和比例风险模型分析生存率、移植通畅率和肢体挽救情况。
糖尿病患者术前更易出现严重肢体缺血（P <.001）、血清肌酐升高（P =.003）或有既往冠状动脉介入史（P =.015）、下肢血管重建史（P <.001）或小截肢史（P =.002）。手术死亡率为4.8%，在本次住院期间有81例移植血管闭塞（12%）和49例大截肢（7.5%）。81例闭塞移植血管中有46例立即恢复通畅，但其二次通畅率在1年时仅为62±16%，5年时为26±18%。胰岛素依赖型糖尿病与早期截肢发生率较高相关（比值比，2.6；95%置信区间[CI]，1.4 - 4.8；P =.004）。总体生存率在5年时为52±4%，10年时为25±5%，有175例移植血管晚期闭塞（27%），共198例相关再次手术和107例晚期截肢（16%）。三次或更多次移植血管翻修后进一步闭塞和/或大截肢的风险分别为65%和71%。胰岛素依赖型糖尿病还与较高的晚期死亡率（风险比[HR]，1.5；95% CI，1.2 - 1.8；P =.001）和截肢率（HR，1.5；95% CI，1.0 - 2.1；P =.026）相关，但年龄、血清肌酐升高、术前严重缺血、合成管道和既往同侧旁路等其他独立变量对生存、移植失败或肢体丧失的影响至少与糖尿病一样大。
糖尿病是影响生存和肢体保留的几个因素之一，但并未对移植血管通畅产生不利影响。移植血管翻修次数是进一步闭塞或截肢的重要预测因素。
