Ihnat Daniel M, Duong Son T, Taylor Zachary C, Leon Luis R, Mills Joseph L, Goshima Kaoru R, Echeverri Jose A, Arslan Bulent
Vascular Surgery, University of Arizona Health Science Center, University Medical Center, Tucson, AZ 85724, USA.
J Vasc Surg. 2008 May;47(5):967-74. doi: 10.1016/j.jvs.2007.12.050. Epub 2008 Apr 18.
A recent randomized trial suggested nitinol self-expanding stents (SES) were associated with reduced restenosis rates compared with simple percutaneous transluminal angioplasty (PTA). We evaluated our results with superficial femoral artery (SFA) SES to determine whether TransAtlantic InterSociety Consensus (TASC) classification, indication for intervention, patient risk factors, or Society of Vascular Surgery (SVS) runoff score correlated with patency and clinical outcome, and to evaluate if bare nitinol stents or expanded polytetrafluoroethylene (ePTFE) covered stent placement adversely impacts the tibial artery runoff.
A total of 109 consecutive SFA stenting procedures (95 patients) at two university-affiliated hospitals from 2003 to 2006 were identified. Medical records, angiographic, and noninvasive studies were reviewed in detail. Patient demographics and risk factors were recorded. Procedural angiograms were classified according to TASC Criteria (I-2000 and II-2007 versions) and SVS runoff scores were determined in every patient; primary, primary-assisted, secondary patency, and limb salvage rates were calculated. Cox proportional hazard model was used to determine if indication, TASC classification, runoff score, and comorbidities affected outcome.
Seventy-one patients (65%) underwent SES for claudication and 38 patients (35%) for critical limb ischemia (CLI). Average treatment length was 15.7 cm, average runoff score was 4.6. Overall 36-month primary, primary-assisted, and secondary rates were 52%, 64%, and 59%, respectively. Limb salvage was 75% in CLI patients. No limbs were lost following interventions in claudicants (mean follow-up 16 months). In 24 patients with stent occlusion, 15 underwent endovascular revision, only five (33%) ultimately remained patent (15.8 months after reintervention). In contrast, all nine reinterventions for in-stent stenosis remained patent (17.8 months). Of 24 patients who underwent 37 endovascular revisions for either occlusion or stenosis, eight (35%) had worsening of their runoff score (4.1 to 6.4). By Cox proportional hazards analysis, hypertension (hazard ratio [HR] 0.35), TASC D lesions (HR 5.5), and runoff score > 5 (HR 2.6) significantly affected primary patency.
Self-expanding stents produce acceptable outcomes for treatment of SFA disease. Poorer patency rates are associated with TASC D lesions and poor initial runoff score; HTN was associated with improved patency rates. Stent occlusion and in-stent stenosis were not entirely benign; one-third of patients had deterioration of their tibial artery runoff. Future studies of SFA interventions need to stratify TASC classification and runoff score. Further evaluation of the long-term effects of SFA stenting on tibial runoff is needed.
最近一项随机试验表明，与单纯经皮腔内血管成形术（PTA）相比，镍钛诺自膨式支架（SES）与再狭窄率降低相关。我们评估了我们在股浅动脉（SFA）应用SES的结果，以确定跨大西洋两岸血管外科学会共识（TASC）分类、干预指征、患者风险因素或血管外科学会（SVS）流出道评分是否与通畅率及临床结局相关，并评估裸镍钛诺支架或膨体聚四氟乙烯（ePTFE）覆膜支架置入是否会对胫动脉流出道产生不利影响。
确定了2003年至2006年在两家大学附属医院进行的109例连续的SFA支架置入手术（95例患者）。详细回顾了病历、血管造影和非侵入性研究。记录患者的人口统计学和风险因素。根据TASC标准（2000年版I和2007年版II）对手术血管造影进行分类，并确定每位患者的SVS流出道评分；计算主要通畅率、主要辅助通畅率、次要通畅率和肢体挽救率。使用Cox比例风险模型确定干预指征、TASC分类、流出道评分和合并症是否影响结局。
71例患者（65%）因间歇性跛行接受SES治疗，38例患者（35%）因严重肢体缺血（CLI）接受治疗。平均治疗长度为15.7 cm，平均流出道评分为4.6。总体36个月的主要通畅率、主要辅助通畅率和次要通畅率分别为52%、64%和59%。CLI患者的肢体挽救率为75%。间歇性跛行患者在干预后无一例肢体丢失（平均随访16个月）。在24例支架闭塞患者中，15例接受了血管腔内翻修，只有5例（33%）最终保持通畅（再次干预后15.8个月）。相比之下，所有9例因支架内狭窄进行的再次干预均保持通畅（17.8个月）。在24例因闭塞或狭窄接受37次血管腔内翻修的患者中，8例（35%）的流出道评分恶化（从4.1降至6.4）。通过Cox比例风险分析，高血压（风险比[HR]0.35）、TASC D级病变（HR 5.5）和流出道评分>5（HR 2.6）显著影响主要通畅率。
自膨式支架治疗SFA疾病可产生可接受的结果。较差的通畅率与TASC D级病变和初始流出道评分不佳相关；高血压与较高的通畅率相关。支架闭塞和支架内狭窄并非完全无害；三分之一的患者胫动脉流出道恶化。未来SFA干预研究需要对TASC分类和流出道评分进行分层。需要进一步评估SFA支架置入对胫动脉流出道的长期影响。
