Giles Kristina A, Pomposelli Frank B, Spence T L, Hamdan Allen D, Blattman Seth B, Panossian Haig, Schermerhorn Marc L
Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
J Vasc Surg. 2008 Jul;48(1):128-36. doi: 10.1016/j.jvs.2008.02.027. Epub 2008 May 23.
Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification.
From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined.
Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates.
Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.
近期数据表明，经皮腔内血管成形术（PTA）可能是治疗严重肢体缺血（CLI）的合适初始疗法。然而，关于基于跨大西洋两岸协作组共识（TASC）分类的腘下血管成形术结果的数据较少。我们报告了根据TASC病变分类进行的腘下血管成形术的经验。
从2004年2月至2007年3月，176条连续肢体（163例患者）因CLI接受了腘下血管成形术。对PTA难治性病变或限流性夹层置入支架。患者根据TASC分类和旁路移植的适用性进行分层。主要结局是无再狭窄、再次干预或截肢。确定了初始通畅率、无二次再狭窄、肢体挽救、通过重复血管成形术或旁路进行的再次干预以及生存率。
中位年龄为73岁（范围39 - 94岁）。技术成功率为93%。平均随访时间为10个月（范围1 - 41个月）。在1年和2年时，无再狭窄、再次干预或截肢的比例分别为39%和35%，传统初始通畅率分别为53%和51%，无二次再狭窄和再次干预的比例分别为63%和61%。在1年、2年和3年时肢体挽救率为84%。2年内，15%的患者接受了旁路手术，18%的患者接受了重复腘下PTA。术后并发症发生率为9%，术中并发症发生率为10%。30天死亡率为5%（181例中的9例）。1年、2年和3年时的总生存率分别为81%、65%和54%。TASC D分类预示技术成功率降低（D类为75%，A、B和C类为100%；P < 0.001），初始再狭窄、再次干预或截肢（风险比[HR]，3.4；95%置信区间[CI]，2.1 - 5.5，P < 0.001），初始通畅率（HR，2.2；95% CI，1.3 - 3.9，P < 0.004），二次再狭窄（HR，3.2；95% CI，1.6 - 6.4，P = 0.001）以及肢体挽救（HR，2.6；95% CI，1.1 - 6.3，P < 0.05）。不适合手术旁路也预示着再狭窄、再次干预或截肢、二次再狭窄、需要重复血管成形术以及较差的初始通畅率和肢体挽救率。
腘下血管成形术是治疗TASC A、B或C类病变的CLI患者的合理初始治疗方法。不适合旁路手术的患者再狭窄、再次干预或截肢的发生率较高；然而，对于这些患者，可尝试进行PTA作为初始截肢的替代方法。虽然CLI患者胫部血管成形术后再狭窄、再次干预或截肢的发生率较高，但通过仔细随访并在必要时进行再次干预，包括15%的患者进行旁路手术，可获得出色的肢体挽救率。
