Ballotta Enzo, Da Giau Giuseppe, Gruppo Mario, Mazzalai Franco, Martella Bruno, Militello Carmelo, Toniato Antonio
Department of Surgical, and Gastroenterological Sciences, University of Padua, Italy.
Surgery. 2009 Apr;145(4):426-34. doi: 10.1016/j.surg.2008.12.005. Epub 2009 Feb 14.
The purpose of this study was to analyze our experience of bypass procedures to an isolated ("blind") popliteal artery segment (IPAS) to revascularize the perigeniculate arteries in patients with critical limb ischemia (CLI), to establish whether such revascularizations could yield acceptable results in terms of patency and limb salvage (LS) rates.
Over a decade, 347 above-knee arterial revascularizations were performed in 293 patients and in 51 (14.7%) of these the outflow vessels were the perigeniculate arteries arising from an IPAS, through a reversed saphenous vein or spliced veins (n = 30, 58.8%; group I) or polytetrafluoroethylene (n = 21, 41.2%; group II) prosthetic grafts. Patency, LS, and survival rates were assessed using Kaplan-Meier life-table analysis. A complete follow-up (range, 0.1-10.4 years; mean, 5.6 years) was obtained in 49 patients.
The IPAS was chosen as the last resort in 39 patients (76.5%) because no other infrapopliteal artery was identified as being available at angiography; in 12 patients (23.5%) it was chosen because of an invasive foot infection or ischemic necrosis overlying the dorsalis pedis or the posterior tibial arteries. The study series was mainly male, with significantly more younger patients in group I (72 +/- 1 years vs 74 +/- 5 years, P = .037). Group I had a statistically higher incidence of diabetes mellitus (76.6% vs 47.6%, P = .033), insulin dependence (56.7% vs 28.6%, P = .047) and history of smoking (80% vs 47.6%, P = .016) than group II. None of the patients died in the perioperative period. There were 3 early graft failures (2 in group I), prompting 3 major amputations. Kaplan-Meier analysis identified 5-year patency and LS rates of 51.4 +/- 9.6% and 90 +/- 4.3%, respectively, in the series as a whole, and the 2 groups had comparable 5-year patency, LS and survival rates.
Revascularizations to an IPAS can be performed with acceptable results in terms of patency and LS rates, even when there is no infrapopliteal runoff vessel. Finding perigeniculate arteries arising from an IPAS with no tibio-peroneal vessel reconstitution at arteriography does not justify a pessimistic attitude to the performance of such revascularizations for LS.
本研究的目的是分析我们对孤立（“盲端”）腘动脉段（IPAS）进行搭桥手术以使严重肢体缺血（CLI）患者的膝周动脉血运重建的经验，以确定这种血运重建在通畅率和肢体挽救（LS）率方面是否能产生可接受的结果。
在十年间，对293例患者进行了347例膝上动脉血运重建手术，其中51例（14.7%）的流出血管是源自IPAS的膝周动脉，通过大隐静脉反转或拼接静脉（n = 30，58.8%；第一组）或聚四氟乙烯（n = 21，41.2%；第二组）人工血管进行。使用Kaplan-Meier生存表分析评估通畅率、LS率和生存率。49例患者获得了完整的随访（范围0.1 - 10.4年；平均5.6年）。
39例患者（76.5%）将IPAS作为最后手段，因为在血管造影时未发现其他腘下动脉可用；12例患者（23.5%）选择IPAS是因为足背动脉或胫后动脉上方存在侵袭性足部感染或缺血性坏死。研究系列主要为男性，第一组年轻患者明显更多（72±1岁对74±5岁，P = 0.037）。第一组糖尿病发病率（76.6%对47.6%，P = 0.033）、胰岛素依赖率（56.7%对28.6%，P = 0.047）和吸烟史（80%对47.6%，P = 0.016）在统计学上高于第二组。围手术期无患者死亡。有3例早期移植失败（第一组2例），导致3例大截肢。Kaplan-Meier分析确定整个系列的5年通畅率和LS率分别为51.4±9.6%和90±4.3%，两组的5年通畅率、LS率和生存率相当。
即使没有腘下流出血管，对IPAS进行血运重建在通畅率和LS率方面也能取得可接受的结果。在血管造影时发现源自IPAS的膝周动脉且无胫腓血管重建，并不足以对进行这种血运重建以挽救肢体持悲观态度。
