Simosa Hector F, Malek Junaid Y, Schermerhorn Marc L, Giles Kristina A, Pomposelli Frank B, Hamdan Allen D
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA.
J Vasc Surg. 2009 Jun;49(6):1426-30. doi: 10.1016/j.jvs.2009.02.238.
Lower extremity bypass graft failure in patients with limb-threatening ischemia carries an amputation rate of greater than 50%. Redo bypass is often difficult due to the lack of conduit, adequate target, or increased surgical risk, and resultant limb salvage rates are reduced significantly compared with the index operation. We set forth to investigate whether endovascular treatment in this setting would result in an acceptable limb salvage rate.
A single-institution, retrospective review from June 2004 to December 2007 of patients with failed grafts who underwent endovascular treatment with percutaneous balloon angioplasty (PTA) of their native circulation was performed. Stents were selectively used in cases of post-PTA residual stenosis or flow-limiting dissection. Technical success was defined as a residual stenosis less than 30%. Percutaneous attempts at bypass graft salvage were excluded. Demographics, comorbidities, procedural data, and follow-up information were recorded. Descriptive, logistic regression and life-table analyses were performed.
Twenty-four lower extremities were treated in 23 patients with failed bypass grafts. Average patency of the index graft before failure was 647 days (range 5-2758). Mean age was 68 years (range 51-85), 62% were male and 81% had diabetes mellitus (DM). 87.5% of limbs treated had TransAtlantic InterSociety Consensus (TASC) C and D lesions and 62% had multiple lesions. Technical success was achieved in 100%. Mean follow-up was 25.6 months. At follow-up, there were 17 PTA failures, which resulted in: amputation (4), redo-bypass (3), and redo-PTA (11). Freedom from surgical revision and PTA failure was 89% (+/- 0.07 SE) and 28% (+/- 0.09 SE) respectively. PTA secondary patency was 72% (+/- 0.09 SE) and limb-salvage was 81% (+/- 0.08 SE) at both 12 and 24 months. Overall survival was 83% (+/- 0.07 SE) and 77% (+/- 0.09 SE) at 12 and 24 months, respectively.
Endovascular treatment of patients with previously failed bypass grafts results in a high rate of limb salvage. This is a reasonable option in selected patients and the primary choice in those with poor targets, conduit, or excess surgical risk. Endovascular salvage should be considered before proceeding to primary amputation.
下肢严重缺血患者的下肢旁路移植失败后截肢率超过50%。由于缺乏合适的血管通路、足够的靶血管或手术风险增加，再次进行旁路移植手术往往很困难，与初次手术相比，最终的肢体挽救率显著降低。我们旨在研究在这种情况下进行血管内治疗是否能获得可接受的肢体挽救率。
对2004年6月至2007年12月期间在单一机构接受血管内治疗（对其自身循环进行经皮球囊血管成形术（PTA））的移植失败患者进行回顾性研究。在PTA后残余狭窄或限流性夹层的情况下选择性使用支架。技术成功定义为残余狭窄小于30%。排除经皮尝试挽救旁路移植的情况。记录人口统计学、合并症、手术数据和随访信息。进行描述性、逻辑回归和生存表分析。
23例移植失败患者的24条下肢接受了治疗。初次移植失败前的平均通畅时间为647天（范围5 - 2758天）。平均年龄为68岁（范围51 - 85岁），62%为男性，81%患有糖尿病（DM）。接受治疗的肢体中87.5%有跨大西洋两岸心血管协会（TASC）C级和D级病变，62%有多处病变。技术成功率达100%。平均随访时间为25.6个月。随访时，有17例PTA失败，导致：截肢（4例）、再次旁路移植（3例）和再次PTA（11例）。免于手术翻修和PTA失败的比例分别为89%（±0.07标准误）和28%（±0.09标准误）。在12个月和24个月时，PTA的二次通畅率为72%（±0.09标准误），肢体挽救率为81%（±0.08标准误）。12个月和24个月时的总生存率分别为83%（±0.07标准误）和77%（±0.09标准误）。
对先前旁路移植失败的患者进行血管内治疗可获得较高的肢体挽救率。这对部分患者是一个合理的选择，对于靶血管、血管通路不佳或手术风险过高的患者是首要选择。在进行初次截肢之前应考虑血管内挽救治疗。
