Al-Khoury Georges, Marone Luke, Chaer Rabih, Rhee Robert, Cho Jae, Leers Steven, Makaroun Michel, Gupta Navyash
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
J Vasc Surg. 2009 Oct;50(4):784-9. doi: 10.1016/j.jvs.2009.05.053. Epub 2009 Jul 22.
Atherosclerotic occlusive disease of the femoral artery is associated with symptoms ranging from claudication to tissue loss. This study examined the clinical and hemodynamic outcomes of isolated femoral endarterectomy (FEA) as well as the predictors of symptom recurrence and need for further intervention.
Patients who underwent an isolated FEA between January 2001 and June 2008 were reviewed. Concurrent superficial femoral artery (SFA) disease was classified into Trans Atlantic Inter-Societal Consensus (TASC) II categories based upon angiographic findings. Hemodynamic success (HS) was defined as a postoperative ankle-brachial index (ABI) increase of >or=0.15. Clinical improvement was classified by Rutherford criteria. Multivariate analysis was used to identify predictors of clinical failure and need for additional intervention (AI). Kaplan-Meier estimates were used to determine the likelihood of both over time.
Ninety-five patients (105 limbs) with a mean age of 68.3 +/- 10.2 years were reviewed. Indications were severe claudication in 68 (64.8%) limbs and critical limb ischemia (CLI) in 37 (35.2%). Mean preprocedural ABI was 0.57 +/- 0.25. The SFA-popliteal segment was classified as: normal in 34% of limbs, TASC A 23%, B 19%, C 9%, and D in 15%. One fatal myocardial infarction accounted for a procedural mortality of 0.95%. Morbidity was 6.7% (four hematomas and three wound infections) and mean hospital stay was 2.5 +/- 3.1 days. Patency was 100% with a mean follow-up of 11 months (1-72). Complete resolution of symptoms was noted in 73.4% with some clinical improvement noted in 91% of limbs. HS was achieved in 85.1% with a mean ABI increase of 0.27 +/- 0.20, and this correlated with >or=2 runoff vessels (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96; P = .045). Kaplan-Meier estimates revealed that 83.8% of patients with marked initial clinical improvement remained symptom free at 2 years, whereas only 28.6% in the group with mild and moderate initial response maintained their clinical status. Freedom from AI at 2 years was 61.8%. Multivariate analysis revealed that TASC C and D lesions (OR 9.3 [2.43-35.63] P = .001) and diabetes (OR 3.64 [1.01-13.15] P = .048) were predictive of recurrent symptoms while extensive endarterectomy and >or=2 vessel tibial runoff decreased the need for AI.
FEA can achieve excellent immediate clinical and hemodynamic outcome in patients with claudication and CLI; however, patients with diabetes and femoropopliteal TASC C and D lesions are likely to experience recurrent symptoms. Long-term symptomatic improvement is associated with the degree of immediate clinical success as well as the status of the run-off vessels. Limited FEA and poor tibial runoff are associated with the need for AI.
股动脉粥样硬化闭塞性疾病与从间歇性跛行到组织缺失等一系列症状相关。本研究探讨了单纯股动脉内膜切除术（FEA）的临床和血流动力学结果，以及症状复发和进一步干预需求的预测因素。
回顾了2001年1月至2008年6月期间接受单纯FEA的患者。根据血管造影结果，将同时存在的股浅动脉（SFA）疾病分为跨大西洋跨学会共识（TASC）II类别。血流动力学成功（HS）定义为术后踝肱指数（ABI）升高≥0.15。临床改善根据卢瑟福标准分类。采用多变量分析确定临床失败和额外干预（AI）需求的预测因素。使用Kaplan-Meier估计来确定两者随时间的可能性。
回顾了95例患者（105条肢体），平均年龄68.3±10.2岁。适应症为68条（64.8%）肢体的严重间歇性跛行和37条（35.2%）肢体的严重肢体缺血（CLI）。术前平均ABI为0.57±0.25。SFA-腘动脉段分类为：34%的肢体正常，TASC A 23%，B 19%，C 9%，D 15%。1例致命心肌梗死导致手术死亡率为0.95%。发病率为6.7%（4例血肿和3例伤口感染），平均住院时间为2.5±3.1天。平均随访11个月（1-72个月）时通畅率为100%。73.4%的患者症状完全缓解，91%的肢体有一定临床改善。85.1%的患者实现了HS，平均ABI升高0.27±0.20，这与≥2条流出血管相关（优势比[OR]0.20；95%置信区间[CI]0.04-0.96；P = 0.045）。Kaplan-Meier估计显示，初始临床改善明显的患者中83.8%在2年时仍无症状，而初始反应为轻度和中度的组中只有28.6%维持其临床状态。2年时无需AI的比例为61.8%。多变量分析显示，TASC C和D病变（OR 9.3[范围2.43-35.63]，P = 0.001）和糖尿病（OR 3.64[范围1.01-13.15]，P = 0.048）可预测症状复发，而广泛的内膜切除术和≥2条胫动脉流出血管可降低AI需求。
FEA可使间歇性跛行和CLI患者取得优异的即时临床和血流动力学结果；然而，糖尿病患者以及股腘动脉TASC C和D病变患者可能会出现症状复发。长期症状改善与即时临床成功程度以及流出血管状态相关。有限的FEA和胫动脉流出不良与AI需求相关。
