LaMuraglia Glenn M, Conrad Mark F, Chung Tom, Hutter Matthew, Watkins Michael T, Cambria Richard P
The Division of Vascular and Endovascular Surgery, General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, Mass 02114, USA.
J Vasc Surg. 2009 Aug;50(2):299-304, 304.e1-4. doi: 10.1016/j.jvs.2009.01.043.
A variety of clinical and anatomic factors influence the choice between infrainguinal bypass surgery (BPG) and percutaneous endovascular procedures (PTA) to treat lower extremity vascular disease. The decision, in part, is dependant on periprocedural morbidity. The goal of this study was to document the contemporary morbidity and mortality of infrainguinal BPG, utilizing the previously validated National Surgical Quality Improvement Program (NSQIP) database.
Data from the private sector NSQIP, a prospectively validated systematic-sample database, using Current Procedural Terminology (CPT) codes for all infrainguinal BPG performed between January 1, 2005, and December 31, 2006, were analyzed. Study endpoints included 30-day death and NSQIP-defined major complications, including graft failure, differentiated between systemic vs operative-site related complications. Potentially associated clinical variables were assessed by univariate methods to create the multivariate models of factors associated with study endpoints.
There were 2404 infrainguinal BPG (infrapopliteal distal anastomosis 42%, prosthetic 29%) performed in the study interval with patient variables: age 67 +/- 12, male 66%, diabetes 44%, limb salvage indications 48%. The 30-day composite mortality/major morbidity was 19.5%. The overall mortality was 2.7% and correlated with (P value, odds ratio [OR]): patient age (<.001, 1.056), low body weight (.007, 0.988), significant preoperative dyspnea (.03, 1.97), dialysis (.003, 5.26), history transient ischemic attack (.03, 2.43), and bleeding disorder (.02, 2.01). Major complications occurred in 18.7% patients, including 7.4% graft thromboses, and 9.4% wound infections. Major systemic complications occurred in 5.9% and correlated with: age (.001, 1.03), history myocardial infarction (.02, 2.37), dialysis (<.001, 2.52), impaired sensorium (.005, 2.93), and general (vs regional) anesthesia (.04, 1.9). Major operative site-related complications occurred in 15.1% and correlated with: history chronic obstructive pulmonary disease (.04, 1.40), limb salvage indication (<.001, 1.71), impaired sensorium (.01, 2.26), non-independent preoperative functional status (.03, 1.37), and operative time (<.001, 1.002). The combination of dialysis and age >80 was identified as the most powerful high-risk composite for death (13.3-fold) and major complications (2.2-fold).
Infrainguinal BPG is accompanied by significant major morbidity and mortality in contemporary practice. These results reinforce the precept that stringent indications for BPG should be maintained, when considering the method of lower extremity revascularization.
多种临床和解剖因素会影响在下肢旁路移植手术（BPG）和经皮血管腔内介入治疗（PTA）之间选择以治疗下肢血管疾病。这一决策部分取决于围手术期发病率。本研究的目的是利用先前验证过的国家外科质量改进计划（NSQIP）数据库记录当代下肢旁路移植手术的发病率和死亡率。
分析来自私营部门NSQIP的数据，这是一个经过前瞻性验证的系统抽样数据库，使用当前手术操作术语（CPT）编码，涵盖2005年1月1日至2006年12月31日期间进行的所有下肢旁路移植手术。研究终点包括30天死亡率和NSQIP定义的主要并发症，包括移植物失败，并区分全身并发症与手术部位相关并发症。通过单变量方法评估潜在相关的临床变量，以建立与研究终点相关因素的多变量模型。
在研究期间共进行了2404例下肢旁路移植手术（腘以下远端吻合42%，人工血管29%），患者变量如下：年龄67±12岁，男性66%，糖尿病44%，肢体挽救指征48%。30天综合死亡率/主要发病率为19.5%。总体死亡率为2.7%，并与以下因素相关（P值，比值比[OR]）：患者年龄（<.001，1.056）、低体重（.007，0.988）、术前明显呼吸困难（.03，1.97）、透析（.003，5.26）、短暂性脑缺血发作史（.03，2.43）和出血性疾病（.02，2.01）。18.7%的患者发生主要并发症，包括7.4%的移植物血栓形成和9.4%的伤口感染。主要全身并发症发生率为5.9%，并与以下因素相关：年龄（.001，1.03）、心肌梗死病史（.02，2.37）、透析（<.001，2.52）、意识障碍（.005，2.93）和全身（与区域）麻醉（.04，1.9）。主要手术部位相关并发症发生率为15.1%，并与以下因素相关：慢性阻塞性肺疾病病史（.04，1.40）、肢体挽救指征（<.001，1.71）、意识障碍（.01，2.26）、术前非独立功能状态（.03，1.37）和手术时间（<.001，1.002）。透析和年龄>80岁的组合被确定为死亡（13.3倍）和主要并发症（2.2倍）最强大的高危组合。
在当代实践中，下肢旁路移植手术伴随着显著的主要发病率和死亡率。这些结果强化了这样一个观念，即在考虑下肢血管重建方法时，应维持严格的下肢旁路移植手术指征。
