Werneck Christiane C F, Lindsay Thomas F
Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, UHN, University of Toronto, Toronto, Canada.
Ann Vasc Surg. 2009 Sep-Oct;23(5):554-9. doi: 10.1016/j.avsg.2009.05.007. Epub 2009 Jul 24.
We examined the efficacy and cost of tibial angioplasty in patients with critical limb ischemia (CLI) at high operative risk.
A retrospective analysis of all consecutive patients who underwent tibial angioplasty with critical ischemia Rutherford class 4 and 5 from January 2001 to April 2007 was performed. Demographic information, presentation, and angiographic characteristics of the lesions were analyzed. The primary end point was freedom from major amputation. Secondary end points were overall survival and recurrence. Cost comparison was performed between the endovascular group and a matched group of high-risk patients submitted to femoral tibial bypass in the same period.
Forty-five patients, with mean age of 69.6 years and a 2.5:1 (male:female) ratio, had 49 limbs treated. The mean follow-up was 7.7 months (range 1-61.5). Eighty percent of the patients were Rutherford class 5. Incidence rates were as follows: diabetes 90%, chronic renal failure 73%, end-stage renal disease (ESRD) on hemodialysis 45%, and coronary disease 69%. Single vessel run-off to the foot was present in 57% of patients and complete occlusion of all tibial vessels in 12%. Only the tibial vessels were angioplastied in 55% of patients. Angiographic success rate was 84%. Thirty-day mortality was 2% and major complications occurred in 6.1%. A poor angiographic result was a statistically significant predictor (p = 0.009) of symptomatic recurrence (43%) (worsening of preexisting symptoms and/or signs or new ones). Cardiac disease was the major cause of mortality beyond 30 days (12.5%). Freedom from major amputation in the entire group was 75.5%, with no difference between tibial and diffuse infrainguinal angioplasty (p = 0.61). Recurrence, especially early recurrence, was a significant predictor of amputation (p = 0.04 and p = 0.0008, respectively). There was a trend toward presence of ESRD and recurrence (p = 0.06). Both average hospital cost ($2,910.60 vs. $17,703.50) and length-of-stay (LOS) (<1 vs. 9 days) were significantly reduced in the angioplasty group (p < 0.0001).
Tibial angioplasty has acceptable rates of limb salvage in patients with CLI considered to be at high risk for surgery, despite high recurrence rates. The presence of diabetes or ESRD did not reduce the rate of success in this series, although ESRD seemed to predict recurrence. The procedure has low morbidity and mortality with lower cost and LOS compared with open revascularization. Aggressive angioplasty should be an option to patients who otherwise would face primary amputation.
我们研究了手术风险高的严重肢体缺血（CLI）患者行胫动脉血管成形术的疗效及成本。
对2001年1月至2007年4月期间接受胫动脉血管成形术且缺血程度为卢瑟福分级4级和5级的所有连续患者进行回顾性分析。分析患者的人口统计学信息、临床表现及病变的血管造影特征。主要终点为免于大截肢。次要终点为总生存率及复发情况。对血管内治疗组与同期接受股-胫动脉旁路移植术的匹配高危患者组进行成本比较。
45例患者（平均年龄69.6岁，男女比例为2.5:1）共49条肢体接受了治疗。平均随访时间为7.7个月（范围1 - 61.5个月）。80%的患者为卢瑟福分级5级。发病率如下：糖尿病90%，慢性肾衰竭73%，接受血液透析的终末期肾病（ESRD）45%，冠心病69%。57%的患者足部存在单支血管流出道，12%的患者所有胫动脉血管完全闭塞。55%的患者仅对胫动脉血管进行了血管成形术。血管造影成功率为84%。30天死亡率为2%，主要并发症发生率为6.1%。血管造影结果不佳是症状复发（43%）（原有症状和/或体征加重及出现新症状）的统计学显著预测因素（p = 0.009）。心脏病是30天以后死亡的主要原因（12.5%）。整个组免于大截肢的比例为75.5%，胫动脉血管成形术与弥漫性股腘动脉血管成形术之间无差异（p = 0.61）。复发，尤其是早期复发，是截肢的显著预测因素（分别为p = 0.04和p = 0.0008）。存在ESRD与复发有一定趋势相关（p = 0.06）。血管成形术组的平均住院费用（2910.60美元对17703.50美元）和住院时间（<1天对9天）均显著降低（p < 0.0001）。
对于被认为手术风险高的CLI患者，尽管复发率高，但胫动脉血管成形术的肢体挽救率可接受。糖尿病或ESRD的存在并未降低本系列的成功率，尽管ESRD似乎可预测复发。与开放性血管重建相比，该手术的发病率和死亡率低，成本和住院时间也更低。对于否则将面临一期截肢的患者，积极的血管成形术应是一种选择。
