Morris-Stiff G, D'Souza J, Raman S, Paulvannan S, Lewis M H
Department of Surgery, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK.
Ann R Coll Surg Engl. 2009 Nov;91(8):637-40. doi: 10.1308/003588409X12486167521271. Epub 2009 Sep 25.
The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit.
All emergency operations performed during the period 1993-2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990.
There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993-2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score > or = III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking.
Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.
本研究旨在审核急性肢体缺血（ALI）手术10年经验的肢体挽救和死亡率结果，并将结果与我们单位之前发表的历史系列进行比较。
从手术室登记册和回顾的患者病历中确定1993年至2003年期间进行的所有急诊手术，以确定手术指征和结果。将数据与1980年至1990年接受手术的类似队列进行比较。
两个时间段之间工作量增加了33%，从87例患者增加到116例。1993年至2003年接受治疗的患者中，特发性ALI患者数量减少（24%对4%；P<0.05），吸烟者减少（71%对39%；P<0.05），间歇性跛行患者增多（17%对35%；P<0.05）。最近，更多患者接受了术前肝素化（33%对80%；P<0.05），接受了预防性抗生素治疗（14%对63%；P<0.05），并且有麻醉医生在手术室（46%对88%；P<0.05）。局部麻醉手术也有所减少（80%对41%；P<0.05）。尽管术前（15%对47%；P<0.05）和术中成像（0%对16%；P<0.05）有所增加，但技术成功率并未提高。虽然并发症发生率相同，均为62%，但最近队列中的心血管并发症较少。动脉栓子切除术的30天死亡率从45%降至33%。多变量分析显示，年龄>70岁、症状持续时间延长、ASA评分>或=III、缺乏预防性抗生素、没有麻醉医生以及在局部麻醉下进行手术与死亡风险增加相关。对肢体挽救产生不利影响的因素包括症状发作到手术的时间延长以及间歇性跛行或吸烟史。
尽管术前和围手术期管理有所改善，但动脉栓子切除术/血栓切除术仍然是一种发病率和死亡率较高的手术。必须进一步努力改善结果，应着眼于早期诊断和转诊，因为从症状发作到手术的延迟是结果的主要决定因素。
