Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands.
J Vasc Surg. 2010 Feb;51(2):360-71.e1. doi: 10.1016/j.jvs.2009.08.051.
Lower extremity arterial revascularization (LEAR) is the gold-standard for critical lower limb ischemia (CLI). The goal of this study was twofold. First, we evaluated the long-term functional status of patients undergoing primary LEAR for CLI. Second, prognostic factors of long-term functional status and survival after primary LEAR for CLI were assessed.
All primary LEAR procedures were analyzed. Patients were stratified by preoperative functional status: ambulatory (group I) vs nonambulatory (group II). Patients were followed-up after 3 and 6 years. Adverse events (AEs) were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. Associated patient demographic/clinical data were analyzed using univariate and multivariate methods.
There were 106 LEAR patients (group I: n = 42, 40% vs group II: n = 64, 60%). Group II patients were significantly older (75 vs 62 years; P = .00), were classified ASA 3-4 more frequently (78% vs 52%; P < .02), had more cardiac disease (n = 42, 66% vs n = 10, 24%; P = .00), renal disease (n = 26, 41% vs n = 7, 17%; P = .00), diabetes (n = 36, 56% vs n = 8, 19%; P = .00), hypertension (n = 47, 73% vs n = 13, 31%; P = .00) and severe CLI (n = 42, 66% vs n = 18, 38%; P < .01). Group II patients had a higher incidence of death (65.6% vs 14.3%; P = .00), minor AEs (n = 38, 26% vs n = 10, 22%; P = .00), surgical AEs (n = 48, 33% vs n = 12, 26%; P < .02) and systemic AEs (n = 24, 86% vs n = 4, 9%; P < .02). Also more unplanned reinterventions occurred in group II (n = 148, 76% vs n = 47, 24%; P = .00). Nonambulatory status was a multivariate independent predictor of nonambulatory status after LEAR during 6 years follow-up (odds ration [OR[: 21.47; 95% confidence interval [CI]: 2.76-166.77; P = .00). Pulmonary disease (OR: 7.49; 95% CI: 2.17-25.80; P = .00), not prescribing beta-blockers (OR: 4.67; 95% CI: 1.28-17.03; P < .02), nonambulatory status (OR: 22.99; 95% CI: 6.27-84.24; P = .00), and systemic AEs (OR: 9.66; 95% CI: 1.84-50.57; P < .01) were independent predictors of death. Functional status was not improved in group II after long-term follow-up.
Nonambulatory patients suffer from extensive comorbid conditions. They are accompanied with an increased occurrence of AEs, unplanned reinterventions, and poor long-term survival rates. Successful LEAR did not improve their functional status after 6 years. This emphasizes that attempts for limb salvage must be carefully considered in these patients.
下肢动脉血运重建（LEAR）是治疗严重下肢缺血（CLI）的金标准。本研究的目的有两个。首先，我们评估了 CLI 患者接受原发性 LEAR 的长期功能状态。其次，评估了原发性 LEAR 后长期功能状态和生存的预后因素。
分析了所有原发性 LEAR 手术。根据术前功能状态对患者进行分层：可走动（组 I）与不可走动（组 II）。术后 3 年和 6 年进行随访。根据预先设定的标准对不良事件（AE）进行分类：轻微、手术、血运重建失败和全身性。使用单变量和多变量方法分析相关患者的人口统计学/临床数据。
共有 106 例 LEAR 患者（组 I：n = 42，40% vs 组 II：n = 64，60%）。组 II 患者年龄明显较大（75 岁 vs 62 岁；P =.00），ASA 分级 3-4 更为常见（78% vs 52%；P <.02），心脏病（n = 42，66% vs n = 10，24%；P =.00）、肾脏疾病（n = 26，41% vs n = 7，17%；P =.00）、糖尿病（n = 36，56% vs n = 8，19%；P =.00）、高血压（n = 47，73% vs n = 13，31%；P =.00）和严重 CLI（n = 42，66% vs n = 18，38%；P <.01）更为常见。组 II 患者的死亡率（65.6% vs 14.3%；P =.00）、轻微 AE（n = 38，26% vs n = 10，22%；P =.00）、手术 AE（n = 48，33% vs n = 12，26%；P <.02）和全身性 AE（n = 24，86% vs n = 4，9%；P <.02）的发生率更高。组 II 还发生了更多的计划外再介入（n = 148，76% vs n = 47，24%；P =.00）。非走动状态是 LEAR 后 6 年随访中不能走动状态的独立预测因素（优势比[OR]：21.47；95%置信区间[CI]：2.76-166.77；P =.00）。肺部疾病（OR：7.49；95% CI：2.17-25.80；P =.00）、未开β受体阻滞剂（OR：4.67；95% CI：1.28-17.03；P <.02）、非走动状态（OR：22.99；95% CI：6.27-84.24；P =.00）和全身性 AE（OR：9.66；95% CI：1.84-50.57；P <.01）是死亡的独立预测因素。组 II 患者在长期随访后功能状态没有改善。
不能走动的患者患有广泛的合并症。他们发生 AE、计划外再介入和长期生存率低的情况更为常见。原发性 LEAR 成功并不能改善他们 6 年后的功能状态。这强调了在这些患者中必须谨慎考虑保肢治疗的尝试。
