Division of Vascular and Endovascular Surgery, University of California-San Francisco, San Francisco, CA 94143, USA.
J Vasc Surg. 2010 Sep;52(3 Suppl):96S-103S. doi: 10.1016/j.jvs.2010.06.015.
Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The patient with diabetes and a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit, and inflow/outflow artery selection play a dominant role in determining clinical success. An adequate caliber, good quality great saphenous vein (GSV) is the optimal graft for distal bypass in the leg. Alternative veins perform acceptably in the absence of GSV, whereas prosthetic and other non-autogenous conduits have markedly inferior outcomes. Graft configuration (reversed, non-reversed, or in situ) seems to have little influence on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, allow for adequate soft tissue coverage of the graft, and simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to outcomes, and highlights the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery.
采用旁路移植术对下肢进行血运重建，以治疗晚期缺血，这是一种已确立的有效疗法。最近的多中心数据证实了自体静脉旁路移植术的首要地位，但在当前实践中，这些手术的应用、技术和结果仍然存在显著的异质性。为了优化长期结果，需要具备丰富的临床判断、创造力、技术精度和细致入微的术后护理。患有糖尿病和严重缺血肢体的患者带来了一些特殊的挑战；然而，许多研究表明，该人群静脉旁路手术的结果非常出色，并定义了治疗标准。技术因素，如移植物和流入/流出动脉的选择，在决定临床成功方面起着主导作用。足够的口径、良好质量的大隐静脉（GSV）是腿部远端旁路的最佳移植物。在没有 GSV 的情况下，其他静脉也可以接受，但假体和其他非自体移植物的结果明显较差。移植物构型（反转、非反转或原位）似乎对结果影响不大。较短的移植物具有更好的通畅率。如果需要，可以通过手术或血管内手段改善流入，起源于股浅动脉或腘动脉的远端起源的移植物（例如）与起源于股总动脉的移植物一样有效。选择的流出血管应向足部提供无阻的血流，保留移植物的长度，允许有足够的软组织覆盖移植物，并简化手术暴露。本综述总结了将患者选择和技术因素与结果联系起来的现有数据，并强调了手术判断和手术计划在当前下肢旁路手术实践中的重要性。
