Chiriano Jason, Bianchi Christian, Teruya Theodore H, Mills Brian, Bishop Vicki, Abou-Zamzam Ahmed M
Loma Linda VA Health Care System, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
Ann Vasc Surg. 2010 Nov;24(8):1110-6. doi: 10.1016/j.avsg.2010.07.012.
Traditional wound care algorithms include aggressive detection of peripheral arterial disease (PAD) and treatment with revascularization for all patients with PAD and lower extremity wounds. Not every patient with PAD and a wound meets Transatlantic Inter-Society Consensus (TASCII) criteria for critical limb ischemia. We hypothesize that a conservative approach to selected patients with PAD and lower extremity wounds may be safe, provide acceptable limb salvage, and that failure of this approach does not translate into increased limb loss.
Veterans referred with PAD and nonhealing ulcers/wounds were prospectively enrolled into our Prevention of Amputation Care Team program. Patients were stratified according to management strategies which included revascularization, primary amputation, palliative limb care, and aggressive local care without revascularization (conservative group). Patients were assigned to conservative management group on the basis of transcutaneous oxygen measurement (TcpO2) and ankle-brachial index (ABI). Healing rates, need for "late" revascularization, major amputation rates, and survival of this conservative group were analyzed in terms of ABI and ankle pressures.
Between January 2006 and March 2009, a total of 190 lower extremity wounds in 178 patients with PAD were analyzed. Forty-nine patients with 52 wounds (27.9%) were deemed candidates for conservative treatment. During mean follow-up of 14.5 months, complete wound healing was documented in 33 patients (35 wounds: 67%). Mean time to complete wound healing was 4.5 months. Predictors of healing included mean ABI (0.62 vs. 0.42 [p < 0.001]) and ankle pressures >70 mm Hg (p = 0.025). Sixteen patients (17 wounds: 33%) were not healed at the time of analysis. Of these, three patients (four wounds: 8%) showed active healing and 13 (13 wounds: 25%) failed conservative management. Nine patients (9 wounds: 17%) underwent late revascularization. There was one case of amputation (2%) and six cases of mortalities (12.2%). There was no increase in the rates of limb loss and mortality in patients who failed conservative management and underwent "late" revascularization.
Conservative management of lower extremity nonhealing wounds in selected patients with PAD is successful in over two-thirds of the patients. The failure of conservative management does not increase mortality or amputation rates. When the TcPO2 is >30 mm Hg, the ABI and the TASC II definition of critical limb ischemia predict wound healing and should be key factors in considering conservative therapy.
传统的伤口护理方案包括积极检测外周动脉疾病（PAD），并对所有患有PAD和下肢伤口的患者进行血管重建治疗。并非每个患有PAD和伤口的患者都符合跨大西洋跨学会共识（TASCII）关于严重肢体缺血的标准。我们假设，对部分患有PAD和下肢伤口的患者采取保守治疗方法可能是安全的，能提供可接受的肢体挽救效果，且这种方法的失败不会导致肢体丢失增加。
将患有PAD和不愈合溃疡/伤口的退伍军人前瞻性纳入我们的截肢预防护理团队项目。根据管理策略对患者进行分层，管理策略包括血管重建、一期截肢、姑息性肢体护理以及不进行血管重建的积极局部护理（保守组）。根据经皮氧分压测量（TcpO2）和踝肱指数（ABI）将患者分配到保守治疗组。根据ABI和踝部压力分析该保守组的愈合率、“晚期”血管重建的需求、大截肢率和生存率。
在2006年1月至2009年3月期间，共分析了178例患有PAD的患者的190处下肢伤口。49例患者的52处伤口（27.9%）被认为适合保守治疗。在平均14.5个月的随访期间，33例患者（35处伤口：67%）实现了伤口完全愈合。伤口完全愈合的平均时间为4.5个月。愈合的预测因素包括平均ABI（0.62对0.42 [p < 0.001]）和踝部压力>70 mmHg（p = 0.025）。在分析时，16例患者（17处伤口：33%）未愈合。其中，3例患者（4处伤口：8%）显示伤口正在愈合，13例（13处伤口：25%）保守治疗失败。9例患者（9处伤口：17%）接受了晚期血管重建。有1例截肢（2%）和6例死亡（12.2%）。保守治疗失败并接受“晚期”血管重建的患者的肢体丢失率和死亡率没有增加。
对部分患有PAD的患者的下肢不愈合伤口进行保守治疗，超过三分之二的患者取得了成功。保守治疗失败不会增加死亡率或截肢率。当TcPO2>30 mmHg时，ABI和TASC II关于严重肢体缺血的定义可预测伤口愈合，应作为考虑保守治疗的关键因素。
