Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02215, USA.
J Vasc Surg. 2011 May;53(5):1251-1259.e1. doi: 10.1016/j.jvs.2010.11.099. Epub 2011 Feb 2.
Major amputation is often selected over infrainguinal bypass in patients with severe systemic comorbidities because it is assumed to have lower perioperative risks, yet this assumption is unproven and largely unexamined.
The 2005 to 2008 National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients undergoing either infrainguinal bypass or major amputation using procedural codes. Patients with systemic or local infections were excluded. A subset of high-risk patients were then defined as American Society of Anesthesiologists (ASA) class 4 or 5, or ASA class 3 with renal failure, dyspnea at rest, ventilator dependence, recent congestive heart failure, or recent myocardial infarct. Propensity score matching was used to obtain two high-risk patient groups matched for preoperative characteristics.
No significant differences in demographic, preoperative, or anesthetic variables were found between the matched, high-risk amputation or bypass groups (792 and 780 patients, respectively). Bypass was associated with a lower 30-day postoperative mortality than amputation (6.54% vs 9.97%; P = .0147). Amputation was associated with higher rates of pulmonary embolism (0.9% vs 0% for amputation vs bypass groups, respectively; P = .009) and urinary tract infection (5.2% vs 2.7%; P = .01), while bypass was associated with higher rates of return to the operating room (14.1% vs 27.6%; P < .001) and a trend toward higher postoperative transfusion requirements (0.9% vs 2.1%; P = .054). The postoperative time to discharge did not differ between the two groups.
The decision to perform an infrainguinal bypass or amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about different perioperative risks between the two procedures.
在患有严重系统性合并症的患者中，常常选择大截肢而不是膝下旁路手术，因为人们认为前者围手术期风险较低，但这种假设尚未得到证实，也尚未得到广泛研究。
使用程序代码从 2005 年至 2008 年国家手术质量改进计划（NSQIP）数据库中确定所有接受膝下旁路或大截肢手术的患者。排除患有系统性或局部感染的患者。然后，将一组高危患者定义为美国麻醉师协会（ASA）分级 4 或 5 级，或 ASA 分级 3 级合并肾衰竭、静息时呼吸困难、呼吸机依赖、近期充血性心力衰竭或近期心肌梗死。采用倾向评分匹配法获得两组术前特征匹配的高危患者。
在匹配的高危截肢或旁路组中（分别为 792 例和 780 例），两组在人口统计学、术前或麻醉变量方面均无显著差异。旁路手术与 30 天术后死亡率低于截肢相关（6.54%比 9.97%；P=0.0147）。截肢与肺栓塞发生率较高相关（分别为 0.9%和 0%，截肢组和旁路组，P=0.009）和尿路感染（5.2%比 2.7%，P=0.01），而旁路手术与返回手术室的比率较高相关（14.1%比 27.6%，P<0.001），并且术后输血需求也呈上升趋势（0.9%比 2.1%，P=0.054）。两组的术后出院时间无差异。
选择进行膝下旁路或截肢手术的决策应取决于通畅率和功能成功率的既定预测因素，而不是基于两种手术之间不同围手术期风险的假设。
