Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
J Vasc Surg. 2011 Sep;54(3):730-5; discussion 735-6. doi: 10.1016/j.jvs.2011.03.236. Epub 2011 Jul 29.
Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI.
A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment.
Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target.
Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI.
尽管开放性外科旁路仍然是治疗严重肢体缺血（CLI）患者的标准血运重建策略，但许多中心现在将外周血管腔内介入（PVI）作为这些患者的一线治疗方法。我们旨在确定同侧 PVI（iPVI）对 CLI 患者后续下肢旁路（LEB）术后结果的影响。
对 2003 年至 2009 年间血管研究组新英格兰（VSGNE）医院内进行的所有下肢旁路（LEB）患者进行回顾性队列分析。主要研究终点是术后 1 年时的主要截肢和移植物闭塞。次要结果包括院内主要不良事件（MAE）、1 年死亡率和复合 1 年主要不良肢体事件（MALE）。使用寿命表分析确定事件发生率，并使用对数秩检验进行比较。使用 Cox 比例风险模型确定多变量预测因素，并进行多层次层次调整。
在 1880 例 LEB 中，32%（n=603）有下肢血运重建史（iPVI，7%；同侧旁路，15%；对侧 PVI，3%；对侧旁路，17%）。与无 iPVI 病史的患者相比，有 iPVI 病史的患者更可能为女性（32%比 41%；P=0.04），更不可能发生组织损失（52%比 63%；P=0.02），更可能需要使用上肢静脉移植物（16%比 5%；P=0.001），并且更可能在旁路手术时接受他汀类药物（71%比 54%；P=0.01）和β受体阻滞剂治疗（92%比 81%；P=0.01）。这些组之间的其他人口统计学因素相似。与指数旁路相比，PVI 或旁路病史并未改变术后 30 天的 MAE 和 1 年死亡率。相比之下，有 iPVI 病史的患者 1 年主要截肢和 1 年移植物闭塞率明显高于无 iPVI 病史的患者（31%比 20%；P=0.046 和 28%比 18%；P=0.009），与有同侧旁路病史的患者相似（1 年主要截肢，29%比 20%；P=0.022；1 年移植物闭塞，33%比 18%；P=0.001）。1 年截肢和移植物闭塞率较高的独立多变量预测因素包括同侧 PVI、同侧旁路、透析依赖、假体移植物和远端（胫部和足部）旁路靶标。
同侧 PVI 对 CLI 患者 LEB 后预后较差具有高度预测性，其 1 年截肢和移植物闭塞率高于无血管再通史的患者，与同侧旁路相似。这些发现提供了信息，可能有助于在 CLI 患者的血管重建方案选择方面做出复杂决策。
