Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA 01655, USA.
J Vasc Surg. 2012 Aug;56(2):353-60. doi: 10.1016/j.jvs.2012.01.041. Epub 2012 Apr 4.
To date, history of a contralateral amputation as a potential predictor of outcomes after lower extremity bypass (LEB) for critical limb ischemia (CLI) has not been studied. We sought to determine if a prior contralateral lower extremity amputation predicts worse outcomes in patients undergoing LEB in the remaining intact limb.
A retrospective analysis of all patients undergoing infrainguinal LEB for CLI between 2003 and 2010 within hospitals comprising the Vascular Study Group of New England was performed. Patients were stratified according to whether or not they had previously undergone a contralateral major or minor amputation before LEB. Primary end points included major amputation and graft occlusion at 1 year postoperatively. Secondary end points included in-hospital major adverse events, discharge status, and mortality at 1 year.
Of 2636 LEB procedures, 228 (8.6%) were performed in the setting of a prior contralateral amputation. Patients with a prior amputation compared to those without were younger (66.5 vs 68.7; P = .034), more like to have congestive heart failure (CHF; 25% vs 16%; P = .002), hypertension (94% vs 85%; P = .015), renal insufficiency (26% vs 14%; P = .0002), and hemodialysis-dependent renal failure (14% vs 6%; P = .0002). They were also more likely to be nursing home residents (8.0% vs 3.6%; P = .036), less likely to ambulate without assistance (41% vs 80%; P < .0002), and more likely to have had a prior ipsilateral bypass (20% vs 12%; P = .0005). These patients experience increased in-hospital major adverse events, including myocardial infarction (MI; 8.9% vs 4.2%; P = .002), CHF (6.1% vs 3.4%; P = .044), deterioration in renal function (9.0% vs 4.7%; P = .006), and respiratory complications (4.2% vs 2.3%; P = .034). They were less likely to be discharged home (52% vs 72%; P < .0001) and less likely to be ambulatory on discharge (25% vs 55%; P < .0001). Although patients with a prior contralateral amputation experienced increased rates of graft occlusion (38% vs 17%; P < .0001) and major amputation (16% vs 7%; P < .0001) at 1 year, there was not a significant difference in mortality (16% vs 10%; P = .160). On multivariable analysis, prior contralateral amputation was an independent predictor of both major amputation (odds ratio, 1.73; confidence interval, 1.06-2.83; P = .027) and graft occlusion (odds ratio, 1.93; confidence interval, 1.39-2.68; P < .0001) at 1 year.
Patients with prior contralateral amputations who present with CLI in the intact limb represent a high-risk population, even among patients with advanced peripheral arterial disease. When considering LEB in this setting, both physicians and patients should expect increased rates of perioperative adverse events, increased rates of 1-year graft occlusion, and decreased rates of limb salvage, when compared with patients who have not undergone a contralateral amputation.
迄今为止，作为预测下肢旁路（LEB）治疗严重肢体缺血（CLI）后结局的潜在预测因子，对侧截肢的历史尚未被研究过。我们旨在确定在剩余的完整肢体中接受 LEB 的患者中，先前发生的对侧下肢截肢是否会导致预后更差。
对 2003 年至 2010 年间在新英格兰血管研究组所属医院接受下肢旁路治疗 CLI 的所有患者进行回顾性分析。根据患者是否在 LEB 之前进行过同侧大或小截肢，将患者分层。主要终点包括术后 1 年时的主要截肢和移植物闭塞。次要终点包括住院期间的主要不良事件、出院状态和 1 年时的死亡率。
在 2636 例 LEB 手术中，228 例（8.6%）是在先前对侧截肢的情况下进行的。与没有截肢的患者相比，有截肢的患者更年轻（66.5 岁比 68.7 岁；P =.034），更可能患有充血性心力衰竭（25%比 16%；P =.002）、高血压（94%比 85%；P =.015）、肾功能不全（26%比 14%；P =.0002）和血液透析依赖的肾衰竭（14%比 6%；P =.0002）。他们也更有可能是疗养院居民（8.0%比 3.6%；P =.036），更不可能在没有帮助的情况下行走（41%比 80%；P <.0002），并且更有可能有同侧旁路（20%比 12%；P =.0005）。这些患者的住院期间主要不良事件发生率增加，包括心肌梗死（MI；8.9%比 4.2%；P =.002）、心力衰竭（6.1%比 3.4%；P =.044）、肾功能恶化（9.0%比 4.7%；P =.006）和呼吸并发症（4.2%比 2.3%；P =.034）。他们更不可能出院回家（52%比 72%；P <.0001），出院时更不可能行走（25%比 55%；P <.0001）。尽管有先前对侧截肢的患者在 1 年内移植物闭塞（38%比 17%；P <.0001）和主要截肢（16%比 7%；P <.0001）的发生率更高，但死亡率无显著差异（16%比 10%；P =.160）。多变量分析显示，先前的对侧截肢是 1 年内主要截肢（比值比，1.73；95%置信区间，1.06-2.83；P =.027）和移植物闭塞（比值比，1.93；95%置信区间，1.39-2.68；P <.0001）的独立预测因子。
在完整肢体中出现 CLI 的有先前对侧截肢的患者是一个高危人群，即使在患有晚期外周动脉疾病的患者中也是如此。在这种情况下考虑 LEB 时，与未行对侧截肢的患者相比，医生和患者都应预期围手术期不良事件发生率增加、1 年内移植物闭塞发生率增加和肢体存活率降低。
