Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif 94148, USA.
J Vasc Surg. 2012 Sep;56(3):686-95. doi: 10.1016/j.jvs.2012.02.034. Epub 2012 May 2.
Patients with advanced peripheral artery disease (PAD) have a high prevalence of cardiovascular (CV) risk factors and shortened life expectancy. However, CV risk factors poorly predict midterm (<5 years) mortality in this population. This study tested the hypothesis that baseline biochemical parameters would add clinically meaningful predictive information in patients undergoing lower extremity bypass operations.
This was a prospective cohort study of patients with clinically advanced PAD undergoing lower extremity bypass surgery. The Cox proportional hazard model was used to assess the main outcome of all-cause mortality. A clinical model was constructed with known CV risk factors, and the incremental value of the addition of clinical chemistry, lipid assessment, and a panel of 11 inflammatory parameters was investigated using the C statistic, the integrated discrimination improvement index, and Akaike information criterion.
The study monitored 225 patients for a median of 893 days (interquartile range, 539-1315 days). In this study, 50 patients (22.22%) died during the follow-up period. By life-table analysis (expressed as percent surviving ± standard error), survival at 1, 2, 3, 4, and 5 years, respectively, was 90.5% ± 1.9%, 83.4% ± 2.5%, 77.5% ± 3.1%, 71.0% ± 3.8%, and 65.3% ± 6.5%. Compared with survivors, decedents were older, diabetic, had extant coronary artery disease, and were more likely to present with critical limb ischemia as their indication for bypass surgery (P < .05). After adjustment for the above, clinical chemistry and inflammatory parameters significant (hazard ratio [95% confidence interval]) for all-cause mortality were albumin (0.43 [0.26-0.71]; P = .001), estimated glomerular filtration rate (0.98 [0.97-0.99]; P = .023), high-sensitivity C-reactive protein (hsCRP; 3.21 [1.21-8.55]; P = .019), and soluble vascular cell adhesion molecule (1.74 [1.04-2.91]; P = .034). Of the inflammatory molecules investigated, hsCRP proved most robust and representative of the integrated inflammatory response. Albumin, eGFR, and hsCRP improved the C statistic and integrated discrimination improvement index beyond that of the clinical model and produced a final C statistic of 0.82.
A risk prediction model including traditional risk factors and parameters of inflammation, renal function, and nutrition had excellent discriminatory ability in predicting all-cause mortality in patients with clinically advanced PAD undergoing bypass surgery.
患有晚期外周动脉疾病（PAD）的患者心血管（CV）风险因素高发，预期寿命缩短。然而，CV 风险因素在外周动脉疾病患者中对中期（<5 年）死亡率的预测能力较差。本研究检验了以下假设：在进行下肢旁路手术的患者中，基线生化参数将提供具有临床意义的预测信息。
这是一项对接受下肢旁路手术的临床晚期 PAD 患者的前瞻性队列研究。Cox 比例风险模型用于评估全因死亡率的主要结果。构建了一个包含已知 CV 风险因素的临床模型，并使用 C 统计量、综合判别改善指数和 Akaike 信息准则研究了添加临床化学、脂质评估和 11 个炎症参数面板的附加价值。
该研究监测了 225 名患者中位数为 893 天（四分位距，539-1315 天）的中位随访期。在这项研究中，50 名患者（22.22%）在随访期间死亡。通过生命表分析（以存活百分比和标准误差表示），分别为 1、2、3、4 和 5 年时的生存率为 90.5%±1.9%、83.4%±2.5%、77.5%±3.1%、71.0%±3.8%和 65.3%±6.5%。与幸存者相比，死者年龄较大，患有糖尿病，有现存的冠状动脉疾病，并且更有可能因临界肢体缺血作为旁路手术的指征（P<.05）。在调整了上述因素后，白蛋白（0.43[0.26-0.71]；P=.001）、估算肾小球滤过率（0.98[0.97-0.99]；P=.023）、高敏 C 反应蛋白（hsCRP；3.21[1.21-8.55]；P=.019）和可溶性血管细胞黏附分子（1.74[1.04-2.91]；P=.034）对全因死亡率有显著意义（风险比[95%置信区间]）。在所研究的炎症分子中，hsCRP 证明最稳健，最能代表综合炎症反应。白蛋白、eGFR 和 hsCRP 提高了 C 统计量和综合判别改善指数，超过了临床模型，并产生了最终的 C 统计量为 0.82。
包括传统危险因素和炎症、肾功能和营养参数的风险预测模型在外周动脉疾病患者中具有出色的预测能力，这些患者接受了临床晚期 PAD 旁路手术。
