Zaraca Francesco, Ponzoni Andrea, Sbraga Patrizio, Stringari Carlo, Ebner Juliane A, Ebner Heinrich
Department of Vascular and Thoracic Surgery, Regional Hospital Bolzano, Bolzano, Italy.
Ann Vasc Surg. 2012 Nov;26(8):1064-70. doi: 10.1016/j.avsg.2011.12.012. Epub 2012 Jun 26.
Since 1963, Fogarty balloon catheter thromboembolectomy is usually adopted as the gold standard treatment for acute limb ischemia. As the success of the procedure depends on complete removal of all thromboembolic material, intraoperative arteriography can be used after arterial thromboembolectomy as a guide for extension of the procedure. It is still a matter of debate whether intraoperative angiography should be routinely performed in all cases or only in selected cases, depending on intraoperative findings, when the surgeon suspects an incomplete disobstruction. Most published evidence derives from analysis of lower-limb thromboembolectomies. The aim of our retrospective study was to elucidate the value of routine completion angiogram in acute arterial embolism of the upper limb.
Clinical and demographic data of 100 patients with acute embolic upper-limb ischemia were prospectively recorded during an 18-year period in a central hospital vascular unit setting. The relevance of intraoperative angiography was retrospectively analyzed. The procedures were divided into two groups: group A, when intraoperative angiography was performed in selected cases (selective angiography); and group B, when angiography was performed as a routine procedure in all cases (routine angiography). All factors associated with reocclusion and mortality were investigated to produce meaningful information that could assist the surgeon to predict outcomes.
Cumulative reocclusion and mortality rates at 24 months were 14.0% and 70.0%, respectively. After upper-limb arterial embolectomy, the rate of extension of the procedure was significantly higher in group B than in group A (26.0% vs. 4.0%, P = 0.002). At 24 months after embolectomy, group B resulted in a lower incidence of reocclusion compared with group A (12.0% vs. 2.0%, P = 0.05), whereas there was no statistical difference between the two groups in terms of mortality (P > 0.05). On univariate analysis, the factor associated with increased 2-year reocclusion rate was only the avoidance of completion angiography, although it lost some of its predictive value on multivariate analysis. Factors associated with increased 2-year mortality rate on univariate analysis included age >80 years, diabetes mellitus [DM], and antiplatelet drug use. Only DM was significantly associated on multivariate analysis.
Routine use of intraoperative angiography influences outcome after embolectomy for upper-limb acute arterial occlusion. Routine use of intraoperative angiography, compared with selective use, results in a higher rate of extension of the procedure for residual lesion and in a lower rate of reocclusion at 24 months. In prevention of reocclusion, completion angiogram has a hazard ratio of 5.44 on multivariate analysis. Postoperative late mortality is mainly affected by old age and DM.
自1963年以来，Fogarty球囊导管血栓切除术通常被用作急性肢体缺血的金标准治疗方法。由于该手术的成功取决于所有血栓栓塞物质的完全清除，术中动脉造影可在动脉血栓切除术后用于指导手术的扩展。对于术中血管造影是应在所有病例中常规进行还是仅在根据术中发现外科医生怀疑疏通不完全的特定病例中进行，仍存在争议。大多数已发表的证据来自对下肢血栓切除术的分析。我们这项回顾性研究的目的是阐明常规完成血管造影在上肢急性动脉栓塞中的价值。
在一家中心医院血管科环境下，对100例急性栓塞性上肢缺血患者在18年期间的临床和人口统计学数据进行前瞻性记录。对术中血管造影的相关性进行回顾性分析。手术分为两组：A组，在特定病例中进行术中血管造影（选择性血管造影）；B组，在所有病例中作为常规程序进行血管造影（常规血管造影）。对所有与再闭塞和死亡率相关的因素进行调查，以得出有助于外科医生预测结果的有意义信息。
24个月时的累积再闭塞率和死亡率分别为14.0%和70.0%。上肢动脉取栓术后，B组手术扩展率显著高于A组（26.0%对4.0%，P = 0.002）。取栓术后24个月，B组再闭塞发生率低于A组（12.0%对2.0%，P = 0.05），而两组在死亡率方面无统计学差异（P > 0.05）。单因素分析显示，与2年再闭塞率增加相关的因素仅为避免完成血管造影，尽管在多因素分析中其预测价值有所降低。单因素分析中与2年死亡率增加相关的因素包括年龄>80岁、糖尿病（DM）和使用抗血小板药物。多因素分析中只有DM有显著相关性。
术中血管造影的常规使用会影响上肢急性动脉闭塞取栓术后的结果。与选择性使用相比，术中血管造影的常规使用导致残余病变手术扩展率更高，24个月时再闭塞率更低。在预防再闭塞方面，多因素分析中完成血管造影的风险比为5.44。术后晚期死亡率主要受老年和DM影响。
