Division of Vascular Surgery, VA Western NY Healthcare System, Buffalo, NY 14215, USA.
J Vasc Surg. 2013 Jul;58(1):98-104.e1. doi: 10.1016/j.jvs.2012.12.076. Epub 2013 May 14.
Failure of prior endovascular (EV) interventions for chronic limb ischemia has been reported to negatively affect patency and limb salvage after subsequent revascularization procedures. The goal of our study was to compare the clinical presentation of patients who failed infrainguinal EV and open revascularizations (OR) and the effect of the initial intervention on final outcomes.
From June 2001 to October 2010, 216 patients (237 limbs; 66 disabling claudication [DC], 171 critical limb ischemia [CLI]) presented with failed infrainguinal OR or EV revascularization for chronic limb ischemia. Clinical presentation, reinterventions, patency and limb salvage rates, and final outcomes were analyzed.
The EV group (n = 143) had more diabetes (44% vs 57%; P = .048) and ulcers (26% vs 38%; P = .039), whereas the OR group (n = 94) had more multilevel revascularizations (59% vs 33%; P < .001), rest pain (23% vs 9%; P = .002), and infrapopliteal interventions (58% vs 38%; P = .038). Presentation at time of failure was non-limb-threatening ischemia in 70% of DC and 16% of CLI patients (P < .001), with no difference in those initially treated with EV or OR. In CLI, 23% presented with acute limb ischemia in the OR group vs 10% in the EV group (P = .024). Early failure (<3 months) occurred in 15% of DC and in 36% of CLI patients and was more in the OR than in the EV group (30% vs 7% for DC [P = .011] and 71% vs 38% for CLI [P = .024]). Overall, 195 (82%) had attempted reinterventions (79% in DC and 85% in CLI; P = .245). In DC patients, 48% of OR had OR + EV and 26% had EV; 32% of EV had OR + EV and 47% had EV reinterventions. In CLI patients, 40% of OR had OR + EV and 42% had EV; 17% of EV had OR + EV; and 70% had EV reinterventions. A patent revascularized limb was achieved in 66% of OR and in 92% of EV patients (P < .001). Patency and limb salvage were significantly better in the EV group, mainly due to the difference in CLI patients, whereas survival was identical.
Clinical presentation after failed infrainguinal revascularization is determined by the initial indication. CLI patients are more likely to present early with acute limb ischemia, especially after OR. EV reinterventions play a significant role in the management of patients with failed revascularization, and EV failure is associated with better outcomes than those after OR failure, likely due to OR patients having more disadvantaged anatomy and advanced disease at the time of their initial presentation.
已有研究报道，慢性肢体缺血患者先前血管内（EV）介入治疗失败会对后续血运重建术后的通畅率和肢体挽救率产生负面影响。本研究旨在比较下肢动静脉旁路术和开放血运重建术（OR）失败患者的临床表现，并分析初始干预措施对最终结果的影响。
2001 年 6 月至 2010 年 10 月，216 例（237 条肢体；66 例为有症状性跛行[DC]，171 例为严重肢体缺血[CLI]）因慢性肢体缺血行下肢动静脉旁路术或 EV 血运重建术失败后再次接受血运重建。分析其临床表现、再干预、通畅率和肢体挽救率以及最终结果。
EV 组（n = 143）患者糖尿病（44% vs. 57%；P =.048）和溃疡（26% vs. 38%；P =.039）的发生率较高，而 OR 组（n = 94）多节段血运重建（59% vs. 33%；P <.001）、静息痛（23% vs. 9%；P =.002）和膝下血管干预（58% vs. 38%；P =.038）的发生率较高。DC 患者中有 70%和 CLI 患者中有 16%（P <.001）在初次治疗后发生非肢体威胁性缺血，EV 和 OR 治疗组之间并无差异。CLI 患者中，OR 组有 23%表现为急性肢体缺血，而 EV 组有 10%（P =.024）。早期失败（<3 个月）发生在 15%的 DC 和 36%的 CLI 患者中，OR 组的发生率高于 EV 组（DC 组：30% vs. 7%；P =.011；CLI 组：71% vs. 38%；P =.024）。总体而言，195 例（82%）患者接受了再干预（DC 患者中为 79%，CLI 患者中为 85%；P =.245）。在 DC 患者中，48%的 OR 患者进行了 OR + EV 治疗，26%的患者进行了 EV 治疗；32%的 EV 患者进行了 OR + EV 治疗，47%的患者进行了 EV 再干预。CLI 患者中，40%的 OR 患者进行了 OR + EV 治疗，42%的患者进行了 EV 治疗；17%的 EV 患者进行了 OR + EV 治疗，70%的患者进行了 EV 再干预。OR 组中有 66%的患者和 EV 组中有 92%的患者（P <.001）实现了血运重建肢体通畅。EV 组的通畅率和肢体挽救率明显更好，主要是因为 CLI 患者的差异，而生存率则相同。
下肢动静脉旁路术和开放血运重建术失败后的临床表现取决于初始指征。CLI 患者更有可能早期出现急性肢体缺血，尤其是 OR 治疗后。EV 再干预在治疗血运重建失败患者方面发挥了重要作用，EV 治疗失败的结果优于 OR 治疗失败的结果，这可能是由于 OR 患者在初始就诊时的解剖结构和疾病程度更差。
