Sheng Neha, Chiriano Jason, Teruya Theodore H, Abou-Zamzam Ahmed M, Bianchi Christian
Jerry L. Pettis VA Hospital, Loma Linda University Medical Center, Department of Cardiovascular and Thoracic Surgery, Loma Linda, CA.
Jerry L. Pettis VA Hospital, Loma Linda University Medical Center, Department of Cardiovascular and Thoracic Surgery, Loma Linda, CA.
Ann Vasc Surg. 2014 Jan;28(1):262.e1-7. doi: 10.1016/j.avsg.2013.01.023. Epub 2013 Sep 29.
Many patients with critical limb ischemia require infrageniculate bypass with a prosthetic graft due to the limited availability of autogenous vein. Prosthetic grafts have been shown to have inferior patency and subject the patient to increased infection rates when compared to bypass with autogenous conduit for lower extremity revascularization. In an effort to avoid the use of prosthetic material, we evaluated the use of remote superficial femoral artery endarterectomy (RSFAE) with distal autogenous revascularization in patients with critical limb ischemia and limited conduit.
This study is a retrospective review of a prospectively maintained database from January 2009 to September 2011. All patients undergoing RSFAE for critical limb ischemia were identified. Patients undergoing RSFAE with simultaneous distal revascularization constituted the study group. Outcome variables, including patency, time to healing, limb salvage, ambulatory status, and survival, were analyzed.
Twenty-one patients underwent RSFAE at our institution. The study group was comprised of 5 patients undergoing RSFAE and adjunct distal revascularization for critical limb ischemia during the study period. Four patients (80%) presented with tissue loss, and 1 (20%) presented with ischemic rest pain. Three (60%) required simultaneous outflow sequential vein bypass and 2 (40%) required distal endovascular revascularization. The distal target vessels for bypass included the infrageniculate popliteal artery, posterior tibial artery, and peroneal artery. The mean operative time was 5.3 hours. The mean length of hospital stay was 8 days. Technical success was 100%, and there were no early reconstruction failures. There was 1 popliteal wound complication, and no groin wound complications during the study follow-up. At 6 months postoperatively, 4 of 5 reconstructions were patent. Two of 5 patients (40%) required percutaneous reintervention for restenosis at 10 and 11 months, respectively. Primary assisted patency was 80% with a mean follow-up of 12.6 months (range 8-22 months). The 4 patients with tissue loss achieved initial wound healing at a mean time of 4.8 months. The limb salvage rate was 80% and there have been no deaths.
Remote superficial femoral artery endarterectomy with distal revascularization allows for autogenous reconstruction in patients with critical limb ischemia and compromised conduit by shortening bypass length. This procedure constitutes an appealing alternative to the use of synthetic material for lower extremity revascularization. Further study is needed to determine whether the long-term results are superior to distal composite bypass or polytetrafluoroethylene bypass alone.
由于自体静脉可用性有限，许多严重肢体缺血患者需要使用人工血管进行膝下旁路移植术。与使用自体血管进行下肢血管重建的旁路移植术相比，人工血管的通畅率较低，且患者感染率增加。为了避免使用人工材料，我们评估了在严重肢体缺血且血管材料有限的患者中使用远端股浅动脉内膜切除术（RSFAE）及远端自体血管重建术的效果。
本研究是对2009年1月至2011年9月前瞻性维护的数据库进行的回顾性分析。确定所有因严重肢体缺血接受RSFAE的患者。同时进行远端血管重建的RSFAE患者构成研究组。分析包括通畅率、愈合时间、肢体挽救情况、活动状态和生存率等结果变量。
我们机构有21例患者接受了RSFAE。研究组包括5例在研究期间因严重肢体缺血接受RSFAE及辅助远端血管重建的患者。4例（80%）出现组织缺损，1例（20%）出现缺血性静息痛。3例（60%）需要同时进行流出道序贯静脉旁路移植术，2例（40%）需要远端血管腔内血管重建术。旁路移植的远端目标血管包括膝下腘动脉、胫后动脉和腓动脉。平均手术时间为5.3小时。平均住院时间为8天。技术成功率为100%，且无早期重建失败病例。在研究随访期间，有1例腘窝伤口并发症，无腹股沟伤口并发症。术后6个月，5例重建中有4例通畅。5例患者中有2例（40%）分别在10个月和11个月因再狭窄需要进行经皮再干预。初次辅助通畅率为80%，平均随访12.6个月（范围8 - 22个月）。4例有组织缺损的患者平均在4.8个月时实现了初始伤口愈合。肢体挽救率为80%，且无死亡病例。
远端股浅动脉内膜切除术及远端血管重建术通过缩短旁路长度，可在严重肢体缺血且血管材料不足的患者中实现自体血管重建。该手术是下肢血管重建中使用合成材料的一种有吸引力的替代方法。需要进一步研究以确定其长期结果是否优于远端复合旁路移植术或单独的聚四氟乙烯旁路移植术。
