Department of Surgery, Oregon Health and Science University, Portland, Ore.
Department of Surgery, Oregon Health and Science University, Portland, Ore.
J Vasc Surg. 2014 Feb;59(2):427-34. doi: 10.1016/j.jvs.2013.08.007. Epub 2013 Oct 5.
This study determined wound complication rates, intervention rates, failure mechanisms, patency, limb salvage, and overall survival after lower extremity revascularization using open vein harvest (OVH) vs endoscopic vein harvest (EVH) for critical limb ischemia.
A single-institution review was conducted of consecutive patients who underwent infrainguinal bypass with a single-segment reversed great saphenous vein between 2005 and 2012.
A total of 251 patients with critical limb ischemia underwent revascularization, comprising 153 with OVH and 98 with EVH. The OVH group had a lower mean body mass index (26.7 vs 29.9 kg/m(2); P = .001). There were no other differences in demographics, comorbidities, medications, smoking, or in the proximal or distal anastomotic site. Median operative times were 249 minutes (OVH) vs 316 minutes (EVH; P < .001). Median postoperative hospital length of stay was 7 days (OVH) vs 5 days (EVH; P < .001). Median follow-up was 295 days (OVH) vs 313 days (EVH; P = .416). During follow-up, 21 OVH grafts (14%) and 27 EVH grafts (28%) underwent an intervention (P = .048). There were a similar number of surgical interventions: 50% (OVH) vs 61% (EVH; P = .449). Failed grafts had a mean of 1.2 stenoses per graft, regardless of harvest method. Median stenosis length was 2.1 cm (OVH) vs 2.5 cm (EVH; P = .402). At 1 and 3 years, the primary patency was 71% and 52% (OVH) vs 58% and 41% (EVH; P = .010), and secondary patency was 88% and 71% (OVH) vs 88% and 64% (EVH; P = .266). A secondary patency Cox proportional hazard model showed EVH had a hazard ratio of 2.93 (95% confidence interval, 1.03-8.33; P = .044). Overall and harvest-related wound complications were 44% and 29% (OVH) vs 37% and 12% (EVH; P = .226 and P = .002). At 5 years, amputation-free survival was 48% (OVH) vs 54% (EVH; P = .305), and limb salvage was 89% (OVH) and 91% (EVH; P = .615).
OVH and EVH have similar failure mechanisms, limb salvage, amputation-free survival, and overall survival. EVH is associated with impaired patency, increased need for intervention, longer operative times, shorter hospital stays, and decreased vein harvest site wound complications. OVH of the great saphenous vein may provide optimal patency but was not necessarily associated with better patient-centered outcomes. Similar limb salvage rates and amputation-free survival may justify the use of EVH, despite inferior patency, to capture shorter hospital stays and decreased wound complications.
本研究旨在比较经皮腔内血管成形术（EVH）与开放式静脉采集（OVH）治疗下肢严重缺血患者的下肢血管重建术后的伤口并发症发生率、干预率、失败机制、通畅率、保肢率和总体生存率。
对 2005 年至 2012 年间连续行下肢旁路术且使用单一节段大隐静脉逆行的患者进行单中心回顾性研究。
共 251 例严重肢体缺血患者接受了血管重建术，其中 153 例采用 OVH，98 例采用 EVH。OVH 组的平均体重指数（26.7 与 29.9 kg/m²；P =.001）更低。两组患者在人口统计学、合并症、药物使用、吸烟史、近端或远端吻合部位方面均无差异。手术时间中位数分别为 249 分钟（OVH）和 316 分钟（EVH；P <.001）。术后中位住院时间分别为 7 天（OVH）和 5 天（EVH；P <.001）。中位随访时间分别为 295 天（OVH）和 313 天（EVH；P =.416）。随访期间，21 例 OVH 移植物（14%）和 27 例 EVH 移植物（28%）需要干预（P =.048）。两组的手术干预次数相似：50%（OVH）与 61%（EVH；P =.449）。失败的移植物每条移植物平均有 1.2 处狭窄，与采集方法无关。狭窄长度中位数分别为 2.1 cm（OVH）和 2.5 cm（EVH；P =.402）。1 年和 3 年时，一级通畅率分别为 71%和 52%（OVH）与 58%和 41%（EVH；P =.010），二级通畅率分别为 88%和 71%（OVH）与 88%和 64%（EVH；P =.266）。二级通畅性 Cox 比例风险模型显示，EVH 的风险比为 2.93（95%置信区间，1.03-8.33；P =.044）。整体和与采集相关的伤口并发症发生率分别为 44%和 29%（OVH）与 37%和 12%（EVH；P =.226 和 P =.002）。5 年时，保肢率分别为 48%（OVH）与 54%（EVH；P =.305），无截肢生存率分别为 89%（OVH）与 91%（EVH；P =.615）。
OVH 和 EVH 的失败机制、保肢率、无截肢生存率和总体生存率相似。EVH 与通畅率受损、更多的干预需求、更长的手术时间、更短的住院时间和减少的静脉采集部位伤口并发症相关。大隐静脉的 OVH 可能提供最佳的通畅率，但不一定与更好的患者为中心的结果相关。相似的保肢率和无截肢生存率可能证明 EVH 的使用是合理的，尽管通畅率较低，但可以缩短住院时间和减少伤口并发症。
