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手术取栓与血管内技术联合应用可能改善急性下肢缺血患者的预后。

The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia.

机构信息

Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.

出版信息

J Vasc Surg. 2014 Mar;59(3):729-36. doi: 10.1016/j.jvs.2013.09.016. Epub 2013 Dec 15.

DOI:10.1016/j.jvs.2013.09.016

PMID:24342067

Abstract

OBJECTIVE

Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called "hybrid procedures," HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI).

METHODS

From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test.

RESULTS

HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04).

CONCLUSIONS

HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion.

摘要

目的

手术动脉血栓切除术（TE）是治疗下肢急性动脉血栓栓塞的有效方法，尤其是在单一大动脉受累的情况下。不幸的是，残余血栓、血栓蔓延、慢性动脉粥样硬化疾病以及球囊导管通过引起的血管损伤可能会限制临床成功率。TE 术后的术中血管造影可以识别任何动脉缺陷，这些缺陷可以通过血管内技术（所谓的“杂交手术”，HP）同时进行纠正。本研究旨在比较急性下肢缺血（ALLI）患者接受手术 TE 与 HP 的结果。

方法

2006 年至 2012 年，我院收治 322 例 ALLI 患者。患者采用单纯 Fogarty 球囊导管（TE 组=112 例）或联合血管内完成（HP 组=210 例）紧急手术治疗。采用 Kaplan-Meier 法计算住院并发症、30 天死亡率、一期和二期通畅率、再介入率、保肢率和总生存率，并采用对数秩检验进行比较。

结果

在 210 例接受手术 TE 后的 HP 中，包括血管成形术（PTA）±支架置入 90 例，导管内动脉内溶栓+PTA±支架置入 24 例，大引导导管血栓碎裂和抽吸+PTA±支架置入 67 例，机械装置真空辅助血栓抽吸 9 例，初次覆膜支架置入 12 例。HP 和 TE 患者的估计一期通畅率分别为 2 年时 90.4%和 70.4%，5 年时 87.1%和 66.3%（风险比，3.1；95%置信区间，1.78-5.41；P<.01）。HP 组保肢的风险比为 2.1（95%置信区间，1.01-4.34；P=0.03）。HP 组 1 年无再介入率为 94.4%，TE 组为 82.1%，5 年时分别为 89%和 73.7%（P=0.04）。