内镜下与开放手术取大隐静脉用于下肢严重缺血的旁路移植术。
Endoscopic versus open saphenous vein graft harvest for lower extremity bypass in critical limb ischemia.
机构信息
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
University of Pittsburgh, Clinical Translational Science Institute, Pittsburgh, Pa.
出版信息
J Vasc Surg. 2014 Jan;59(1):136-44. doi: 10.1016/j.jvs.2013.06.072.
OBJECTIVE
Endoscopic vein harvest (EVH) has been demonstrated to improve early morbidity when compared with conventional open vein harvest (OVH) technique for infrainguinal bypass surgery. However, recent literature suggests conflicting results regarding mid- and long-term patency with EVH. The purpose of this study is to compare graft patency between harvest techniques specifically in patients with critical limb ischemia.
METHODS
This retrospective study compared two groups of patients (EVH = 39 and OVH = 49) undergoing lower extremity revascularization from January 2009 to December 2011. Outcome measures included patency rates, postoperative complications, and wound infection. Graft patency was assessed using Kaplan-Meier curves.
RESULTS
Both groups were matched for demographics and indications for bypass (critical limb ischemia). Median follow-up was 22 months. There was a significant reduction in the incidence of wound infection at the vein harvest site in the EVH group (OVH = 20%; EVH = 0%; P < .001), nevertheless, the difference was not significant when only the anastomotic sites were included (OVH = 12.2%; EVH = 15.4%; P = .43). The hospital length of stay was comparable between the two groups (EVH = 8.73 ± 9.69; OVH = 6.35 ± 3.28; P = .26) with no significant difference in the recovery time. Primary graft patency rate was 43.2% in the EVH group and 69.4% in the OVH group (P = .007) at 3 years. The most common reason for loss of primary patency was graft occlusion (61.5%) in the OVH group and vein graft stenosis (54.5%) in the EVH group. The average number of vascular reinterventions per bypass graft was significantly lower in the OVH group compared with the EVH group (OVH = 0.37; EVH = 1.28; P < .001).
CONCLUSIONS
Our findings demonstrate inferior primary patency when using the technique of EVH. Additionally, we identified a significantly higher rate of reintervention in the EVH cohort as well as a higher rate of vein graft body stenosis. However, EVH was associated with a decreased rate of wound complications with similar limb salvage and secondary patency rates when compared to OVH. EVH should therefore be selectively utilized in patients at high risk for wound complications.
目的
与传统的开放式静脉采集（OVH）技术相比，内镜静脉采集（EVH）可降低下肢旁路手术的早期发病率。然而，最近的文献表明，EVH 与中期和长期通畅率存在矛盾的结果。本研究的目的是比较两种采集技术在伴有严重肢体缺血患者中的移植物通畅率。
方法
本回顾性研究比较了两组患者（EVH = 39 例，OVH = 49 例），他们于 2009 年 1 月至 2011 年 12 月接受下肢血运重建术。研究结果包括通畅率、术后并发症和伤口感染。通过 Kaplan-Meier 曲线评估移植物通畅率。
结果
两组患者的人口统计学特征和旁路手术适应证（严重肢体缺血）相匹配。中位随访时间为 22 个月。EVH 组静脉采集部位伤口感染发生率显著降低（OVH = 20%；EVH = 0%；P<.001），然而，当仅包括吻合部位时，差异无统计学意义（OVH = 12.2%；EVH = 15.4%；P=.43）。两组患者的住院时间相似（EVH = 8.73±9.69；OVH = 6.35±3.28；P=.26），康复时间无显著差异。EVH 组和 OVH 组 3 年时的原发性移植物通畅率分别为 43.2%和 69.4%（P=.007）。OVH 组最常见的原发性通畅丧失原因是移植物闭塞（61.5%），EVH 组是静脉移植物狭窄（54.5%）。与 EVH 组相比，OVH 组的每例旁路移植血管再介入次数明显较低（OVH = 0.37；EVH = 1.28；P<.001）。
结论
本研究结果表明，EVH 技术的原发性通畅率较低。此外，我们发现 EVH 组的再干预率显著较高，静脉移植物体狭窄率也较高。然而，与 OVH 相比，EVH 与较低的伤口并发症发生率相关，肢体挽救率和继发性通畅率相似。因此，EVH 应选择性地用于有伤口并发症高风险的患者。
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