Kempe Kelly, Starr Brett, Stafford Jeanette M, Islam Arsalla, Mooney Ashley, Lagergren Emily, Corriere Matthew A, Edwards Matthew S
Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC.
J Vasc Surg. 2014 Sep;60(3):702-7. doi: 10.1016/j.jvs.2014.03.273. Epub 2014 Apr 24.
Acute lower extremity ischemia secondary to arterial thromboembolism is a common problem. Contemporary data regarding this problem are sparse. This report examines a 10-year single-center experience and describes the surgical management and outcomes observed.
Procedural codes were used to identify consecutive patients treated surgically for acute lower extremity embolization from January 2002 to September 2012. Patients presenting >7 days after onset of symptoms, occlusion of grafts/stents, and cases secondary to trauma or iatrogenic injury were excluded. Data collected included demographics, medical comorbidities, presenting clinical characteristics, procedural specifics, and postoperative outcomes. Results were evaluated using descriptive statistics, product-limit survival analysis, and logistic regression multivariable modeling.
The study sample included 170 patients (47% female). Mean age was 69.1 ± 16.0 years. Of these, 82 patients (49%) had a previous history of atrial fibrillation, and four (2%) were therapeutically anticoagulated (international normalized ratio ≥2.0) at presentation. Presentation for 83% was >6 hours after symptom onset, and 9% presented with a concurrent acute stroke. Femoral artery exploration with embolectomy was the most common procedural management and was used for aortic, iliac, and infrainguinal occlusion. Ten patients (6%) required bypass for limb salvage during the initial operation. Local instillation of thrombolytic agents as an adjunct to embolectomy was used in 16%, fasciotomies were performed in 39%, and unexpected return to the operating room occurred in 24%. Ninety-day amputation above or below the knee was required during the index hospitalization in 26 patients (15%). In-hospital or 30-day mortality was 18%. Median (interquartile range) length of stay was 8 days (4, 16 days), and 36% of patients were discharged to a nursing facility. Recurrent extremity embolization occurred in 23 patients (14%) at a median interval of 1.6 months. The 5-year amputation freedom and survival estimates were 80% and 41%, respectively. Predictors of 90-day amputation included prior vascular surgery, gangrene, and fasciotomy. Predictors of 30-day mortality included age, history of coronary artery disease, prior vascular surgery, and concurrent stroke.
Despite advances in contemporary medical care, lower extremity arterial embolization remains a condition that is associated with significant morbidity and mortality. Furthermore, the condition is resource-intensive to treat and is likely preventable (initially or in recurrence) in a substantial subset of patients.
继发于动脉血栓栓塞的急性下肢缺血是一个常见问题。关于这一问题的当代数据较为匮乏。本报告审视了一项为期10年的单中心经验，并描述了所观察到的手术治疗及结果。
使用程序编码来识别2002年1月至2012年9月期间接受急性下肢栓塞手术治疗的连续患者。排除症状发作7天以上就诊的患者、移植物/支架闭塞的患者以及继发于创伤或医源性损伤的病例。收集的数据包括人口统计学资料、合并症、就诊时的临床特征、手术细节以及术后结果。使用描述性统计、乘积限生存分析和逻辑回归多变量建模对结果进行评估。
研究样本包括170例患者（47%为女性）。平均年龄为69.1±16.0岁。其中，82例患者（49%）有房颤病史，4例患者（2%）就诊时正在接受抗凝治疗（国际标准化比值≥2.0）。83%的患者在症状发作6小时后就诊，9%的患者并发急性卒中。股动脉探查取栓术是最常见的手术治疗方法，用于主动脉、髂动脉和腹股沟下闭塞。10例患者（6%）在初次手术期间需要行旁路手术以挽救肢体。16%的患者在取栓术基础上局部滴注溶栓剂作为辅助治疗，39%的患者进行了筋膜切开术，24%的患者意外返回手术室。26例患者（15%）在首次住院期间需要行膝上或膝下截肢术。住院期间或30天死亡率为18%。中位（四分位间距）住院时间为8天（4，16天），36%的患者出院后入住护理机构。23例患者（14%）发生复发性肢体栓塞，中位间隔时间为1.6个月。5年截肢自由率和生存率估计分别为80%和41%。90天截肢的预测因素包括既往血管手术史、坏疽和筋膜切开术。30天死亡率的预测因素包括年龄、冠状动脉疾病史、既往血管手术史和并发卒中。
尽管当代医疗有所进步，但下肢动脉栓塞仍然是一种与高发病率和死亡率相关的疾病。此外，这种疾病的治疗资源消耗大，在相当一部分患者中（初始或复发时）可能是可预防的。
