Kumada Yoshitaka, Nogaki Haruhiko, Ishii Hideki, Aoyama Toru, Kamoi Daisuke, Takahashi Hiroshi, Murohara Toyoaki
Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu, Japan.
Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
J Vasc Surg. 2015 Feb;61(2):400-4. doi: 10.1016/j.jvs.2014.09.007. Epub 2014 Oct 23.
Lower extremity bypass surgery has been widely performed to treat critical limb ischemia (CLI) in patients on hemodialysis (HD). However, the clinical outcome still remains unclear. We investigated the limb salvage rate after infrapopliteal bypass surgery in HD patients with CLI.
From April 2006 to January 2013, 226 patients with 236 limbs who electively underwent bypass surgery for treatment of CLI due to infrapopliteal disease were enrolled. Patients were grouped by those who were on HD (n = 177) and those who were not (n = 49). They were monitored for 5 years or until December 2013 if the follow-up period was <5 years. Amputation-free survival, defined as freedom from major amputation or all-cause death, was primarily evaluated. Incidence of reintervention was also analyzed.
Ulcer/gangrene was present in 206 patients (91.2%), and 233 limbs (98.7%) were treated using autogenous vein. Age was younger (67 ± 9 vs 72 ± 9 years; P = .0011) and ulcer/gangrene was more prevalent (93.8% vs 81.6%, P = .0080) in HD patients than in non-HD patients. During the follow-up period (median, 28 months), 33 (14.6%) major amputations and 28 reinterventions (12.4%) occurred, and 65 patients (28.8%) died. The 5-year amputation-free survival rate was significantly lower in HD patients than in non-HD patients (43.6% vs 78.8%, P = .0033), and the adjusted hazard ratio (HR) for amputation or death for HD patients was 2.36 (95% confidence interval [CI], 1.13-4.92; P = .022). Compared with non-HD patients, the status of HD was similarly an independent risk of major amputation (72.4% vs 92.5%; adjusted HR, 4.36; 95% CI, 1.04-18.3; P = .045) and mortality (56.9% vs 83.2%; adjusted HR, 2.81; 95% CI, 1.30-6.09; P = .0085). However, freedom from reintervention was comparable between the two groups (84.3% vs 86.8%; P = .89). In HD patients, body mass index (HR, 0.86; 95% CI, 0.76-0.96; per 1 kg/m(2) increase; P = .014) and C-reactive protein (HR, 1.06; 95% CI, 1.01-1.11; P = .014) independently predicted major amputation. Elevated C-reactive protein levels were also associated with death (HR, 1.04; 95% CI, 1.01-1.09; P = .047).
The clinical outcome after infrapopliteal bypass surgery was poorer in HD patients with CLI compared with non-HD patients. Malnutrition or chronic inflammation was associated with poor outcome in HD patients with CLI due to infrapopliteal occlusive disease.
下肢搭桥手术已广泛用于治疗接受血液透析（HD）患者的严重肢体缺血（CLI）。然而，临床结果仍不明确。我们调查了CLI的HD患者腘动脉以下搭桥手术后的肢体挽救率。
2006年4月至2013年1月，纳入226例患者的236条肢体，这些患者因腘动脉以下疾病选择性接受搭桥手术治疗CLI。患者分为HD组（n = 177）和非HD组（n = 49）。对他们进行5年的监测，若随访期<5年，则监测至2013年12月。主要评估无截肢生存，定义为无大截肢或全因死亡。还分析了再次干预的发生率。
206例患者（91.2%）存在溃疡/坏疽，233条肢体（98.7%）使用自体静脉治疗。HD患者年龄较轻（67±9岁 vs 72±9岁；P = 0.0011），溃疡/坏疽更常见（93.8% vs 81.6%，P = 0.0080）。在随访期（中位数28个月）内，发生33例（14.6%）大截肢和28例再次干预（12.4%），65例患者（28.8%）死亡。HD患者的5年无截肢生存率显著低于非HD患者（43.6% vs 78.8%，P = 0.0033），HD患者截肢或死亡的调整后风险比（HR）为2.36（95%置信区间[CI]，1.13 - 4.92；P = 0.022）。与非HD患者相比，HD状态同样是大截肢（72.4% vs 92.5%；调整后HR，4.36；95% CI，1.04 - 18.3；P = 0.045）和死亡（56.9% vs 83.2%；调整后HR，2.81；95% CI，1.30 - 6.09；P = 0.0085）的独立风险因素。然而，两组间再次干预的无发生率相当（84.3% vs 86.8%；P = 0.89）。在HD患者中，体重指数（HR，0.86；95% CI，0.76 - 0.96；每增加1 kg/m²；P = 0.014）和C反应蛋白（HR，1.06；95% CI，1.01 - 1.11；P = 0.014）独立预测大截肢。C反应蛋白水平升高也与死亡相关（HR，1.04；95% CI，1.01 - 1.09；P = 0.047）。
与非HD患者相比，CLI的HD患者腘动脉以下搭桥手术后的临床结果较差。营养不良或慢性炎症与腘动脉以下闭塞性疾病的CLI的HD患者的不良结局相关。
