Reifsnyder Thomas, Arhuidese Isibor J, Hicks Caitlin W, Obeid Tammam, Massada Karen E M, Khaled Alaa, Qazi Umair, Malas Mahmoud B
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institution, Baltimore, MD.
Department of Surgery, Frank H. Netter School of Medicine, Quinnipiac University, Hamden, CT.
Ann Vasc Surg. 2016 Jan;30:52-8. doi: 10.1016/j.avsg.2015.10.003. Epub 2015 Nov 6.
The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD).
We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards.
There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05).
In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.
在血管内介入治疗日益增多的时代，膝下旁路手术的作用仍是激烈争论的主题。在本研究中，我们评估了下肢开放性血运重建治疗外周动脉疾病（PAD）的当代长期疗效。
我们评估了2007年1月1日至2014年7月31日期间在我们机构接受自体静脉导管膝下旁路手术治疗间歇性跛行或严重肢体缺血的所有患者。采用Kaplan-Meier和Cox回归分析来评估移植物失败情况并确定其预测因素。结局根据血管外科学会标准进行定义。
368例患者（平均年龄67±11.4岁）共置入428条自体静脉移植物（股-腘：32%，股-胫：39%，腘-胫：27%，胫-胫：2%）。大多数患者为男性（59%）、白人（73%），表现为严重肢体缺血（81%）。65例（15%）为再次旁路手术。分别有15%和14%的病例使用了上肢静脉和拼接静脉导管。1年、3年和5年的原发性通畅率分别为66%、59%和55%。1年、3年和5年的初级辅助通畅率分别为78%、69%和64%。1年、3年和5年的次级通畅率分别为88%、84%和82%。取自下肢的移植物比取自上肢的移植物通畅率更高，近端旁路比远端旁路的通畅率更高（所有P<0.05）。平均随访2±1.8年后肢体挽救率为88%。移植物失败的显著预测因素为年龄较小、糖尿病和高脂血症（所有P<0.05）。
在这个当代患者队列中，我们证明了下肢血运重建的膝下旁路手术在有症状的PAD患者中具有良好的长期疗效。通过仔细选择自体导管、密切监测高危人群和管理合并症，可优化通畅率和肢体挽救率。
