Špillerová K, Settembre N, Biancari F, Albäck A, Venermo M
University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
Eur J Vasc Endovasc Surg. 2017 Apr;53(4):567-575. doi: 10.1016/j.ejvs.2017.01.008. Epub 2017 Feb 16.
This study aimed to evaluate the impact of angiosome targeted (direct) revascularisation according to revascularisation method in patients with diabetes.
This retrospective study cohort comprised 545 diabetic patients with critical limb ischaemia and tissue loss (Rutherford 5, 6). All patients underwent infrapopliteal endovascular (PTA) or open surgical revascularisation between January 2008 and December 2013. Differences in the outcome after direct revascularisation, bypass surgery, and PTA were investigated by means of Cox proportional hazards analysis. The endpoints were wound healing, leg salvage, and amputation free survival.
Overall, 60.3% of the ischaemic wounds healed during 1 year of follow-up. The highest wound healing rate was achieved after direct bypass (77%) and the worst after indirect PTA (52%). The Cox proportional hazards analysis showed that the number of affected angiosomes <3 (HR 1.37, 95% CI 1.01-1.84) was associated with improved wound healing, whereas wound healing was poorest after indirect PTA (p = .001). When Cox proportional hazard analysis was adjusted for the number of affected angiosomes, direct bypass gave the best wound healing (p = 0.003). The overall amputation rate was 25.1% at 1 year of follow-up, and the Cox proportional hazards analysis indicated that haemodialysis compared with patients with no haemodialysis (HR 2.55, 95% CI 1.49-4.38), C-reactive protein ≥10 mg/dL (HR 2.05, 95% CI 1.45-2.90), atrial fibrillation (HR 1.54, 95% CI 1.05-2.26), and number of affected angiosomes >3 (HR 1.75, 95% CI 1.24-2.46) were significantly associated with poor leg salvage. Direct PTA was associated with a lower rate of major amputation compared with indirect PTA (HR 0.57 95% CI 0.37-0.89).
In diabetics, indirect endovascular revascularisation leads to significantly worse wound healing and leg salvage rates compared with direct revascularisation. Therefore, endovascular procedures should be targeted according to the angiosome concept. In bypass surgery, however, the concept is of less value and the artery with the best runoff should be selected as the outflow artery.
本研究旨在根据血运重建方法评估血管体靶向（直接）血运重建对糖尿病患者的影响。
本回顾性研究队列包括545例患有严重肢体缺血和组织缺损的糖尿病患者（卢瑟福分级5、6级）。所有患者在2008年1月至2013年12月期间接受了腘动脉以下血管腔内治疗（PTA）或开放性手术血运重建。通过Cox比例风险分析研究直接血运重建、旁路手术和PTA术后结局的差异。终点指标为伤口愈合、保肢和无截肢生存。
总体而言，60.3%的缺血性伤口在1年随访期间愈合。直接旁路术后伤口愈合率最高（77%），间接PTA术后最差（52%）。Cox比例风险分析显示，受累血管体数量<3个（风险比1.37，95%置信区间1.01-1.84）与伤口愈合改善相关，而间接PTA术后伤口愈合最差（p = 0.001）。当对受累血管体数量进行Cox比例风险分析校正后，直接旁路术的伤口愈合效果最佳（p = 0.003）。1年随访时总体截肢率为25.1%，Cox比例风险分析表明，与未进行血液透析的患者相比，血液透析（风险比2.55，95%置信区间1.49-4.38）、C反应蛋白≥10mg/dL（风险比2.05，95%置信区间1.45-2.90）、心房颤动（风险比1.54，95%置信区间1.05-2.26）以及受累血管体数量>3个（风险比1.75，95%置信区间1.24-2.46）与保肢不良显著相关。与间接PTA相比，直接PTA的大截肢率较低（风险比0.57，95%置信区间0.37-0.89）。
在糖尿病患者中，与直接血运重建相比，间接血管腔内血运重建导致伤口愈合和保肢率显著更差。因此，血管腔内治疗应根据血管体概念进行靶向治疗。然而，在旁路手术中，该概念的价值较小，应选择血流灌注最佳的动脉作为流出道动脉。
