Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan.
Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan; Center of Vascular Diseases, Edogawa Hospital, Tokyo, Japan.
J Vasc Surg. 2018 Mar;67(3):826-837. doi: 10.1016/j.jvs.2017.07.116. Epub 2017 Sep 29.
The aim of this study was to elucidate the efficacy of paramalleolar or inframalleolar bypass (PIMB) in hemodialysis-dependent (HD) patients with critical limb ischemia (CLI) and nonhemodialysis-dependent (NHD) patients in terms of clinical outcomes.
Between January 2000 and December 2013, there were 333 consecutive arteriosclerosis obliterans patients with CLI who underwent 401 PIMB procedures for limb salvage (LS). Of the 333 patients, 188 (56.5%) were HD patients. Vein grafts were exclusively used, and 172 paramalleolar and 229 inframalleolar bypasses were performed. Five-year primary and secondary cumulative graft patency, LS, and amputation-free survival (AFS) rates were compared between the two groups, and the independent determinants of these outcomes were identified in each group.
The 5-year primary and secondary cumulative graft patency rates were 53% and 82% in HD patients and 69% and 92% in NHD patients (primary cumulative graft patency, P < .05; secondary cumulative graft patency, nonsignificant), respectively. The LS rates were 87% and 99% (P < .01) in HD patients and NHD patients, respectively. Overall, 48% and 70% of HD and NHD patients were ambulatory before PIMB (P < .01), and 73% and 85% of HD and NHD patients were ambulatory 12 months after PIMB (including 1-year survivors; nonsignificant), respectively, demonstrating drastic post-PIMB improvement in HD patients. The 5-year AFS rates in the HD and NHD groups were 27% and 69% (P < .01), respectively, demonstrating very poor AFS rates in HD patients. In HD patients, factors negatively associated with AFS were female gender (hazard ratio [HR], 2.102; 95% confidence interval [CI], 1.254-3.524), history of congestive heart failure (HR, 2.075; 95% CI, 1.395-3.085), and preoperative nonambulatory status (HR, 1.974; 95% CI, 1.305-2.986), whereas older age (HR, 2.601; 95% CI, 1.372-4.931) and history of congestive heart failure (HR, 2.928; 95% CI, 1.496-5.731) were identified as independent factors negatively associated with AFS in NHD patients.
The use of PIMB for CLI was associated with excellent LS rates in both HD and NHD patients with low operative mortality and complications. However, the AFS rate observed in HD patients was significantly lower than that observed in NHD patients, indicating the necessity of a specific management program to improve AFS after LS in HD patients.
本研究旨在阐明在接受血液透析（HD）的终末期肾病（ESRD）患者和非血液透析（NHD）患者中，通过旁路转流术（paramalleolar 或 inframalleolar bypass，PIMB）治疗严重肢体缺血（CLI）的临床效果。
2000 年 1 月至 2013 年 12 月期间，333 例连续动脉粥样硬化闭塞症合并 CLI 的患者接受了 401 次 PIMB 手术以进行肢体挽救（LS）。333 例患者中，188 例（56.5%）为 HD 患者。本研究仅使用静脉移植物，进行了 172 例 paramalleolar 和 229 例 inframalleolar 旁路转流术。比较了两组患者的 5 年主要和次要累计移植物通畅率、LS 率和免于截肢生存率（AFS），并在每组中确定了这些结果的独立决定因素。
HD 患者的 5 年主要和次要累计移植物通畅率分别为 53%和 82%，NHD 患者分别为 69%和 92%（主要累计移植物通畅率，P<0.05；次要累计移植物通畅率，无显著性差异）。HD 患者和 NHD 患者的 LS 率分别为 87%和 99%（P<0.01）。总体而言，48%和 70%的 HD 和 NHD 患者在 PIMB 前可步行（P<0.01），73%和 85%的 HD 和 NHD 患者在 PIMB 后 12 个月可步行（包括 1 年幸存者；无显著性差异），表明 HD 患者 PIMB 后步行能力显著改善。HD 组和 NHD 组的 5 年 AFS 率分别为 27%和 69%（P<0.01），表明 HD 患者的 AFS 率非常低。在 HD 患者中，与 AFS 相关的负性因素为女性（风险比 [HR]，2.102；95%置信区间 [CI]，1.254-3.524）、充血性心力衰竭史（HR，2.075；95%CI，1.395-3.085）和术前非步行状态（HR，1.974；95%CI，1.305-2.986），而年龄较大（HR，2.601；95%CI，1.372-4.931）和充血性心力衰竭史（HR，2.928；95%CI，1.496-5.731）是与 NHD 患者 AFS 相关的独立负性因素。
在 HD 和 NHD 患者中，使用 PIMB 治疗 CLI 与较低的手术死亡率和并发症相关，LS 率非常高。然而，与 NHD 患者相比，HD 患者的 AFS 率显著降低，这表明需要制定特定的管理方案以提高 HD 患者 LS 后的 AFS。
