Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (K.H., D.A.C.).
Clinical Effectiveness Unit, the Royal College of Surgeons of England, London, United Kingdom (K.H., A.S.J., S.W., D.A.C.).
Circulation. 2018 May 1;137(18):1921-1933. doi: 10.1161/CIRCULATIONAHA.117.029834. Epub 2018 Jan 9.
The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes.
Individual-patient records from Hospital Episode Statistics were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus.
The estimated 1-year risk of major amputation decreased from 5.7% (in 2006-2007) to 3.9% (in 2014-2015) following endovascular revascularization, and from 11.2% (2006-2007) to 6.6% (2014-2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures.
Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.
在过去十年中，英格兰可提供的下肢血运重建术式的数量和种类有所增加。我们研究了这些治疗方法的发展是否转化为患者治疗途径和结局的改善。
利用医院入院统计数据中的个体患者记录，确定了 2006 年 1 月至 2015 年 12 月期间在英格兰因下肢外周动脉疾病接受腔内（血管成形术）或手术（内膜切除术、深部血管成形术或旁路移植术）下肢血运重建的 103934 例患者。从医院入院统计数据和国家统计局死亡率记录中确定血管重建术后 1 年内的主要下肢截肢和死亡情况。采用竞争风险回归估计主要截肢和死亡的累积发生率，调整患者年龄、性别、合并症评分、干预适应证（间歇性跛行、严重肢体缺血但无组织丢失记录、严重肢体缺血伴溃疡记录、严重肢体缺血伴坏疽/骨髓炎记录）和合并糖尿病。
腔内血运重建后，1 年主要截肢风险从 2006-2007 年的 5.7%降至 2014-2015 年的 3.9%，手术治疗后从 2006-2007 年的 11.2%降至 2014-2015 年的 6.6%。两种血运重建术后的死亡风险也有所降低。所有适应证类别均观察到这些趋势，其中溃疡或坏疽伴严重肢体缺血患者的降幅最大。总体而言，研究期间发病率增加，更多的患者使用侵入性较小的方法治疗外周动脉疾病谱的严重端。
我们的研究结果表明，2006 年至 2015 年间，血管重建后总体生存率提高，主要下肢截肢风险降低。这些观察结果表明，在英国血管服务中心化和专业化的过程中，下肢血运重建后患者的结局得到了改善。
