Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Vasc Surg. 2018 Jul;68(1):168-175. doi: 10.1016/j.jvs.2017.10.076. Epub 2018 Jan 11.
Pedal (inframalleolar) bypass is a long-standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes.
We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes.
We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively (P = .08). The endovascular patients were older at baseline (P = .009), with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared with 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P < .0001), but freedom from major amputation was similar (84.9% vs 82.8%; P = .42). Primary patency (53.1% vs 38.2%; P = .002) and primary assisted patency (76.6% vs 51.7%; P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs 73.8%; P = .13).
Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the "gold standard" of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.
在存在缺血性组织损失的患者中，踝下（跗下）旁路是治疗胫骨动脉疾病的一种长期疗法。腔内胫骨介入是一种有吸引力的替代方法，其围手术期死亡率或并发症风险较低。我们的目的是比较这两种治疗方法在通畅性和肢体相关临床结果方面的效果。
我们对 2006 年至 2013 年间因缺血性足部伤口和胫下动脉疾病而就诊并接受再血管化手术（踝下目标的开放手术旁路或腔内胫骨介入）的患者进行了回顾性图表审查。收集了基线人口统计学和合并症、手术细节以及术后结果的数据。主要结果是索引伤口的成功愈合，评估死亡率、主要截肢和通畅性作为次要结果。
我们确定了 417 名符合入选标准的患者；105 名接受了手术旁路治疗，312 名接受了腔内介入治疗，平均随访 25.0 和 20.2 个月（P=0.08）。腔内组患者的基线年龄较大（P=0.009），血脂异常（P=0.02）、既往脑血管意外（P=0.04）和吸烟史（P=0.04）的发生率较高。术后 30 天内，死亡率无差异（P=0.31），但旁路患者的住院时间更长（P<0.0001），出院至护理机构的比例更高（P<0.001），心肌梗死（P=0.03）和伤口并发症（P<0.001）的发生率更高。6 个月时，旁路组的伤口愈合率为 22.4%，而腔内组为 29.0%（P=0.02）。1 年时，旁路组的生存率更高（86.2% vs 70.4%；P<0.0001），但主要截肢率无差异（84.9% vs 82.8%；P=0.42）。旁路组的初始通畅率（53.1% vs 38.2%；P=0.002）和初始辅助通畅率（76.6% vs 51.7%；P<0.0001）较高，但次要通畅率无差异（77.3% vs 73.8%；P=0.13）。
与手术旁路至踝下靶目标的“金标准”相比，腔内胫骨介入治疗与较差的初始通畅率相关，但与相似的次级通畅率和伤口愈合率相关。在患有胫骨动脉疾病的患者中，腔内介入治疗应被视为一种风险较低的替代方案，可提供相似的临床结果。
