Lo Zhiwen Joseph, Lin Zhimin, Pua Uei, Quek Lawrence Han Hwee, Tan Bien Ping, Punamiya Sundeep, Tan Glenn Wei Leong, Narayanan Sriram, Chandrasekar Sadhana
Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore.
University Surgical Cluster, National University Health System, Singapore.
Ann Vasc Surg. 2018 May;49:9-16. doi: 10.1016/j.avsg.2018.01.061. Epub 2018 Feb 9.
To review patient characteristics and outcomes of in-patient diabetic foot limb salvage and identify risk factors predicting for endovascular limb salvage failure.
Retrospective study of limb salvage attempts in 809 patients between August 2013 and July 2015.
Sixty-eight percent of our study population were male with mean age at 65 years and 73% presented with Rutherford grade 6 critical limb ischemia, with the remaining 27% Rutherford grade 5. Eighty-one percent had toe pressures of less than 50 mm Hg, 64% had infrainguinal trans-Atlantic inter-society consensus (TASC II) C or D lesions while 78% had infrapopliteal TASC II C or D lesions. Seven hundred seventy-seven patients (96%) underwent endovascular-first approach limb salvage, with 95% requiring infrapopliteal angioplasty, with 84% of them requiring 2-vessel or 3-vessel revascularization. Thirty-two patients (4%) underwent surgical bypass limb salvage, with 63% performed as salvage procedures for failed angioplasties. The mean in-patient stay was 12.3 days within the endovascular group and 31.1 days within the bypass group (P < 0.01). One-year limb salvage was successful in 88% of endovascular group, as compared with 72% in bypass group (P = 0.01). Overall 1-year survival was 93% within the endovascular group and 88% within the bypass group (P = 0.27). The mean in-patient cost was SGD$5,518 within the endovascular group and SGD$15,141 within the bypass group (P < 0.01). Multivariate analysis showed that independent predictors for failure of endovascular limb salvage include end-stage renal failure (ESRF) (odds ratio [OR] 2.04, P = 0.01), toe pressures <50 mm Hg (OR 2.15, P = 0.01), infrainguinal TASC II patterns C or D (OR 1.99, P = 0.03), and indirect angiosome revascularization (OR 2.03, P = 0.02).
Within our study population of Asian ethnicity, most in-patient diabetic foot peripheral arterial disease presented with Rutherford grade 6 disease, with mostly TASC II C or D lesions and required infrapopliteal revascularization. As most patients had multiple comorbidities and were poor surgical candidates, the majority underwent endovascular-first approach revascularization. Independent predictors of endovascular limb salvage failure include ESRF, toe pressures <50 mm Hg, infrainguinal TASC II patterns C or D, and indirect angiosome revascularization.
回顾住院患者糖尿病足肢体挽救的患者特征及结局，并确定预测血管腔内肢体挽救失败的危险因素。
对2013年8月至2015年7月期间809例患者的肢体挽救尝试进行回顾性研究。
我们研究人群中68%为男性，平均年龄65岁，73%表现为卢瑟福分级6级严重肢体缺血，其余27%为卢瑟福分级5级。81%的患者趾压低于50 mmHg，64%有腹股沟下跨大西洋血管外科学会共识（TASC II）C或D级病变，而78%有腘动脉以下TASC II C或D级病变。777例患者（96%）接受了血管腔内优先入路的肢体挽救，其中95%需要腘动脉以下血管成形术，其中84%需要双支或三支血管重建。32例患者（4%）接受了外科搭桥肢体挽救，其中63%作为血管成形术失败后的挽救手术。血管腔内组的平均住院时间为12.3天，搭桥组为31.1天（P<0.01）。血管腔内组1年肢体挽救成功率为88%，而搭桥组为72%（P=0.01）。血管腔内组总体1年生存率为93%，搭桥组为88%（P=0.27）。血管腔内组的平均住院费用为5518新元，搭桥组为15141新元（P<0.01）。多变量分析显示，血管腔内肢体挽救失败的独立预测因素包括终末期肾衰竭（ESRF）（比值比[OR]2.04，P=0.01））、趾压<50 mmHg（OR 2.15，P=0.01）、腹股沟下TASC II C或D型（OR 1.99，P=0.03）以及间接血管体血管重建（OR 2.03，P=0.02）。
在我们的亚洲种族研究人群中，大多数住院糖尿病足外周动脉疾病患者表现为卢瑟福分级6级疾病，大多为TASC II C或D级病变，需要腘动脉以下血管重建。由于大多数患者有多种合并症且不是手术的合适人选，大多数患者接受了血管腔内优先入路的血管重建。血管腔内肢体挽救失败的独立预测因素包括ESRF、趾压<50 mmHg、腹股沟下TASC II C或D型以及间接血管体血管重建。
