Mohapatra Abhisekh, Lowenkamp Mikayla N, Henry Jon C, Boitet Aureline, Avgerinos Efthimios D, Chaer Rabih A, Makaroun Michel S, Leers Steven A, Hager Eric S
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.
Ann Vasc Surg. 2018 Jul;50:80-87. doi: 10.1016/j.avsg.2017.11.066. Epub 2018 Feb 23.
Endovascular strategies are often preferred for revascularization of ischemic foot wounds secondary to infrapopliteal disease because of the less invasive technique and faster recovery. Bypass is typically reserved for failures or lesions not amenable to balloon angioplasty. However, the effects of an endovascular-first approach on subsequent bypass grafts are largely unknown. This study evaluates the effects of prior endovascular tibial interventions (PTIs) on successive bypasses to pedal targets.
Patients who presented with ischemic tissue loss and tibial arterial occlusive disease to University of Pittsburgh Medical Center between 2006 and 2013 and underwent a surgical bypass to pedal arteries were included in this study. A retrospective chart review was conducted to obtain patient demographics, past medical history, extent of disease, prior tibial endovascular interventions, the treatment intervention, subsequent interventions, wound healing status, limb salvage, and patient survival. The primary outcome was primary patency of the pedal bypass graft.
From 122 eligible patients, 27 had a PTI, whereas 95 had no prior endovascular tibial intervention (nPTI) in the treatment of ischemic pedal wounds with mean follow-up of 24.5 and 20.5 months, respectively (P = 0.36). The 2 groups were largely similar in terms of demographics, comorbidities, wound size, and degree of ischemia. Runoff scores between the 2 groups were also comparable (5.0 ± 1.6 for PTI and 4.8 ± 1.9 for nPTI, P = 0.59). The plantar artery was a more common target vessel in the PTI group, whereas the posterior tibial artery was targeted more often in the nPTI group (P = 0.04). At 12 months, those with a PTI exhibited a shorter primary patency (34.8% vs. 60.2%, P = 0.04). In a multivariate model, PTI was a significant risk factor for primary patency loss (hazard ratio 2.51, P = 0.004). Primary assisted patency and secondary patency were similar between the 2 groups. Wound healing was improved in those patients who had a prior endovascular intervention with 63.8% healed at 1 year compared with only 34.8% of those without intervention (P = 0.01). Amputation-free survival was similar (P = 0.68), as was survival alone (P = 0.50).
Despite a decrease in primary patency, pedal bypass was not otherwise negatively affected by a PTI. Similar primary assisted patency, secondary patency, wound healing, and survival between the 2 patient populations indicate that an endovascular-first approach is a feasible treatment strategy to achieve similar clinical outcomes in the management of ischemic foot wounds.
由于血管内治疗技术侵入性较小且恢复较快，对于腘动脉以下疾病继发的缺血性足部伤口进行血运重建时，血管内治疗策略通常更受青睐。旁路移植术通常用于血管成形术失败或病变不适于球囊血管成形术的情况。然而，血管内优先治疗方法对后续旁路移植的影响在很大程度上尚不清楚。本研究评估了先前的胫动脉血管内介入治疗（PTI）对后续向足部目标血管进行旁路移植的影响。
本研究纳入了2006年至2013年间因缺血性组织丢失和胫动脉闭塞性疾病就诊于匹兹堡大学医学中心并接受了足部动脉手术旁路移植的患者。进行回顾性病历审查以获取患者人口统计学资料、既往病史、疾病范围、先前的胫动脉血管内介入治疗、治疗干预措施、后续干预措施、伤口愈合状况、肢体挽救情况和患者生存情况。主要结局是足部旁路移植血管的原发性通畅率。
在122例符合条件的患者中，27例接受了PTI，而95例在治疗缺血性足部伤口时未进行过先前的胫动脉血管内介入治疗（nPTI），平均随访时间分别为24.5个月和 20.5个月（P = 0.36）。两组在人口统计学、合并症、伤口大小和缺血程度方面基本相似。两组间的流出道评分也相当（PTI组为5.0±1.6，nPTI组为4.8±1.9，P = 0.59）。足底动脉在PTI组中是更常见的目标血管，而胫后动脉在nPTI组中更常作为目标血管（P = 0.04）。在12个月时，接受PTI的患者原发性通畅时间较短（34.8% 对6 0.2%，P = 0.04）。在多变量模型中，PTI是原发性通畅丧失的一个重要危险因素（风险比2.51，P = 0.004）。两组间的原发性辅助通畅率和继发性通畅率相似。先前接受血管内介入治疗的患者伤口愈合情况有所改善，1年时愈合率为63.8%，而未接受介入治疗的患者仅为34.8%（P = 0.01）。无截肢生存率相似（P = 0.68），总生存率也相似（P = 0.50）。
尽管原发性通畅率有所下降，但PTI并未对足部旁路移植产生其他负面影响。两组患者在原发性辅助通畅率、继发性通畅率、伤口愈合和生存率方面相似，这表明血管内优先治疗方法是一种可行的治疗策略，在缺血性足部伤口管理中可实现相似的临床结局。
