Davis Frank M, Albright Jeremy, Gallagher Katherine A, Gurm Hitinder S, Koenig Gerald C, Schreiber Theodore, Grossman P Michael, Henke Peter K
Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI.
Ann Vasc Surg. 2018 Aug;51:106-112. doi: 10.1016/j.avsg.2017.12.025. Epub 2018 Mar 5.
Acute limb ischemia (ALI) of the lower extremity is a potentially devastating condition that requires urgent and definitive management. This challenging scenario is often treated with endovascular, open surgical, or hybrid revascularization (HyR) in an urgent basis, but the comparative effects of such therapies remain poorly defined. The purpose of this study was to compare the outcomes of endovascular, open surgical, and HyR for ALI in the contemporary era.
A large statewide cardiovascular consortium of 45 hospitals was queried for patients between January 2012 and June 2015 who underwent an endovascular, open surgical, or HyR for ALI deemed at high risk of limb loss if not treated within 24 hr (Rutherford class IIA or IIB). A propensity score weighted analysis was performed controlling for demographics, medical history, and procedure type for patients. The primary outcomes were 30-day morbidity and mortality.
A total of 1,480 patients underwent endovascular revascularization (ER; n = 818), open surgical revascularization (OSR; n = 195), or hybrid revascularization (HyR; n = 467) for ALI. The mean age was similar across revascularization technique with an increased predominance of male gender in open surgery cohort. Comorbidities for all groups were consistent with peripheral arterial disease. The most common endovascular procedures were angioplasty (93%) and thrombolysis (49.8%), whereas the most common surgical revascularization was femoral to popliteal bypass (32.8%), femoral to tibial bypass (28.2%), and thrombectomy (19.0%); ER as compared with OSR and HyR procedures was associated with less transfusion (OSR versus ER, odds ratio [OR] 2.7; HyR versus ER, OR 2.8; P < 0.001) and major amputation (OSR versus ER, OR 3.4; HyR versus ER, OR 4.0; P < 0.001) within 30 days of intervention. There was no difference in 30-day freedom from reintervention, myocardial infarction (MI), or mortality.
Among patients requiring urgent revascularization for Rutherford grade IIA and IIB ischemia, ER has lower 30-day morbidity but similar mortality and rates of reintervention. Although long-term patency rates were not compared, ER may offer superior short-term outcomes compared with open surgery and hybrid revascularization.
下肢急性肢体缺血（ALI）是一种潜在的毁灭性疾病，需要紧急且明确的治疗。这种具有挑战性的情况通常在紧急情况下采用血管内治疗、开放手术或杂交血管重建术（HyR）进行治疗，但这些治疗方法的比较效果仍不明确。本研究的目的是比较当代血管内治疗、开放手术和HyR治疗ALI的效果。
对一个由45家医院组成的大型全州心血管联盟进行查询，以获取2012年1月至2015年6月期间因ALI接受血管内治疗、开放手术或HyR的患者，这些患者如果在24小时内未接受治疗则有肢体丢失的高风险（卢瑟福分级IIA或IIB）。对患者的人口统计学、病史和手术类型进行倾向评分加权分析。主要结局为30天的发病率和死亡率。
共有1480例患者因ALI接受了血管内血管重建术（ER；n = 818）、开放手术血管重建术（OSR；n = 195）或杂交血管重建术（HyR；n = 467）。不同血管重建技术的患者平均年龄相似，开放手术队列中男性占比更高。所有组的合并症与外周动脉疾病一致。最常见的血管内手术是血管成形术（93%）和溶栓术（49.8%），而最常见的手术血管重建是股腘动脉旁路移植术（32.8%）、股胫动脉旁路移植术（28.2%）和血栓切除术（19.0%）；与OSR和HyR手术相比，ER手术在干预后30天内输血较少（OSR与ER相比，比值比[OR] 2.7；HyR与ER相比，OR 2.8；P < 0.001），大截肢较少（OSR与ER相比，OR 3.4；HyR与ER相比，OR 4.0；P < 0.001）。30天内再次干预、心肌梗死（MI）或死亡率无差异。
在因卢瑟福IIA和IIB级缺血需要紧急血管重建的患者中，ER的30天发病率较低，但死亡率和再次干预率相似。虽然未比较长期通畅率，但与开放手术和杂交血管重建术相比，ER可能提供更好的短期效果。
