Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK; University of Swansea, College of Medicine, Swansea, UK.
Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK; Division of Population Medicine, Cardiff University, Cardiff, UK.
Eur J Vasc Endovasc Surg. 2018 Dec;56(6):834-848. doi: 10.1016/j.ejvs.2018.07.017. Epub 2018 Aug 24.
The importance of the angiosome concept in tibial artery revascularisation remains controversial. The aim of this review was to assess the outcomes of direct revascularisation (revascularisation to the angiosome of tissue loss; DR) versus indirect revascularisation (IR) in infrapopliteal arteries.
A previously conducted systematic review was updated according to PRISMA guidelines. Studies comparing DR with IR by both endovascular and surgical means for patients with localised tissue loss were included. Meta-analyses were performed to assess the effect of DR versus IR on wound healing (total and time to healing), limb salvage, mortality, and re-intervention rates, with multiple sensitivity analyses. Outcome data quality was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.
Seven studies (2278 limbs) were identified in the updated search, which when combined with the previous search resulted in 22 studies, comprising 4146 limbs, being included. Wound healing rates (odds ratio [OR] 0.51; 95% CI 0.39-0.68, p < 0.001), time to wound healing (standard mean difference [SMD] -1.70; 95% CI -3.34 to -0.07, p = .04) and limb salvage (OR 0.37; 95% CI 0.24-0.58, p < .0001) were significantly better with DR compared with IR. Sensitivity analyses were concordant with the primary analysis for these outcomes, with the exception of the effect of wound healing rates between DR and IR, which was lost on sensitivity analysis for bypass surgery. Mode of revascularisation had no effect on mortality or on re-intervention rates. GRADE outcomes were very low.
DR of the tibial vessels appears to result in improved wound healing and limb salvage rates compared with IR, with no effect on mortality or re-intervention rates. For surgical revascularisation the importance of DR appears to be lost for wound healing. When possible, these low quality data suggests DR should be undertaken in preference to IR.
在胫骨动脉再血管化中，血管铸型概念的重要性仍存在争议。本综述的目的是评估直接再血管化（向组织损失的血管铸型进行再血管化；DR）与间接再血管化（IR）在腘下动脉中的治疗效果。
根据 PRISMA 指南，对之前进行的系统综述进行了更新。纳入了比较局部组织损失患者经腔内和手术方式进行 DR 与 IR 的研究。采用荟萃分析评估 DR 与 IR 对创面愈合（总愈合率和愈合时间）、肢体存活率、死亡率和再干预率的影响，并进行了多次敏感性分析。使用推荐评估、制定与评价（GRADE）工具来确定结局数据质量。
更新后的检索共确定了 7 项研究（2278 条肢体），与之前的检索结果相结合，共纳入了 22 项研究（4146 条肢体）。DR 的创面愈合率（比值比 [OR] 0.51；95%置信区间 [CI] 0.39-0.68，p<0.001）、愈合时间（标准化均数差 [SMD] -1.70；95%CI -3.34 至-0.07，p=0.04）和肢体存活率（OR 0.37；95%CI 0.24-0.58，p<0.0001）明显优于 IR。DR 与 IR 相比，除了在旁路手术的敏感性分析中丢失了 DR 与 IR 之间的创面愈合率的影响外，这些结局的敏感性分析结果与主要分析结果一致。再血管化方式对死亡率或再干预率没有影响。GRADE 结局质量非常低。
与 IR 相比，DR 似乎能提高胫骨血管的创面愈合和肢体存活率，而对死亡率或再干预率没有影响。对于手术再血管化，DR 对创面愈合的重要性似乎丧失。在可能的情况下，这些低质量的数据表明，DR 应该优先于 IR。
