O'Brien-Irr Monica S, Dryjski Maciej L, Dosluoglu H Hasan, Shalaby Sherif, Cherr Gregory, Rivero Mariel, Kuoduomas Dimitrios, Harris Linda M
Division of Vascular Surgery, Department of Surgery, University of Buffalo, State University of New York, Buffalo, NY.
Division of Vascular Surgery, Department of Surgery, University of Buffalo, State University of New York, Buffalo, NY; Gates Vascular Institute, Kaleida Health, Buffalo, NY.
Ann Vasc Surg. 2019 Feb;55:96-103. doi: 10.1016/j.avsg.2018.07.038. Epub 2018 Sep 12.
To evaluate outcomes after lower extremity revascularization for critical limb ischemia with tissue loss in patients with chronic immune-mediated inflammatory disease.
A retrospective medical record review of all lower extremity revascularization for critical limb ischemia with tissue loss at a university-affiliated hospital over a 3-year period was completed for demographics, comorbidities, lower extremity revascularization indication, angiogram results, complications, mortality, limb salvage, and reintervention. Chronic immune-mediated inflammatory disease (CIID) and control (no autoimmune disease) were compared by chi-squared test, Student's t-test, Kaplan-Meier, and Cox Regression.
There were 349 procedures performed (297 patients): (1) 44 (13%) primary amputations and (2) 305 (87%) lower extremity revascularizations, in which 83% were endovascular interventions; 12% was bypass; and 5% was hybrid, in which 40% was infrainguinal and 60% was infrageniculate, 72% Wounds Ischemia Infection Score System (WIFi) tissue loss class 2-3, 35% CIID. No differences were noted between CIID and control for primary amputation (P = 0.11), lower extremity revascularization type (P = 0.50), or lower extremity revascularization anatomic level (P = 0.43). Mean age was 71 + 13 years, and 56% of the patients were of male gender. Those with CIID were of similar age as controls (71 ± 14 vs. 71 ± 13; P = 0.87) and presented with comparable runoff: (1) ≤1 vessel (52% vs. 47%; P = 0.67), (2) WIFi tissue loss classification class 2-3 (66% vs. 76%; P = 0.09), and (3) WIFi infection classification class 2-3 (29% vs. 30%; P = 0.9). They were also less likely to be male (47% vs. 61%; P = 0.022) or current smokers (13% vs. 27%; P = 0.008). Postoperative mortality (P = 0.70) morbidity and reoperation (0.31) were comparable. Twenty-four-month survival was similar for CIID and control (83% ± 5% vs. 86% + 3%; P = 0.78), as was the amputation-free interval (69% ± 5% vs. 61% ± 4%; P = 0.18) and need for target extremity revascularization (40% vs. 53%; P = 0.04). Use of steroids and other anti-inflammatory medications was associated with improved 24-month amputation-free interval (87% ± 9% vs. 63% ± 3%; P = 0. 05). Dialysis (odds ratio: 2.6; 1.5-4.7; P = 0.001), WIFi infection class 2-3 (odds ratio: 2.8; 1.6-4.9; P < 0.001), prerunoff vessel (0-1 vs. 2-3) to the foot (odds ratio: 0.52; 0.37-0.73; P < 0.001), steroids/other anti-inflammatory agents (0.29; 0.06-0.96; P = 0.04), and statins (0.44; 0.25-0.77; P = 0.005) were independent predictors of 24-month amputation-free interval (Cox proportional hazard ratio).
Patients with critical limb ischemia, tissue loss, and concomitant CIID can be successfully treated with lower extremity revascularization with similar limb salvage and need for reintervention. Steroid/anti-inflammatory use appears beneficial.
评估慢性免疫介导性炎症疾病患者因严重肢体缺血伴组织缺损而进行下肢血运重建后的结局。
对一所大学附属医院3年内所有因严重肢体缺血伴组织缺损而进行下肢血运重建的患者的病历进行回顾性分析，内容包括人口统计学资料、合并症、下肢血运重建指征、血管造影结果、并发症、死亡率、肢体挽救情况及再次干预情况。采用卡方检验、学生t检验、Kaplan-Meier法和Cox回归分析对慢性免疫介导性炎症疾病（CIID）组和对照组（无自身免疫性疾病）进行比较。
共进行了349例手术（涉及297例患者）：（1）44例（13%）一期截肢手术；（2）305例（87%）下肢血运重建手术，其中83%为血管腔内介入治疗，12%为旁路移植术，5%为杂交手术，杂交手术中40%为腹股沟下手术，60%为膝下手术；72%的患者伤口缺血感染评分系统（WIFi）组织缺损分级为2-3级，35%的患者患有CIID。CIID组和对照组在一期截肢手术（P = 0.11）、下肢血运重建类型（P = 0.50）或下肢血运重建解剖部位（P = 0.43）方面未发现差异。患者平均年龄为71±13岁，56%为男性。CIID组患者年龄与对照组相似（71±14岁 vs. 71±13岁；P = 0.87），且血管流出道情况相当：（1）≤1支血管（52% vs. 47%；P = 0.67），（2）WIFi组织缺损分级为2-3级（66% vs. 76%；P = 0.09），（3）WIFi感染分级为2-3级（29% vs. 30%；P = 0.9）。CIID组患者男性比例（47% vs. 61%；P = 0.022）和当前吸烟者比例（13% vs. 27%；P = 0.008）也较低。术后死亡率（P = 0.70）、发病率及再次手术率（0.31）相当。CIID组和对照组24个月生存率相似（83%±5% vs. 86%±3%；P = 0.78），无截肢间期（69%±5% vs. 61%±4%；P = 0.18）及目标肢体血运重建需求（40% vs. 53%；P = 0.04）也相似。使用类固醇和其他抗炎药物与24个月无截肢间期改善相关（87%±9% vs. 63%±3%；P = 0.05）。透析（比值比：2.6；1.5 - 4.7；P = 0.001）、WIFi感染分级为2-3级（比值比：2.8；1.6 - 4.9；P < 0.001）、足部流入血管（0 - 1支 vs. 2 - 3支）（比值比：0.52；0.37 - 0.73；P < 0.001）、类固醇/其他抗炎药物（0.29；0.06 - 0.96；P = 0.04）及他汀类药物（0.44；0.25 - 0.77；P = 0.005）是24个月无截肢间期的独立预测因素（Cox比例风险比）。
严重肢体缺血、组织缺损且合并CIID的患者可通过下肢血运重建成功治疗，肢体挽救情况及再次干预需求相似。使用类固醇/抗炎药物似乎有益。
