Kassegne Tchala, Della Schiava Nellie, Henni Samir, Feugier Patrick, Picquet Jean, Ammi Myriam
Department of Vascular Surgery, Angers Hospital, Angers University, Angers, France.
Department of Vascular surgery, University Hospital, Lyon, France.
Ann Vasc Surg. 2019 Nov;61:48-54. doi: 10.1016/j.avsg.2019.02.019. Epub 2019 May 7.
In case of acute thrombosis, lower limb bypasses can, in certain cases, be cleared by local intra-arterial fibrinolysis (LIF). The aim of this study is to evaluate the secondary patency of thrombosed bypasses after fibrinolysis.
This retrospective study includes all patients hospitalized for thrombosed bypasses of the lower limbs that were treated with in situ fibrinolysis using urokinase, between 2004 and 2013, in 2 French university hospital centers. Fibrinolysis was indicated in case of recent thrombosis (<3 weeks) provoking acute limb ischemia without sensory-motor deficit and in the absence of general contraindications. The secondary patency of the grafts was defined as the time after fibrinolysis without a new thrombotic event.
There were 207 patients, hospitalized for recent thrombosis of 244 bypasses. The LIF was efficient in 74% of the cases (n = 180). Secondary patency of these bypasses was 54.2% and 32.4% overall, 68.3% and 50.3% for the suprainguinal bypasses, and 48.3% and 21.5% for the infrainguinal bypasses at 1 and 5 years, respectively. There is a significant difference (P = 0.002) regarding the permeability of the suprainguinal and infrainguinal bypasses. The survival rate was 75% (±6.4%) at 5 years and the limb salvage rate was 89% (±3.3%), 78.2% (±5.1%), and 75% (±5.8%) at 1, 3, and 5 years, respectively. The only independent factor influencing the secondary patency of infrainguinal bypasses that was significant in a multivariate analysis was the infragenicular localization of the distal anastomosis (P = 0.023).
LIF is an effective approach that often allows the identification of the underlying cause, permitting elective adjunctive treatment of the underlying cause. Although LIF is at least as effective as its therapeutic alternatives described in the literature, the secondary patency of the bypasses remains modest and encourages close monitoring, particularly in patients with an infragenicular bypass.
在急性血栓形成的情况下，下肢旁路移植血管在某些病例中可通过局部动脉内纤溶治疗（LIF）实现再通。本研究旨在评估纤溶治疗后血栓形成的旁路移植血管的二期通畅率。
这项回顾性研究纳入了2004年至2013年间在法国2家大学医院中心因下肢旁路移植血管血栓形成而住院，并接受原位尿激酶纤溶治疗的所有患者。近期血栓形成（<3周）导致急性肢体缺血且无感觉运动障碍，且无全身禁忌证时，可进行纤溶治疗。移植物的二期通畅定义为纤溶治疗后无新血栓形成事件的时间。
共有207例患者因近期244条旁路移植血管血栓形成而住院。LIF治疗在74%的病例（n = 180）中有效。这些旁路移植血管的总体二期通畅率在1年和5年时分别为54.2%和32.4%，腹股沟上旁路移植血管分别为68.3%和50.3%，腹股沟下旁路移植血管分别为48.3%和21.5%。腹股沟上和腹股沟下旁路移植血管的通畅性存在显著差异（P = 0.002）。5年生存率为75%（±6.4%），肢体挽救率在1年、3年和5年时分别为89%（±3.3%）、78.2%（±5.1%）和75%（±5.8%）。多因素分析中，唯一对腹股沟下旁路移植血管二期通畅有显著影响的独立因素是远端吻合口位于膝下（P = 0.023）。
LIF是一种有效的方法，通常能够明确潜在病因，从而允许对潜在病因进行选择性辅助治疗。尽管LIF至少与文献中描述的其他治疗方法一样有效，但旁路移植血管的二期通畅率仍然不高，这就需要密切监测，尤其是对于膝下旁路移植血管的患者。
