Division of Vascular and Endovascular Surgery, Boston University, School of Medicine, Boston, Mass.
Division of Vascular and Endovascular Surgery, University of California San Diego, School of Medicine, La Jolla, Calif.
J Vasc Surg. 2020 Mar;71(3):862-868. doi: 10.1016/j.jvs.2019.05.038. Epub 2019 Aug 5.
It has been suggested that more bypass outflow targets for bypass grafts improve patency and outcomes. Our objective was to examine this in a multicenter contemporary series of axillary to femoral artery grafts.
The Vascular Quality Initiative database was queried for all axillary-unifemoral (AxUF) and axillary-bifemoral (AxBF) bypass grafts performed between 2010 and 2017 for claudication, rest pain, and tissue loss. Patients with acute limb ischemia were excluded. Patients' demographics and comorbidities as well as operative details and outcomes were recorded. Univariable, multivariable, and Kaplan-Meier analyses were used to assess long-term outcomes.
There were 412 (32.9%) AxUF grafts and 839 (67.1%) AxBF grafts identified. Overall, the mean age of the patients was 68.3 years, 51.1% were male, and 84.7% were white. Compared with AxBF grafts, AxUF grafts were more often performed for urgent cases; in patients who were younger, male, nonambulatory, and diabetic; and in those with preoperative anticoagulation, critical limb ischemia, prior bypass, aneurysm repair, peripheral vascular intervention, and major amputation (P < .05 for all). There were no significant differences between AxUF and AxBF grafts in perioperative wound complications (4.2% vs 2.9%; P = .23), cardiac complications (7.3% vs 10.4%; P = .08), pulmonary complications (4.1% vs 6%, P = .18), early stenosis/occlusion (0.2% vs 0.8%; P = .22), perioperative mortality (2.9% vs 3.2%; P = .77), and length of stay (6.4 ± 5.6 days vs 6.7 ± 8 days; P = .29). The mean estimated blood loss (268.1 mL vs 348.6 mL; P < .001) and mean operative time (201 minutes vs 224.1 minutes; P < .001) were significantly lower for AxUF grafts. Kaplan-Meier analysis showed that AxUF and AxBF grafts had similar freedom from graft occlusion (62.6% vs 71.8%; P = .074), major adverse limb event-free survival (57.1% vs 66.6%; P = .052), and survival (86% vs 86%; P = .897) at 1 year. Major amputation-free survival was lower for AxUF grafts (63.7% vs 73%; P = .028). Multivariable analysis also showed that the type of graft configuration did not independently predict occlusion/death (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.77-1.46; P = .72), amputation/death (HR, 1.12; 95% CI, 0.83-1.51; P = .45), major adverse limb event/death (HR, 0.97; 95% CI, 0.73-1.3; P = .85), or mortality (HR, 0.91; 95% CI, 0.65-1.26; P = .55). Three-year survival after placement of AxUF and AxBF grafts was similar (75.1% vs 78.2%; P = .414).
AxUF and AxBF grafts have similar perioperative and 1-year outcomes. Graft patency was not significantly different between an AxBF graft and an AxUF graft at 1 year. Overall, patients treated with these reconstructions have many comorbidities and low long-term survival.
有研究表明，增加旁路流出目标可提高旁路移植术的通畅率和效果。我们的目的是在腋股动脉旁路移植术的多中心当代系列中研究这一点。
在 2010 年至 2017 年期间，血管质量倡议数据库中检索了所有用于跛行、静息痛和组织损失的腋-股（AxUF）和腋-双股（AxBF）旁路移植术患者。排除急性肢体缺血患者。记录患者的人口统计学和合并症以及手术细节和结果。使用单变量、多变量和 Kaplan-Meier 分析评估长期结果。
共确定了 412 例（32.9%）AxUF 旁路移植术和 839 例（67.1%）AxBF 旁路移植术。总体而言，患者的平均年龄为 68.3 岁，51.1%为男性，84.7%为白人。与 AxBF 旁路移植术相比，AxUF 旁路移植术更常用于紧急情况；在年龄较小、男性、非步行、糖尿病患者中；以及术前抗凝、临界肢体缺血、旁路手术、动脉瘤修复、外周血管介入治疗和大截肢患者中（所有患者均为 P<0.05）。AxUF 和 AxBF 旁路移植术在围手术期伤口并发症（4.2% vs 2.9%；P=0.23）、心脏并发症（7.3% vs 10.4%；P=0.08）、肺部并发症（4.1% vs 6%，P=0.18）、早期狭窄/闭塞（0.2% vs 0.8%；P=0.22）、围手术期死亡率（2.9% vs 3.2%；P=0.77）和住院时间（6.4±5.6 天 vs 6.7±8 天；P=0.29）方面无显著差异。AxUF 旁路移植术的平均估计失血量（268.1 毫升 vs 348.6 毫升；P<0.001）和平均手术时间（201 分钟 vs 224.1 分钟；P<0.001）显著较低。Kaplan-Meier 分析显示，AxUF 和 AxBF 旁路移植术在 1 年内的吻合口闭塞（62.6% vs 71.8%；P=0.074）、主要不良肢体事件无事件生存（57.1% vs 66.6%；P=0.052）和生存（86% vs 86%；P=0.897）方面相似。AxUF 旁路移植术的主要截肢无事件生存较低（63.7% vs 73%；P=0.028）。多变量分析还表明，移植构型类型不能独立预测闭塞/死亡（风险比 [HR]，1.06；95%置信区间 [CI]，0.77-1.46；P=0.72）、截肢/死亡（HR，1.12；95% CI，0.83-1.51；P=0.45）、主要不良肢体事件/死亡（HR，0.97；95% CI，0.73-1.3；P=0.85）或死亡率（HR，0.91；95% CI，0.65-1.26；P=0.55）。AxUF 和 AxBF 旁路移植术后 3 年的生存率相似（75.1% vs 78.2%；P=0.414）。
AxUF 和 AxBF 旁路移植术具有相似的围手术期和 1 年结果。在 1 年时，AxBF 旁路移植术和 AxUF 旁路移植术的通畅率无显著差异。总体而言，接受这些重建手术的患者存在许多合并症和较低的长期生存率。
