Center for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland.
Department of Vascular Surgery, Turku University Hospital, Turku, Finland.
J Vasc Surg. 2020 Apr;71(4):1268-1275. doi: 10.1016/j.jvs.2019.07.061. Epub 2019 Sep 5.
The objective of this study was to assess factors predisposing patients to recurrent acute lower limb ischemia (RALLI).
Acute lower limb ischemia patients treated with catheter-directed thrombolysis (CDT) at Tampere University Hospital and Turku University Hospital between March 2002 and December 2015 were included. The patients' baseline demographics, comorbidities, and other characteristics were assessed retrospectively. Significant factors revealed by univariable analysis were tested in a multivariable model for associations with RALLI. A patency analysis was performed, and the risks of reocclusion were identified. The limb salvage rates after reocclusion were evaluated.
Altogether, 303 consecutive patients with a mean age of 71 years (standard deviation, 11.8 years) were included. Of them, 159 (52.5%) were men. A total of 164 (54.1%) native arterial and 139 (45.9%) bypass graft occlusions were initially treated with CDT. On completion of CDT, 204 additional endovascular or conventional surgical procedures on 203 patients were performed to obtain adequate distal perfusion. During a median follow-up of 40 months (interquartile range, 69 months), 40 (24.4%) cases of RALLI occurred in native arteries and 90 (64.7%) in bypass graft patients (P < .001). In native arteries, the absence of appropriate anticoagulant and antiplatelet medication was independently associated with the development of acute reocclusions (hazard ratio, 6.51) in the Cox multivariable regression analysis. The patency rates were 86.6%, 72.2%, and 68.0% at 1 year, 5 years, and 9 years, respectively. In bypass grafts, worsened tibial runoff (crural index III: hazard ratio, 2.40) was independently associated with RALLI. The respective patency rates were 60.5%, 34.0%, and 29.2% for synthetic conduits and 30.8%, 20.5%, and 13.7% for autologous vein grafts at 1 year, 5 years, and 9 years. Altogether, 38 (29.2%) major amputations were performed on patients with reocclusions. Patients with synthetic conduits demonstrated superior limb salvage rates after reocclusion in comparison to native arteries or vein grafts (P = .025).
Appropriate post-thrombolytic antiplatelet or anticoagulant treatment after native arterial events is of great importance, but additional data are needed to improve treatment algorithms. Adequate outflow in bypass graft patients is crucial. Patients with prosthetic bypass grafts have superior limb salvage rates after reocclusion.
本研究旨在评估导致急性下肢缺血（ALI）复发的患者的相关因素。
研究纳入了 2002 年 3 月至 2015 年 12 月在坦佩雷大学医院和图尔库大学医院接受导管溶栓治疗的急性下肢缺血患者。回顾性评估患者的基线人口统计学、合并症和其他特征。单变量分析显示的显著因素在多变量模型中进行了与 RALLI 相关的关联测试。进行了通畅性分析，并确定了再闭塞的风险。评估了再闭塞后的保肢率。
总共纳入了 303 例平均年龄为 71 岁（标准差 11.8 岁）的连续患者。其中 159 例（52.5%）为男性。164 例（54.1%）为原发性动脉闭塞，139 例（45.9%）为旁路移植闭塞。在完成 CDT 治疗后，203 名患者中有 204 名接受了额外的血管内或传统手术治疗，以获得足够的远端灌注。在中位随访 40 个月（四分位距 69 个月）期间，在原发性动脉中发生了 40 例（24.4%）RALLI，在旁路移植患者中发生了 90 例（64.7%）（P<.001）。在原发性动脉中，缺乏适当的抗凝和抗血小板药物治疗与 Cox 多变量回归分析中的急性再闭塞的发生（危险比，6.51）独立相关。通畅率分别为 1 年、5 年和 9 年时的 86.6%、72.2%和 68.0%。在旁路移植中，胫后动脉血流恶化（踝肱指数 III：危险比，2.40）与 RALLI 独立相关。相应的通畅率分别为合成移植物的 1 年、5 年和 9 年时的 60.5%、34.0%和 29.2%，自体静脉移植物的 30.8%、20.5%和 13.7%。总共对再闭塞患者进行了 38 例（29.2%）的主要截肢。与原发性动脉或静脉移植物相比，再闭塞后的合成移植物患者的保肢率更高（P=.025）。
原发性动脉事件后适当的溶栓后抗血小板或抗凝治疗非常重要，但需要更多的数据来改善治疗方案。旁路移植患者的充分流出量至关重要。人造旁路移植患者再闭塞后的保肢率更高。
