Ochoa Chaar Cassius Iyad, Gholitabar Navid, Detrani Mara, Jorshery Saman Doroodgar, Kim Tanner I, Zhuo Haoran, Zhang Yawei, Dardik Alan
Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
Ann Vasc Surg. 2020 Aug;67:395-402. doi: 10.1016/j.avsg.2020.02.015. Epub 2020 Mar 13.
Multiple societal guidelines recommend medical optimization and exercise therapy for patients with claudication prior to lower extremity revascularization (LER). However, the application of those guidelines in practice remains unknown. Our hypothesis is that vascular surgeons (VS) are more adherent to guidelines compared to non-VS treating claudication.
The records of patients undergoing LER for claudication in a single center were reviewed, and adherence to guidelines prior to LER was assessed. Patients received conservative therapy if the impact of claudication on quality of life was documented, ankle-brachial index (ABI) was obtained, and patients were treated with at least 3 months of walking exercise and smoking cessation when indicated.
There were 187 patients treated for claudication (VS = 65, non-VS = 122). There were 161 patients who underwent endovascular intervention, 19 patients had an open revascularization, and 7 patients had a hybrid procedure. Patients treated by VS were younger and more likely to be African American. Patients treated by non-VS were more likely to have hyperlipidemia, coronary artery disease, smoke, and be on antiplatelet and statin medications. VS was more likely to assess pattern of symptoms with claudication and obtain ABIs compared to non-VS, although the mean ABIs were no different. VS was more likely to use walking exercises and smoking cessation when indicated before LER. Even though 70.8% and 31.1% of patients treated by VS and non-VS respectively were recommended walking exercises, only 33.8% and 18.0% were given a period of 3 months to benefit from it prior to LER. Conservative therapy was significantly higher among VS compared to non-VS but was overall low (VS = 12.3%, non-VS = 3.3%, P = 0.016). After a mean follow-up of 3.1 ± 1.3 years, there was no difference in mortality or major amputation.
Although adherence to guidelines in the medical management of vascular claudication prior to LER was higher among VS compared with non-VS, overall rates of adherence were low. Stricter institutional protocols and oversight across specialties are needed to reinforce the application of the established standards of care.
多项社会指南推荐在下肢血管重建术（LER）前对间歇性跛行患者进行医学优化和运动疗法。然而，这些指南在实际中的应用情况尚不清楚。我们的假设是，与治疗间歇性跛行的非血管外科医生相比，血管外科医生（VS）更遵守指南。
回顾了在单一中心接受LER治疗间歇性跛行患者的记录，并评估了LER前对指南的遵守情况。如果记录了间歇性跛行对生活质量的影响、获得了踝臂指数（ABI），并且患者在有指征时接受了至少3个月的步行锻炼和戒烟，则给予患者保守治疗。
有187例患者接受了间歇性跛行治疗（VS = 65例，非VS = 122例）。有161例患者接受了血管内介入治疗，19例患者进行了开放性血管重建，7例患者进行了杂交手术。由VS治疗的患者更年轻，更可能是非洲裔美国人。由非VS治疗的患者更可能患有高脂血症、冠状动脉疾病、吸烟，并且正在服用抗血小板和他汀类药物。与非VS相比，VS更有可能评估间歇性跛行的症状模式并获得ABI，尽管平均ABI没有差异。VS在LER前更有可能在有指征时使用步行锻炼和戒烟。尽管分别有70.8%和31.1%接受VS和非VS治疗的患者被建议进行步行锻炼，但在LER前只有33.8%和18.0%的患者有3个月的时间从中受益。VS中的保守治疗明显高于非VS，但总体较低（VS = 12.3%，非VS = 3.3%，P = 0.016）。平均随访3.1±1.3年后，死亡率或大截肢率没有差异。
尽管与非VS相比，VS在LER前对血管性间歇性跛行的医学管理中对指南的遵守率更高，但总体遵守率较低。需要更严格的机构协议和跨专业监督来加强既定护理标准的应用。
