Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
J Vasc Surg. 2020 Dec;72(6):1976-1986. doi: 10.1016/j.jvs.2019.09.067. Epub 2020 Apr 10.
Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention.
Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications.
There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P < .01) and aortounifemoral bypass (P < .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004).
Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.
尽管血管内治疗取得了进展，但腹主动脉-股动脉旁路移植术（AFB；腹主动脉-单侧股动脉和腹主动脉-双侧股动脉旁路移植术）仍是治疗主髂动脉闭塞性疾病最持久的选择。虽然 AFB 降低了主髂动脉再介入的发生率，但剖腹手术相关和腹股沟伤口并发症对发病率和再介入的影响尚不清楚。本研究的目的是确定 AFB 后非血管并发症的发生率，并确定其对再介入的影响。
查询了 2000 年至 2017 年的 AFB 机构数据。主要终点包括剖腹手术相关和腹股沟伤口并发症。总再介入定义为剖腹手术和腹股沟伤口并发症以及移植物通畅性的复合结果。Kaplan-Meier 分析估计了无再介入的生存率。Fine-Gray 法用于竞争性长期风险确定剖腹手术并发症的预测因素。Logistic 回归，调整患者水平聚类的变异性，确定伤口并发症的预测因素。
281 例患者的 553 条肢体（272 例腹主动脉-双侧股动脉旁路移植术和 9 例腹主动脉-单侧股动脉旁路移植术；年龄 67.6±11.0 岁；50.5%为女性）。90 例（32%）患者有既往腹部手术史，3.2%有既往腹疝（VH）修补史，2.9%有未治疗的 VH，0.7%有小肠梗阻病史。大多数患者因跛行而行 AFB（66.2%）；87.2%的患者为 TransAtlantic Inter-Society Consensus（TASC）D 病变，31.4%需要肾上级夹闭或更高位夹闭，16.4%需要同时行肾内脏动脉血运重建，6.4%正在接受抗凝治疗。67 例（12.1%）股动脉需要再次暴露，32.4%需要股流出道辅助，1.8%需要同时行下肢旁路移植。30 天死亡率为 2.9%。中位随访 5.3 年（四分位距 7.3 年）期间，21%的患者发生剖腹手术并发症（VH，15.3%；小肠梗阻，7.5%；其他，2.1%），其中 10.0%需要手术干预。67 例（12%）腹股沟有伤口并发症；4.9%需要干预。未调整的 1 年、3 年和 5 年移植物再介入无复发生存率分别为 93.3%（95%置信区间 90.1%-96.5%）、85.3%（80.7%-90.2%）和 79.6%（74.1%-85.5%）。1 年、3 年和 5 年总再介入无复发生存率分别为 82.1%（95%置信区间 77.4%-87.1%）、73.6%（68.0%-79.6%）和 65.1%（58.7%-72.2%）。剖腹手术并发症的预测因素是未治疗的 VH（P=0.01）和高血压（P=0.01）。保护因素是胸腹联合入路（P<0.01）和腹主动脉-单侧股动脉旁路移植术（P<0.01）。伤口并发症的预测因素包括体重指数（每公斤增加 1.07；置信区间 1.01-1.15；P=0.018）、抗凝治疗（2.59；置信区间 1.01-8.37；P=0.049）和既往髂动脉支架置入（2.60；置信区间 1.36-4.94；P=0.004）。
尽管 AFB 是一种持久的重建方法，其移植物再介入的需求很少，但剖腹手术和腹股沟伤口相关并发症对发病率和 AFB 后的再介入有显著影响。在 AFB 的术前计划和患者选择中，以及在讨论结果时，应考虑到剖腹手术和腹股沟伤口并发症的预测因素。
