Skripochnik Edvard, Bannazadeh Mohsen, Jasinski Patrick, Loh Shang A
Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY.
Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY.
Ann Vasc Surg. 2020 Nov;69:317-323. doi: 10.1016/j.avsg.2020.05.050. Epub 2020 Jun 2.
Acute limb ischemia (ALI) is challenging to treat because of high morbidity and mortality. Endovascular-first options beginning with thrombolysis are technically feasible with similar results to open surgery. We examined our experience with thrombolysis to identify patients and target conduits that are predictive of improved outcomes.
We performed a retrospective review of our institutional database of thrombolysis cases for arterial lower extremity disease. Thrombolysis was the index procedure, and any subsequent treatment was a reintervention. Conversion to open surgery perioperatively such as thromboembolectomy or bypass was considered a technical failure. Primary outcomes included primary patency, secondary patency, amputation-free survival (AFS), and survival. Secondary outcomes included conversion to open, reintervention <30 days, and amputation <30 days. Descriptive statistics and analysis of variance were performed for preoperative and intraoperative risk factors. Kaplan-Meier estimation and Cox proportional hazard models were used for primary and secondary outcomes.
Ninety-nine patients with ALI were treated with thrombolysis from 2007 to 2017. Thrombolysis was attempted on native artery (40%), vein bypass (7%), prosthetic bypass (33%), and stent (19%). Rutherford class distribution was 50% class 1, 41% class 2a, 5% class 2b, and 3% class 3. Technical success was 70%, characterized by an all-endovascular approach, patency at 30 days, and AFS for 30 days. Primary patency at 1- and 2-years was 31% and 22%, respectively. Secondary patency at 1- and 2-years was 39% and 27%, respectively. Overall, 30% required conversion to open surgery at the time of the index procedure, 7% reintervention <30 days, 5% mortality <30 days, and 5% major amputation <30 days. Prosthetic grafts and vein bypasses had the worst primary and secondary patency (P < 0.05). Five out of 7 vein bypasses required open conversion. Thrombolysis of native arteries was most successful maintaining primary patency (P < 0.05), secondary patency (P < 0.05), and AFS (P < 0.05). Patients who had adjunctive procedures at the time of thrombolysis had a significantly greater primary patency (P < 0.05) and secondary patency (P < 0.05) but not greater AFS.
Outcomes in thrombolysis for ALI have not significantly improved 20 years after the STILE trial. Technical success and mid-term patency rates are modest at best. Thrombolysis of vein bypasses and prosthetic grafts have poor technical success and primary patency compared with native arteries. However, aggressive adjunctive interventions during thrombolysis appear to improve primary and secondary patency.
急性肢体缺血（ALI）因高发病率和死亡率而治疗颇具挑战性。以溶栓开始的血管内优先治疗方案在技术上可行，其结果与开放手术相似。我们研究了我们在溶栓方面的经验，以确定可预测改善结局的患者和目标血管。
我们对机构内下肢动脉疾病溶栓病例数据库进行了回顾性研究。溶栓是索引手术，任何后续治疗均为再次干预。围手术期转为开放手术，如血栓切除术或旁路移植术，被视为技术失败。主要结局包括原发性通畅、继发性通畅、无截肢生存率（AFS）和生存率。次要结局包括转为开放手术、30天内再次干预和30天内截肢。对术前和术中危险因素进行描述性统计和方差分析。采用Kaplan-Meier估计和Cox比例风险模型分析主要和次要结局。
2007年至2017年，99例ALI患者接受了溶栓治疗。溶栓尝试的血管包括自体动脉（40%）、静脉旁路（7%）、人工血管旁路（33%）和支架（19%）。卢瑟福分级分布为1级50%、2a级41%、2b级5%和3级3%。技术成功率为70%，其特征为全血管内治疗方法、30天时通畅以及30天的AFS。1年和2年时的原发性通畅率分别为31%和22%。1年和2年时的继发性通畅率分别为39%和27%。总体而言，30%的患者在索引手术时需要转为开放手术，7%在30天内再次干预，5%在30天内死亡，5%在30天内进行大截肢。人工血管移植物和静脉旁路的原发性和继发性通畅情况最差（P<0.05）。7例静脉旁路中有5例需要转为开放手术。自体动脉溶栓在维持原发性通畅（P<0.05）、继发性通畅（P<0.05）和AFS（P<0.05）方面最为成功。溶栓时进行辅助手术的患者原发性通畅（P<0.05）和继发性通畅（P<0.05）显著更高，但AFS无显著差异。
在STILE试验20年后，ALI溶栓的结局并未显著改善。技术成功率和中期通畅率充其量也只是一般。与自体动脉相比，静脉旁路和人工血管移植物的溶栓技术成功率和原发性通畅情况较差。然而，溶栓期间积极的辅助干预似乎可改善原发性和继发性通畅。
