Levin Scott R, Farber Alik, Osborne Nicholas H, Beck Adam W, McFarland Graeme E, Rybin Denis, Cheng Thomas W, Siracuse Jeffrey J
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
Division of Vascular Surgery, University of Michigan, Ann Arbor, Mich.
J Vasc Surg. 2021 Feb;73(2):564-571.e1. doi: 10.1016/j.jvs.2020.06.118. Epub 2020 Jul 21.
Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC.
The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries.
Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival.
In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.
鉴于间歇性跛行（IC）很少进展为慢性肢体威胁性缺血和肢体缺失，IC选择性干预的安全性和耐久性至关重要。IC患者是否能从胫动脉干预中获益存在争议，且支持其效用的数据有限。尽管血管内治疗有所扩展，但手术旁路移植术仍普遍进行。我们试图评估IC患者胫动脉旁路移植术的结果。
查询血管质量倡议（2003 - 2018年）中为IC进行的腹股沟下旁路移植术。比较胫动脉旁路移植术和腘动脉旁路移植术的围手术期及1年结果。
在5347例腹股沟下旁路移植术中，分别有1173例（22%）为胫动脉旁路移植术，4184例（78%）为腘动脉旁路移植术。总体而言，平均年龄为65±10岁，患者多为男性（72%）且经常吸烟（42%）。胫动脉旁路移植术通常针对胫后动脉（40%）、胫腓干（23%）和胫前动脉（19%）。大隐静脉用于胫动脉旁路移植术的比例高于腘动脉旁路移植术（78%对54%；P <.001）。与腘动脉旁路移植术相比，接受胫动脉旁路移植术的患者行走功能受损和既往同侧旁路移植术的情况更常见，且服用抗血小板药物和他汀类药物的频率更低（所有P <.05）。在围手术期，胫动脉旁路移植术患者术后住院时间更长（4.5±3.5天对3.5±2.8天），肺部并发症更多（1.3%对0.6%），返回手术室的比例更高（7%对4%；所有P <.05）。围手术期心肌梗死（1.2%对0.8%；P =.19）、中风（0.4%对0.4%；P =.91）和死亡率（0.3%对0.3%；P =.86）在两组间相似。在1年时，与腘动脉旁路移植术相比，胫动脉旁路移植术的通畅/无死亡生存率更低（81%对89%；P <.001），同侧大截肢/无死亡生存率更低（90%对94%；P <.001），再次干预/截肢/无死亡生存率更低（73%对80%；P <.001），但患者生存率相似（96%对97%；P =.07）。多变量分析显示，与腘动脉旁路移植术相比，胫动脉旁路移植术独立与闭塞/死亡增加（风险比[HR]，1.65；95%置信区间[CI]，1.28 - 2.11；P <.001）、同侧大截肢/死亡（HR，1.6；95% CI，1.12 - 2.19；P =.003）以及同侧再次干预/截肢/死亡（HR，1.51；95% CI，1.28 - 1.79；P <.001）相关，患者生存率相似。
在IC患者中，胫动脉旁路移植术与包括大截肢在内的不良结果相关。外科医生在提供此类干预之前应穷尽非手术治疗方法，并向患者告知实际的预后期望。
