Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
J Vasc Surg. 2021 Jul;74(1):124-133.e3. doi: 10.1016/j.jvs.2020.12.084. Epub 2021 Feb 3.
Despite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB.
Institutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores <6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency.
In 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P = .005), respiratory failure (11% vs 1%; P = .005), and mortality (8% vs 0%; P ≤ .006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P < .01), primary-assisted (P < .01), and secondary patency (P = .01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P < .01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P = .01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P = .01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P < .01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P = .01) were protective.
The SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning.
尽管取得了进展，但腹主动脉-股动脉旁路移植术（AFB）仍然是治疗主髂动脉闭塞性疾病最持久的选择。虽然已经证实流出道与 AFB 通畅性有关，但 SVS 股部流出道评分系统与通畅性的相关性尚未得到评估。本研究旨在评估 SVS 流出道评分系统与 AFB 后基于肢体的原发性通畅率之间的关系。
从 2000 年至 2017 年检索了接受 AFB 治疗且术前有流出道成像的患者的机构数据。根据 1997 年 SVS 下肢缺血报告标准，根据股浅动脉和股深动脉闭塞性疾病的存在情况对流出道评分进行赋值（最低 1 分，最高 10 分）。基于肢体的通畅率是主要终点。Kaplan-Meier 分析用于比较流出道评分≥6 分和<6 分的肢体之间的长期基于肢体的通畅率和免于再次干预的情况。使用倾向评分加权 Cox 比例风险模型评估流出道评分≥6 分与原发性通畅丧失之间的关系，同时控制与原发性通畅相关的其他因素。
在 161 例患者中，316 条肢体接受了血运重建。患者的平均年龄为 66.7±11.3 岁，女性占 51.6%。大多数肢体因跛行而接受血运重建（56.5%）。大多数（89.4%）为 TransAtlantic InterSociety Consensus 分级 D 病变，27.3%需要肾以上或更高位夹闭，11.2%接受了同时肠系膜干预。41.8%和 2.9%的肢体分别需要股流出道辅助和同时进行下肢旁路手术。流出道评分≥6 分的患者 30 天内心肌梗死（11% vs 1%；P=0.005）、呼吸衰竭（11% vs 1%；P=0.005）和死亡率（8% vs 0%；P≤0.006）的发生率更高。中位随访时间为 4.0 年（四分位距，6.5 年）。1、3 和 5 年的原发性通畅率分别为 94.6%（95%置信区间，91.9%-97.3%）、89.2%（95%置信区间，85.4%-93.2%）和 81.4%（95%置信区间，76.0%-87.1%）。5 年原发性辅助通畅率、继发性通畅率和免于再次干预率分别为 84.9%（95%置信区间，79.7%-90.5%）、91.7%（95%置信区间，87.3%-96.3%）和 83.3%（95%置信区间，78.3%-88.7%）。流出道评分≥6 分的患者原发性（对数秩 P<0.01）、原发性辅助（P<0.01）和继发性通畅率较低。与原发性通畅丧失相关的因素包括高流出道评分（评分≥6：风险比[HR]，4.1；95%置信区间，2.1-8.0；P<0.01）、同时肠系膜内膜切除术（HR，13.5；95%置信区间，1.9-97.8；P=0.01）和慢性肾脏病（HR，4.6；95%置信区间，1.5-14.6；P=0.01）。年龄增加（每年 0.94；95%置信区间，0.91-0.97；P<0.01）和高脂血症（HR，0.44；95%置信区间，0.23-0.85；P=0.01）是保护因素。
SVS 股部流出道评分是与 AFB 肢体长期通畅率相关的重要因素。评分≥6 预示着肢体结局较差和手术并发症发生率较高。SVS 评分可以从术前轴位影像学研究中确定，并可作为决策和手术计划的指导。
