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. 2021 Jul;74(1):161-169.e1. doi: 10.1016/j.jvs.2021.01.029. Epub 2021 Feb 4.
Covered stents (CS) to treat superficial femoral artery (SFA) occlusive disease have become more common. However, concerns about patients presenting with acute limb ischemia (ALI) after failure due to coverage of important collaterals have been raised. Herein, we determine if CS are associated with ALI after failure.
Vascular Quality Initiative peripheral vascular intervention and infrainguinal bypass datasets were queried from 2010 to 2020 for patients who underwent SFA stenting with a bare metal stent (BMS) or CS and who also had a subsequent ipsilateral SFA endovascular reintervention or bypass recorded in the Vascular Quality Initiative. The initial SFA stenting procedure will be referred to as the index procedure and the subsequent procedure will be referred to as the reintervention. Patients with aneurysmal pathology, prior infrainguinal bypass, and ALI at the index procedure were excluded. Patients with pre-index inflow/outflow procedures were not excluded. The primary outcome was ALI at reintervention. Other outcomes included higher degree of ischemia (claudication vs rest pain vs tissue loss vs ALI) and reoperative factors. Predictors of the primary outcome were determined with multivariable logistic regression. The index treatment length and pre-index ankle-brachial index were forced into the model.
There were 3721 patients: 3338 with index BMS, 383 with index CS. The mean patients age was 66.3 ± 11.0 years and 59.2% were male. Baseline covariates were similar between the groups; during the index procedure, more patients with BMS underwent plain balloon angioplasty (68.7% vs 62.1%; P = .001) and had shorter total index treatment length (median, 15.0 cm [interquartile range, 10.0-25.0 cm] vs 20.0 cm [interquartile range, 12.0-30.0 cm]; P < .001). At reintervention, ALI was the presenting symptom for 12.0% of the CS cohort vs 6.3% of the BMS cohort (P < .001). More patients with an index CS underwent major amputation at the time of reintervention (2.6% vs 1.0%; P = .006). Reinterventions for the patients with a CS more often used bypass, pharmacologic thrombolysis, and mechanical thrombolysis. CS at the index procedure was a predictor of ALI at reintervention (odds ratio, 1.87; 95% confidence interval, 1.31-2.65; P = .001) while controlling for age, time difference between procedures, body mass index, chronic obstructive pulmonary disorder, preoperative anticoagulation and antiplatelet, prior carotid intervention and major amputation, index procedure fluoroscopy time and treatment length, and pre-index ankle-brachial index.
In patients undergoing reintervention for failed SFA stents, CS are more likely to present with ALI than those with failed SFA BMS.
覆膜支架（CS）治疗股浅动脉（SFA）闭塞性疾病已越来越普遍。然而，人们对因重要侧支血管被覆盖而导致支架置入术失败后出现急性肢体缺血（ALI）的患者表示担忧。本研究旨在确定 CS 是否与支架置入术失败后的 ALI 有关。
从 2010 年至 2020 年，我们查询了血管质量倡议（VQI）外周血管介入和旁路数据集，纳入了接受股浅动脉裸金属支架（BMS）或 CS 治疗且随后在 VQI 中记录了同侧股浅动脉腔内再介入或旁路治疗的患者。初始股浅动脉支架置入术将称为索引手术，随后的手术将称为再介入。排除具有动脉瘤病理、既往下肢旁路和索引手术时存在 ALI 的患者。未排除索引术前的入流/流出手术。主要结局为再介入时的 ALI。其他结局包括更高程度的缺血（跛行与静息痛与组织损失与 ALI）和再次手术的因素。采用多变量逻辑回归确定主要结局的预测因素。索引治疗长度和术前踝肱指数被强制纳入模型。
共有 3721 例患者：3338 例接受索引 BMS，383 例接受索引 CS。患者平均年龄为 66.3±11.0 岁，59.2%为男性。两组间的基线协变量相似；在索引手术期间，更多接受 BMS 的患者接受单纯球囊血管成形术（68.7%比 62.1%；P=0.001），并且总索引治疗长度更短（中位数 15.0cm[四分位距，10.0-25.0cm]比 20.0cm[四分位距，12.0-30.0cm]；P<0.001）。在再介入时，CS 组的 ALI 为 12.0%，BMS 组为 6.3%（P<0.001）。在再介入时，更多接受 CS 索引的患者接受了主要截肢（2.6%比 1.0%；P=0.006）。CS 索引手术的再介入更常使用旁路、药物溶栓和机械溶栓。CS 索引手术是再介入时 ALI 的预测因素（比值比，1.87；95%置信区间，1.31-2.65；P=0.001），同时控制了年龄、手术时间差、体重指数、慢性阻塞性肺疾病、术前抗凝和抗血小板、颈动脉介入和主要截肢、索引手术透视时间和治疗长度以及术前踝肱指数。
在因股浅动脉支架置入术失败而接受再介入治疗的患者中，CS 支架置入术失败后更有可能出现 ALI，而不是 BMS 支架置入术失败。
