Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
J Vasc Surg. 2021 Jun;73(6):2009-2020.e4. doi: 10.1016/j.jvs.2020.12.094. Epub 2021 Feb 4.
The Global Limb Anatomic Staging System (GLASS) has been proposed to facilitate clinical decision-making regarding revascularization for chronic limb threatening ischemia (CLTI). The purpose of the present study was to define its relationship to the treatment outcomes in CLTI.
Consecutive patients who had undergone peripheral angiography for rest pain or tissue loss from January 2017 to July 2019 at a tertiary referral center with a dedicated limb preservation program were reviewed. Subjects with significant aortoiliac disease, previous infrainguinal stenting or functioning bypass grafts, or GLASS stage 0 were excluded. The GLASS score was assigned from the preintervention angiography findings, and the treating surgeon determined the primary infrapopliteal target artery pathway for the limb at risk. The demographic data, procedural details, and clinical outcomes were analyzed.
The study cohort included 167 patients and 194 limbs, of which 175 of 194 limbs (90%) had presented with tissue loss and 149 of 182 limbs (83%) with WIfI (Wound, Ischemia and foot Infection) stage 3 or 4. The GLASS stage was GLASS 1 in 14%, GLASS 2 in 18%, and GLASS 3 in 68%. GLASS 3 anatomy was present in 85% of 52 limbs treated by bypass and 55% of 108 limbs treated by endovascular intervention (EVI; P < .001). Revascularization was not performed in 34 limbs, most of which were GLASS 3 (85%). Immediate technical failure for EVI (ie, failure to establish target artery pathway) occurred exclusively in the setting of GLASS 3 anatomy (n = 13; 22%). After a median follow-up of 10 months, limb-based patency after EVI was significantly lower in GLASS 3 than in GLASS 1 or 2 limbs (42% vs 59%; P = .018). GLASS 3 was associated with reduced major adverse limb events-free survival in both the EVI group (P = .002) and the overall revascularized cohort (P = .001). GLASS 3 was also associated with significantly reduced overall survival, amputation-free survival, and reintervention-free survival. In a Cox proportional hazards model, GLASS 3 (hazard ratio, 2.35; 95% confidence interval, 1.30-4.24; P = .005) and WIfI wound grade 3 (hazard ratio, 2.64; 95% confidence interval, 1.26-5.53; P = .010) were independent predictors of reduced major adverse limb events-free survival after revascularization.
GLASS stage 3 was strongly associated with major adverse clinical outcomes after revascularization in patients with CLTI.
全球肢体解剖分期系统（GLASS）的提出旨在为慢性肢体威胁性缺血（CLTI）的血管再通治疗提供临床决策便利。本研究的目的是确定其与 CLTI 治疗结果的关系。
回顾 2017 年 1 月至 2019 年 7 月期间，在一家拥有专门肢体保存计划的三级转诊中心因静息痛或组织丧失而行外周血管造影的连续患者。排除有明显主髂动脉疾病、先前的下肢血管腔内成形术或通畅旁路移植术或 GLASS 分期 0 的患者。根据术前血管造影结果分配 GLASS 评分，治疗外科医生确定风险肢体的主要腘动脉目标动脉通路。分析患者的人口统计学数据、手术细节和临床结果。
该研究队列包括 167 名患者和 194 条肢体，其中 194 条肢体中的 175 条（90%）出现组织丧失，182 条肢体中的 149 条（83%）出现 WIfI（伤口、缺血和足部感染）3 或 4 期。GLASS 分期在 14%的患者中为 GLASS 1，在 18%的患者中为 GLASS 2，在 68%的患者中为 GLASS 3。52 条接受旁路治疗的肢体中有 85%存在 GLASS 3 解剖结构，108 条接受血管内介入治疗（EVI）的肢体中有 55%存在 GLASS 3 解剖结构（P<.001）。34 条肢体未进行血运重建，其中大多数为 GLASS 3（85%）。EVI 立即出现技术失败（即无法建立目标动脉通路）仅发生在 GLASS 3 解剖结构中（n=13；22%）。在中位 10 个月的随访后，EVI 后肢体通畅率在 GLASS 3 组明显低于 GLASS 1 或 2 组（42% vs 59%；P=.018）。GLASS 3 与 EVI 组（P=.002）和整个血运重建队列（P=.001）的主要不良肢体事件无事件生存率降低相关。GLASS 3 还与总体生存率、免于截肢生存率和免于再干预生存率显著降低相关。在 Cox 比例风险模型中，GLASS 3（风险比，2.35；95%置信区间，1.30-4.24；P=.005）和 WIfI 伤口 3 级（风险比，2.64；95%置信区间，1.26-5.53；P=.010）是血运重建后主要不良肢体事件无事件生存率降低的独立预测因素。
GLASS 分期 3 与 CLTI 患者血管再通后的主要不良临床结局密切相关。
