肝脏疾病与股浅动脉旁路术后的死亡率和主要发病率增加相关，但与血管内介入治疗后无关。
Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention.
机构信息
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA; Division of Vascular Surgery, University of Washington, Seattle, WA, USA.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA.
出版信息
Eur J Vasc Endovasc Surg. 2021 Jun;61(6):964-970. doi: 10.1016/j.ejvs.2021.02.015. Epub 2021 Mar 24.
OBJECTIVE
Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated.
METHODS
The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors.
RESULTS
In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p = .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p = .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p = .022), and renal complications (1.9% vs. 0.8%; p = .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention.
CONCLUSION
Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.
目的
肝脏疾病会增加腹部手术后（包括血管内主动脉瘤修复术）的死亡率。然而，其对血管内和开放治疗外周血管疾病的死亡率和发病率的影响尚未得到广泛评估。
方法
利用国家外科质量改进计划评估了 2005 年至 2016 年间接受下肢旁路和血管内介入治疗的患者。天冬氨酸氨基转移酶血小板比值（APRI 评分）是世界卫生组织推荐的一种识别肝脏疾病的非侵入性工具，用于计算所有患者的分数。比值>0.5 用于识别有肝纤维化的患者。评估有无肝纤维化患者的人口统计学、合并症和 30 天结局。在 APRI 评分>0.5 的患者中进行亚组分析，以评估增加终末期肝病模型（MELD）评分对结局的影响。多变量回归用于解释基线因素的差异。
结果
共有 17603 例患者接受了下肢旁路手术。纤维化与更高的死亡率（3.8%比 2.4%；p<0.001）、主要并发症（23%比 20%；p=0.020）、肺部（5.1%比 2.9%；p<0.001）和肾脏并发症（1.9%比 1.1%；p=0.007）相关。这些差异在多变量调整后仍然存在。共有 7830 例患者接受了血管内介入治疗。纤维化也与更高的死亡率（4.7%比 2.2%；p<0.001）、肺部（3.9%比 2.5%；p=0.022）和肾脏并发症（1.9%比 0.8%；p=0.003）相关。调整后，只有肾脏并发症仍然存在。在有肝纤维化的患者亚组分析中，MELD 评分>15 的患者在接受旁路手术后的发病率（31%比 17%；p<0.001）和死亡率（7.2%比 1.8%；p<0.001）增加，但血管内介入治疗后没有增加。
结论
在下肢旁路手术后，肝纤维化与 30 天死亡率和主要并发症增加相关，随着 MELD 评分增加，结局恶化。对于有肝纤维化的患者，外科医生可能会考虑首选血管内治疗外周动脉疾病。
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