Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
J Vasc Surg. 2021 Sep;74(3):771-779. doi: 10.1016/j.jvs.2021.02.045. Epub 2021 Mar 26.
There is an increasing incidence of peripheral arterial disease (PAD). The most common symptomatic presentation of PAD is intermittent claudication (IC), reproducible leg pain with ambulation. The progression of symptoms beyond IC is rare, and a nonprocedural approach of smoking cessation, supervised exercise therapy, and best medical therapy can mitigate progression of IC. Despite the lack of limb- or life-threatening sequelae of IC, invasive treatment strategies of IC have experienced rapid growth. Within our health care system, PAD is treated by multiple disciplines with varying practice patterns, providing an opportunity to investigate the progression of IC based on treatment strategy. This study aims to compare PAD progression and amputation in patients with IC with and without revascularization.
This institutional review board-approved, single institute retrospective study reviewed all patients with an initial diagnosis of IC between June 11, 2003, and April 24, 2019. Revascularization was defined as endovascular or open. Time to chronic limb-threatening ischemia (CLTI) diagnosis and amputation were stratified by revascularization status using the Kaplan-Meier method. The association between revascularization status and each of CLTI progression and amputation using multivariable Cox regression, adjusting for demographic and clinical potential confounding variables was assessed.
We identified 1051 patients who met the inclusion criteria. Of these patients, 328 had at least one revascularization procedure and 723 did not. The revascularized group was younger than the nonrevascularized group (60.3 years vs 62.1 years; P = .013). There was no significant difference in sex or comorbidities in the two groups other than a higher rate of diabetes mellitus type 2 (32.3% vs 16.3%; P < .001) and COPD (4.3% vs 1.7%; P = .017) in the revascularized group. Multivariable Cox regression found revascularization of patients with IC to be significantly associated with the progression to CLTI (hazard ratio, 2.9; 95% confidence interval, 2.0-4.2) and amputation (hazard ratio, 4.5; 95% confidence interval, 2.2-9.5). These findings were also demonstrated in propensity-matched cohorts of 218 revascularized and 340 nonrevascularized patients.
Revascularization of patients with IC is associated with an increased rate of progression to CLTI and increased amputation rates. Given these findings, further studies are required to identify which, if any, patients with IC benefit from revascularization procedures.
外周动脉疾病（PAD）的发病率不断上升。PAD 最常见的症状表现为间歇性跛行（IC），即行走时出现可再现的腿部疼痛。IC 症状的进展较为罕见，通过戒烟、监督运动疗法和最佳药物治疗等非手术方法，可以减缓 IC 的进展。尽管 IC 不会导致肢体或生命受到威胁，但 IC 的侵袭性治疗策略却迅速发展。在我们的医疗体系中，多学科会治疗 PAD，且各学科的治疗模式存在差异，这为我们提供了一个基于治疗策略来研究 IC 进展的机会。本研究旨在比较有和没有血运重建的 IC 患者的 PAD 进展和截肢情况。
本回顾性单机构研究经机构审查委员会批准，纳入了 2003 年 6 月 11 日至 2019 年 4 月 24 日期间初次诊断为 IC 的所有患者。血运重建定义为血管内或开放手术。使用 Kaplan-Meier 方法根据血运重建情况对慢性肢体威胁性缺血（CLTI）的诊断和截肢时间进行分层。使用多变量 Cox 回归评估血运重建状态与 CLTI 进展和截肢之间的关系，并对人口统计学和临床潜在混杂变量进行调整。
本研究共纳入 1051 名符合条件的患者，其中 328 名患者至少接受了一次血运重建，723 名患者未接受血运重建。与非血运重建组相比，血运重建组患者年龄更小（60.3 岁比 62.1 岁；P=0.013）。两组患者的性别或合并症无显著差异，但血运重建组的 2 型糖尿病（32.3%比 16.3%；P<0.001）和慢性阻塞性肺病（4.3%比 1.7%；P=0.017）发生率更高。多变量 Cox 回归发现，IC 患者的血运重建与 CLTI 的进展（风险比，2.9；95%置信区间，2.0-4.2）和截肢（风险比，4.5；95%置信区间，2.2-9.5）显著相关。在对 218 名血运重建患者和 340 名非血运重建患者进行倾向评分匹配的队列中，也观察到了上述结果。
IC 患者的血运重建与 CLTI 进展率和截肢率增加有关。鉴于这些发现，需要进一步研究以确定哪些 IC 患者从血运重建中获益。
