Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York.
Department of Surgery, Albert Einstein College of Medicine, Bronx, New York.
Ann Vasc Surg. 2021 Aug;75:194-204. doi: 10.1016/j.avsg.2021.02.024. Epub 2021 Apr 2.
Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention.
We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models.
A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization.
An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.
腔内治疗越来越多地用于患有复杂多节段疾病和慢性肢体威胁性缺血（CLTI）的患者。在这些患者中，自体静脉移植物的膝下旁路被认为是金标准。然而，许多患者往往缺乏理想的大隐静脉，导致使用非自体假体移植物。我们比较了首次血运重建时接受开放型非自体移植物或腔内介入治疗的 CLTI 患者的保肢率和生存率。
我们回顾性分析了 2009 年至 2016 年期间在我院首次接受腔内或开放血管重建的连续患者。患者分为腔内介入或开放旁路非自体移植物（NAC）组。主要终点是免于截肢的生存率（AFS）、免于再干预、初始通畅率和总生存率。采用倾向评分法构建匹配队列。采用 Kaplan-Meier 和 Cox 比例风险模型评估结果。
共确定了 125 例血运重建术。其中腔内介入治疗 65 例，NAC 旁路 60 例。在未匹配分析中，与腔内组相比，NAC 组围手术期心肌梗死（7% vs. 0%，P=0.05）和截肢（10% vs. 2%，P=0.04）的风险更高。在匹配分析中，与开放组相比，腔内组 30 天内截肢率（1.5% vs. 10%，P=0.04）和住院时间（中位数天数，1 天 vs. 9 天，P<0.01）较低。虽然没有统计学意义，但与 NAC 组相比，腔内组两年 AFS （76% vs. 65%，P=0.07）的发生率呈上升趋势。与 NAC 组（85% vs. 77%，P=0.29）相比，腔内组的总生存率无显著差异。在匹配的 Cox 分析中，与腔内血管重建相比，非自体移植物的使用与肢体丧失的风险增加相关（HR 2.03，95%CI 0.94-4.38，P=0.07）。
与 NAC 相比，“腔内优先”方法提供了有利的围手术期结果和相当的 AFS，并且在自体移植物不可用时可能更为可取。
