Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan.; Department of Rehabilitation, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan..
Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine, Showa-ku, Nagoya, Aichi Japan.
Ann Vasc Surg. 2022 Jul;83:275-283. doi: 10.1016/j.avsg.2021.10.064. Epub 2021 Dec 10.
The purpose of this study was to evaluate the effect of preoperative motor and cognitive activities of daily living (ADL) on long-term outcomes of patients with chronic limb-threatening ischemia (CLTI) after distal bypass.
A retrospective review was performed for patients who underwent distal bypass for CLTI from 2013 to 2019 at multiple centers in Japan. Comparisons were made among patients with high and low motor and cognitive ADL based on the functional independence measure (FIM). The primary endpoint was limb salvage and the secondary endpoints were survival, amputation free survival (AFS), major adverse limb events (MALE), readmission, and wound healing.
A total of 226 distal bypasses were performed in 185 patients (169 males; median age, 76 years; diabetes mellitus, 70%; end-stage renal disease with hemodialysis, 40%). The patients were divided into high (n = 93, 50%) and low (n = 92, 50%) FIM-motor cases, and high (n = 157, 85%) and low (n = 28, 15%) FIM-cognitive cases. FIM-motor (high vs. low) and FIM-cognitive (high vs. low) were not significantly associated with limb salvage, freedom from MALE, freedom from readmission, and wound healing. The 1- and 3-year survival rates were significantly lower in low FIM-motor cases (93% vs. 70% at 1 year, 73% vs. 46% at 3 years, P = 0.0011); and in low FIM-cognitive cases (87% vs. 50% at 1 year, 63% vs. 45% at 3 years, P < 0.001). The 1- and 3-year AFS rates were significantly lower in low FIM-motor cases (92% vs. 67% at 1 year, 69% vs. 44% at 3 years, P < 0.001); and in low FIM-cognitive cases (85% vs. 49% at 1 year, 59% vs. 44% at 3 years, P < 0.001). In multivariate analysis, independent risk factors for survival were hemodialysis (HR = 2.17; 95% confidence interval (CI), 1.23-3.83; P = .0078), low FIM-cognitive (HR = 3.45; 95% CI, 1.78-6.71; P < 0.001), and ejection fraction (HR = 0.98; 95% CI, 0.95-0.99; P = 0.019).
FIM-motor and FIM-cognitive were predictive factors for long-term survival and AFS of CLTI patients after distal bypass, but had no influence on limb salvage, MALE, readmission, and wound healing. These results suggest that the motor and cognitive status of ADL should be assessed using FIM before distal bypass for patients with CLTI.
本研究旨在评估慢性肢体威胁性缺血（CLTI）患者在接受远端旁路手术后，术前日常生活活动（ADL）中的运动和认知功能对长期结局的影响。
回顾性分析了 2013 年至 2019 年在日本多个中心接受远端旁路治疗 CLTI 的患者。根据功能独立性测量（FIM）比较了高和低运动及认知 ADL 的患者。主要终点是肢体挽救，次要终点是生存率、无截肢生存率（AFS）、主要不良肢体事件（MALE）、再入院和伤口愈合。
共对 185 例（169 例男性；中位年龄 76 岁；糖尿病 70%；终末期肾病行血液透析 40%）患者的 226 例远端旁路手术进行了分析。患者分为高（n=93，50%）和低（n=92，50%）FIM-运动病例，以及高（n=157，85%）和低（n=28，15%）FIM-认知病例。FIM-运动（高与低）和 FIM-认知（高与低）与肢体挽救、免于 MALE、免于再入院和伤口愈合均无显著相关性。低 FIM-运动病例的 1 年和 3 年生存率显著较低（1 年时分别为 93%和 70%，3 年时分别为 73%和 46%，P=0.0011）；低 FIM-认知病例的 1 年和 3 年生存率也显著较低（1 年时分别为 87%和 50%，3 年时分别为 63%和 45%，P<0.001）。低 FIM-运动病例的 1 年和 3 年 AFS 率显著较低（1 年时分别为 92%和 67%，3 年时分别为 69%和 44%，P<0.001）；低 FIM-认知病例的 1 年和 3 年 AFS 率也显著较低（1 年时分别为 85%和 49%，3 年时分别为 59%和 44%，P<0.001）。多变量分析显示，生存率的独立危险因素包括血液透析（HR=2.17；95%置信区间[CI]，1.23-3.83；P=0.0078）、低 FIM-认知（HR=3.45；95%CI，1.78-6.71；P<0.001）和射血分数（HR=0.98；95%CI，0.95-0.99；P=0.019）。
FIM-运动和 FIM-认知是 CLTI 患者远端旁路手术后长期生存和 AFS 的预测因素，但对肢体挽救、MALE、再入院和伤口愈合无影响。这些结果表明，在为 CLTI 患者进行远端旁路手术前，应使用 FIM 评估 ADL 的运动和认知状态。
