Lotfy Hassan, El-Nadar Ahmed Abou, Shaalan Wael, Emam Ali El, Ibrahim Akram, Naga Ahmad
Department of Vascular Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
Gamal Abdel Nasser Hospital Health Insurance, Alexandria, Egypt.
J Endovasc Ther. 2022 Oct;29(5):763-772. doi: 10.1177/15266028211065957. Epub 2021 Dec 29.
Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI.
198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow).
176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001).
WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.
严重肢体缺血（CLI）若未得到妥善治疗，死亡率很高。CLI血运重建的主要目的是促进伤口愈合，而这在很大程度上取决于微血管循环。现有的评估血运重建成功与否的工具在评估局部微血管组织灌注方面存在不足，而伤口充血（WB）可反映这种灌注情况。需要一种可靠的技术来评估足部病变部位的毛细血管血流。本研究旨在通过血管造影评估CLI患者血运重建后足部感兴趣部位的WB情况及其对肢体挽救的影响。
纳入198例患有适合血管腔内血运重建（EVR）的腹股沟下动脉粥样硬化病变的CLI患者（卢瑟福分级5/6级）。通过EVR对肢体进行直接或间接血运重建。直接血运重建意味着根据血管体概念成功实现了感兴趣区域的血运重建。进行一次造影完成检查以评估WB。患者分为两组，即WB阳性组和WB阴性组。若观察研究人员之间存在分歧，则利用计算机二维彩色编码数字减影血管造影（DSA）（Syngo iFlow）分析DSA系列图像的血流动力学变化。
157例患者的176条肢体血运重建成功。成功血运重建率为88.9%（176/198），22条肢体出现技术失败。121例患者WB阳性，55例患者WB阴性。98条肢体（55.7%）实现了目标区域的直接血运重建。WB阳性组和WB阴性组实现病变部位直接血流的比例存在显著差异（36.4%对19.3%，p≤0.001）。我们注意到，在足部病变直接血运重建患者和间接血运重建患者之间，在肢体挽救方面没有显著差异。对患者进行了25.2±12.7个月的随访。到第一年末，WB阳性患者的肢体挽救率显著更高（98%对63%，p<0.001），两年后（97%对58%，p<0.001）以及三年后（94%对51.5%，p<0.001）亦是如此。
WB是患有软组织病变的CLI患者伤口愈合的重要预测指标和预后因素。
