Yale School of Medicine, New Haven, CT.
Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT.
Ann Vasc Surg. 2022 Oct;86:260-267. doi: 10.1016/j.avsg.2022.04.051. Epub 2022 May 16.
Percutaneous deep venous arterialization (pDVA) has emerged as a new modality for limb salvage in patients with chronic limb threatening ischemia (CLTI) and no standard option for revascularization. The proportion of patients facing major amputation who are eligible for this technology remains unknown. This study aims to provide a real-life estimate of patient eligibility for pDVA to reduce major amputations.
Electronic medical records of 100 consecutive patients with peripheral arterial disease (PAD) who underwent major amputation of 106 limbs were reviewed. Angiograms performed ≤6 months before amputation were assessed by two vascular surgeons. Disease severity was categorized using the Global Limb Anatomic Staging System (GLASS) and patients were classified as ideal, possible, or not candidates for pDVA. Ideal candidates had ≥1 patent tibial artery, no target in the foot, and no proximal disease. Possible candidates had ≥1 patent tibial artery with PAD, no target in the foot, and proximal disease amenable to endovascular therapy. Patients were not eligible if there was no patent tibial artery, extensive PAD, or an arterial target in the foot for bypass.
Of 106 limbs reviewed, 35 (33%) did not undergo angiography ≤6 months before amputation because of infection (n = 14), advanced tissue loss (n = 10), failed revascularizations (n = 8), advanced limb ischemia (n = 2), and refusing revascularization (n = 1). Thus, 69 lower extremity angiograms (2 incomplete excluded) in 68 patients were analyzed. A total of 15 patients with 16 limbs (23.2%) were identified as candidates for pDVA (ideal = 7, possible = 9). There were no differences in demographics between the two groups, but candidates for pDVA were less likely to have hyperlipidemia and congestive heart failure than those who were not candidates. The pDVA candidates underwent significantly fewer interventions before major amputation compared to patients who were not candidates (1.50 ± 0.73 vs. 2.61 ± 2.57, P = 0.007). Angiographically, patients who were pDVA candidates had significantly higher Inframalleolar GLASS grades (1.81 ± 0.40 vs. 0.86 ± 0.41, P < 0.0001) but lower Femoropopliteal Glass grades (0.73 ± 1.10 vs. 2.43 ± 1.71, P < 0.0001) than patients who were not candidates. There was no significant difference in GLASS stage between these two groups (P = 0.368). After mean follow-up of 48 months, there was no difference in mortality between both groups (40% vs. 32.1%, P = 0.567).
Among patients considered for revascularization, 23.2% had favorable angiography and 14.7% could have benefited for pDVA as a new therapeutic modality for limb salvage. 33% of major amputations were performed for clinically-deemed unsalvageable CLTI.
经皮深静脉动脉化（pDVA）作为一种新的肢体挽救方法，已经在患有慢性肢体威胁性缺血（CLTI）且没有标准血管重建选择的患者中出现。仍然不知道有多少面临主要截肢的患者符合这项技术的条件。本研究旨在提供真实生活中 pDVA 患者资格的估计，以减少主要截肢。
回顾了 100 例接受 106 条肢体大截肢的外周动脉疾病（PAD）患者的连续电子病历。由两名血管外科医生评估在截肢前≤6 个月进行的血管造影。使用全球肢体解剖分期系统（GLASS）对疾病严重程度进行分类，并将患者分为理想、可能或不适合 pDVA 的候选者。理想的候选者有≥1 条通畅的胫骨动脉，足部没有目标，并且没有近端疾病。可能的候选者有≥1 条通畅的胫骨动脉，伴有 PAD，足部没有目标，并且近端疾病适合血管内治疗。如果没有通畅的胫骨动脉、广泛的 PAD 或足部的动脉目标进行旁路，则患者不合格。
在审查的 106 条肢体中，由于感染（n=14）、晚期组织丧失（n=10）、血管重建失败（n=8）、晚期肢体缺血（n=2）和拒绝血管重建（n=1），有 35 条肢体（33%）在截肢前≤6 个月未进行血管造影。因此，分析了 68 例患者的 69 例下肢血管造影（排除 2 例不完整）。共确定 15 例 16 肢（23.2%）适合 pDVA（理想者 7 例，可能者 9 例）。两组患者在人口统计学方面无差异，但与非候选者相比，pDVA 候选者更不可能患有高脂血症和充血性心力衰竭。与非候选者相比，pDVA 候选者在大截肢前接受的干预明显更少（1.50±0.73 对 2.61±2.57，P=0.007）。血管造影显示，pDVA 候选者的 infraMalleolar GLASS 分级明显较高（1.81±0.40 对 0.86±0.41，P<0.0001），但 femoropopliteal Glass 分级明显较低（0.73±1.10 对 2.43±1.71，P<0.0001），而不是非候选者。两组之间的 GLASS 分期无显著差异（P=0.368）。在平均 48 个月的随访后，两组之间的死亡率无差异（40%对 32.1%，P=0.567）。
在考虑血管重建的患者中，23.2%的患者血管造影良好，14.7%的患者可能受益于 pDVA 作为肢体挽救的新治疗方法。33%的大截肢是为了治疗临床上认为无法挽救的 CLTI。
