Division of Vascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA.
Division of Vascular Surgery, Department of Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, CA.
J Vasc Surg. 2022 Oct;76(4):997-1005.e2. doi: 10.1016/j.jvs.2022.04.042. Epub 2022 Jun 10.
In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway after intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events (MALE) after infrainguinal revascularization for CLTI.
Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aortoiliac disease, prior infrainguinal stents, or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. MALE included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation.
We analyzed 184 unique limbs in 163 patients. This cohort was composed of 66.9% male patients with a mean age of 72 years. Baseline characteristics included diabetes (66%), tissue loss (91%), and advanced WIfI stages (30% stage 3, 51% stage 4). Global Limb Anatomic Staging System stage 3 anatomic patterns were common (n = 119 [65%]). Sixty limbs were treated with open bypass (65% involving tibial targets) and 124 underwent endovascular intervention (70% including infrapopliteal targets). The 12-month freedom from MALE and loss of LBP were 74.0% ± 3.7% and 48.6% ± 4.2%, respectively. Diabetes (hazard ratio [HR], 2.56; 95% confidence interval [CI], 1.13-5.83; P = .025) and loss of LBP (HR, 4.12; 95% CI, 1.96-8.64; P < .001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR, 4.97; 95% CI, 1.89-13.09; P = .001). Loss of LBP impacted both intermediate-risk limbs (HR, 2.85; 95% CI, 1.02-7.97; P = .047 in WIfI stages 1-3) and high-risk limbs (HR, 3.99; 95% CI, 1.32-12.11; P = .014 in WIfI stage 4). However, the loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs 8% major limb amputation at 12 months in limbs without vs with maintained LBP).
The anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).
2019 年，全球慢性肢体威胁性缺血（CLTI）血管指南引入了基于肢体的通畅性（LBP）的概念，定义为干预后目标动脉通路的通畅性得以维持。本研究旨在探讨 CLTI 下肢血运重建后 LBP 与主要肢体不良事件（MALE）之间的关系。
纳入 2016 年至 2019 年期间在一家专门的肢体保存团队治疗的 CLTI 患者。排除腹主动脉疾病、下肢血管内支架置入术或现有的旁路移植术的患者。回顾患者的人口统计学、全球肢体解剖分期系统评分、伤口、缺血、足部感染（WIfI）分期、血管重建细节和肢体特异性结果。LBP 通过无再介入、闭塞、临界狭窄（>70%）或存在 CLTI 症状的血液动力学障碍来定义。MALE 包括血栓切除术或溶栓、新旁路、开放手术移植物修复和/或大截肢。
我们分析了 163 例患者的 184 条肢体。该队列由 66.9%的男性患者组成，平均年龄为 72 岁。基线特征包括糖尿病（66%）、组织丧失（91%）和晚期 WIfI 分期（30%的第 3 期，51%的第 4 期）。常见的是 3 期的全球肢体解剖分期系统解剖模式（n=119[65%]）。60 条肢体接受了开放旁路治疗（65%涉及胫骨靶标），124 条接受了血管内介入治疗（70%包括腘下靶标）。12 个月时的免于 MALE 和 LBP 丧失的比例分别为 74.0%±3.7%和 48.6%±4.2%。糖尿病（风险比[HR]，2.56；95%置信区间[CI]，1.13-5.83；P=0.025）和 LBP 丧失（HR，4.12；95%CI，1.96-8.64；P<0.001）是 Cox 比例风险模型中 MALE 的独立预测因素。LBP 丧失是血管重建后主要肢体截肢的唯一独立预测因素（HR，4.97；95%CI，1.89-13.09；P=0.001）。LBP 丧失对中等风险的肢体（HR，2.85；95%CI，1.02-7.97；P=0.047 在 WIfI 分期 1-3）和高风险的肢体（HR，3.99；95%CI，1.32-12.11；P=0.014 在 WIfI 分期 4）都有影响。然而，LBP 丧失对 WIfI 分期为 4 期的患者影响最大（12 个月时，LBP 维持与不维持的肢体之间的主要肢体截肢率分别为 31%和 8%）。
无论最初采用的干预模式如何，以 LBP 衡量的血运重建的解剖耐久性都是 CLTI 治疗结果的关键决定因素。LBP 丧失对晚期肢体威胁（WIfI 分期 4 期）的患者最为不利。
