Bontinis Vangelis, Bontinis Alkis, Koutsoumpelis Andreas, Giannopoulos Argirios, Ktenidis Kiriakos
Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
J Vasc Surg. 2023 Mar;77(3):957-963.e3. doi: 10.1016/j.jvs.2022.07.183. Epub 2022 Aug 8.
The objective of this study was to evaluate the application of the Global Anatomic Staging System (GLASS) in the endovascular treatment of chronic limb-threatening ischemia (CLTI).
We performed systematic research between June 2019 and February 2022, including articles investigating the relationship of GLASS classification with the outcomes of endovascular interventions in the treatment of CLTI. Data from the included studies were pooled and meta-analyzed. The primary endpoints were limb-based patency (LBP) at 1-year follow-up and immediate technical failure (ITF). Secondary endpoints included major amputation. We performed subgroup analysis between studies that reported on calcium modifier inclusion during GLASS classification and studies that did not.
Eleven studies, including 1816 patients (1975 limbs) met the inclusion criteria. The pooled ITF rates for GLASS stages I, II, and III are 5.52% (95% confidence interval [CI], 3.74%-8.07%), 7.39% (95% CI, 5.32%-10.18%), and 21.07% (95% CI, 13.48%-31.39%) respectively. The pooled LBP for GLASS stages I, II, and III are 68.43% (95% CI, 53.44%-80.37%), 41.52% (95% CI, 18.91%-68.37%), and 38.64% (95% CI, 19.83%-61.57%). The relative risk (RR) for ITF regarding composite GLASS I and II stages vs GLASS III is 3.96 (95% CI, 1.96-7.98). The RR for LBP of GLASS I and II versus GLASS stage III is 1.51 (95% CI, 0.86-2.64). Pooled major amputation rates for the composite GLASS I, II and GLASS III stages are 7.62% (95% CI, 5.44%-10.58%) and 15.43% (95% CI, 11.72%-20.05%) respectively, whereas the RR between GLASS I, II, and GLASS III stages is 1.84 (95% CI, 1.18-2.87).
Our study demonstrated that patients with CLTI undergoing endovascular interventions classified as GLASS stage III had almost a four-fold risk increase for ITF and 1.84 times the risk of major amputation compared with stages I and II. Additionally, GLASS classification correctly predicted ITF for all three stages, whereas it failed to predict stage I and II LBP outcomes. Safe conclusions regarding LBP cannot be drawn due to the low quality and small number of the included studies, necessitating further research. Furthermore, we displayed the importance of calcium moderator inclusion in the accurate classification of GLASS.
本研究的目的是评估全球解剖分期系统（GLASS）在慢性肢体威胁性缺血（CLTI）血管内治疗中的应用。
我们在2019年6月至2022年2月期间进行了系统研究，包括调查GLASS分类与CLTI血管内干预治疗结果之间关系的文章。汇总纳入研究的数据并进行荟萃分析。主要终点是1年随访时的肢体通畅率（LBP）和即刻技术失败（ITF）。次要终点包括大截肢。我们在报告GLASS分类期间纳入钙调节剂的研究和未纳入的研究之间进行了亚组分析。
11项研究，包括1816例患者（1975条肢体）符合纳入标准。GLASS I、II和III期的汇总ITF率分别为5.52%（95%置信区间[CI]，3.74%-8.07%）、7.39%（95%CI，5.32%-10.18%）和21.07%（95%CI，13.48%-31.39%）。GLASS I、II和III期的汇总LBP分别为68.43%（95%CI，53.44%-80.37%）、41.52%（95%CI，18.91%-68.37%）和38.64%（95%CI，19.83%-61.57%）。GLASS I和II期与GLASS III期复合的ITF相对风险（RR）为3.96（95%CI，1.96-7.98）。GLASS I和II期与GLASS III期的LBP RR为1.51（95%CI，0.86-2.64）。GLASS I、II期与GLASS III期复合的汇总大截肢率分别为7.62%（95%CI，5.44%-10.58%）和15.43%（95%CI，11.72%-20.05%），而GLASS I、II期与GLASS III期之间的RR为1.84（95%CI，1.18-2.87）。
我们的研究表明，与I期和II期相比，接受血管内干预且分类为GLASS III期的CLTI患者发生ITF的风险增加近四倍，大截肢风险增加1.84倍。此外，GLASS分类正确预测了所有三个阶段的ITF，而未能预测I期和II期的LBP结果。由于纳入研究的质量低且数量少，无法得出关于LBP的可靠结论，需要进一步研究。此外，我们展示了在GLASS的准确分类中纳入钙调节剂的重要性。
