Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA.
Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA.
J Vasc Surg. 2023 Apr;77(4):1147-1154.e3. doi: 10.1016/j.jvs.2022.12.035. Epub 2022 Dec 27.
Transmetatarsal amputation (TMA) allows for maintenance of ambulatory function for patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage for patients with chronic limb threatening ischemia (CLTI). We hypothesized that CLTI patients requiring TMA will have better healing and functional outcomes with open bypass than with endovascular revascularization.
Consecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. The baseline characteristics, including WIfI (wound, ischemia, foot infection) stage, noninvasive vascular studies, healing, and ambulatory outcomes, were collected. Catheter-based angiographic images were evaluated using the GLASS (global limb anatomic staging system). The primary outcomes were TMA healing and community ambulation. The secondary outcomes were TMA that had healed at study end, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses were performed.
A total of 346 TMAs had been performed in 318 patients, 209 of whom had had peripheral artery disease (PAD). The median follow-up was 2.5 years. Patients with PAD had had significantly lower rates of healing compared with those without PAD (64% vs 77%; P = .007). Revascularization was performed in 185 limbs, with 102 treated endovascularly and 83 with open surgery. The patients who had undergone endovascular surgery were significantly less likely to have had the TMA healed at any point (55% vs 76%; P = .003) and less likely to have remained healed at study end (49% vs 66%; P = .02). Patients with GLASS stage 3 anatomy were significantly more likely to have healed after open surgery (75% vs 45%; P = .003). Long-term ambulation data were available for 72% of the revascularized patients. Endovascular surgery was associated with a lower likelihood of community ambulation after TMA (34% vs 57%; P = .002). On multivariable analysis, open surgery was significantly associated with TMA healing (odds ratio, 2.8; P = .007) and ambulation (odds ratio, 2.9; P = .001).
For patients with CLTI and significant tissue loss requiring TMA, an initial open approach to revascularization was associated with improved healing and higher rates of ambulation compared with endovascular interventions. The metabolic requirement for healing of a TMA in patients with CLTI might be better met by open revascularization.
对于前足组织大量丧失的患者，经跖骨截肢术（TMA）可维持步行功能。对于患有慢性肢体威胁性缺血（CLTI）的患者，有效再血管化是优化肢体保存的关键。我们假设，对于需要 TMA 的 CLTI 患者，开放式旁路移植术比血管内血管重建术具有更好的愈合和功能结果。
回顾性分析 2008 年至 2020 年期间在三个附属医院进行的连续 TMA。收集基线特征，包括 WIfI（伤口、缺血、足部感染）分期、无创血管研究、愈合和步行结果。使用 GLASS（肢体解剖分期系统）评估基于导管的血管造影图像。主要结果是 TMA 愈合和社区步行。次要结果是研究结束时 TMA 愈合、术后任何步行功能、大截肢和死亡率。进行了描述性统计以及单变量、多变量和 Kaplan-Meier 分析。
在 318 名患者中进行了 346 次 TMA，其中 209 名患者患有外周动脉疾病（PAD）。中位随访时间为 2.5 年。与无 PAD 的患者相比，患有 PAD 的患者的愈合率明显较低（64%对 77%；P=0.007）。在 185 条肢体中进行了血运重建，其中 102 条经血管内治疗，83 条经开放手术治疗。接受血管内手术的患者在任何时候 TMA 愈合的可能性明显较低（55%对 76%；P=0.003），并且在研究结束时保持愈合的可能性也较低（49%对 66%；P=0.02）。GLASS 分级 3 解剖结构的患者接受开放手术后明显更有可能愈合（75%对 45%；P=0.003）。接受血管重建的患者中，有 72%可获得长期步行数据。TMA 后，血管内手术与社区步行的可能性较低相关（34%对 57%；P=0.002）。多变量分析显示，开放式手术与 TMA 愈合（优势比，2.8；P=0.007）和步行（优势比，2.9；P=0.001）显著相关。
对于患有 CLTI 且需要 TMA 治疗的大量组织丧失的患者，与血管内介入治疗相比，初始开放式血运重建与愈合改善和更高的步行率相关。CLTI 患者 TMA 愈合的代谢需求可能通过开放式血运重建更好地满足。
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