Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
Division of Vascular and Endovascular Surgery, Montefiore Medical Center, Bronx, NY, USA.
Vascular. 2024 Jun;32(3):632-639. doi: 10.1177/17085381231154290. Epub 2023 Jan 25.
Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality.
A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed.
The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality.
Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.
急性下肢缺血是血管外科最常见的急症之一，也是导致相当高发病率和死亡率的原因。本研究旨在评估急性下肢缺血血管重建的结果，并确定与围手术期发病率和死亡率相关的因素。
在 2014 年至 2019 年期间，在一家学术医疗中心，共有 354 名患者因急性下肢缺血接受了紧急血管重建。对患者的人口统计学、合并症、肢体缺血的病因和严重程度以及手术特征进行回顾性记录。分析了包括术后并发症、围手术期肢体丧失和死亡率在内的结果。
患者平均年龄为 69 ± 17 岁，52%为女性。50%的患者出现 Rutherford 分级 IIb 缺血。动脉栓塞是最常见的肢体缺血病因，占 33%的病例。241 例（68%）患者行开放手术血管重建，53 例（15%）和 60 例（17%）患者分别采用腔内和杂交方法。44%的患者发生术后不良事件，包括伤口并发症（11%）、心脏（5%）和肺部（16%）并发症、中风（4%）、尿路感染（10%）、肾衰竭（14%）、出血（5%）和间隔综合征（3%）。21%的患者需要计划再次手术。103 例（29%）患者发生主要不良心血管事件，57 例（16%）患者发生主要不良肢体事件。中位住院时间为 10 天（IQR=4）；49%的患者出院到熟练护理机构，19%的患者在 30 天内再次入院。入院期间截肢率为 10%，围手术期死亡率为 20%。性别、胫骨流出量和肢体缺血的病因是肢体丧失的独立预测因素。与男性相比，女性肢体丧失风险较低（OR，0.11；95%CI，0.023，0.38）。与三血管流出相比，胫骨流出不良（单血管或膝下无血流）是肢体丧失的显著预测因素（OR，14.92；95%CI，1.92，115.88）。与其他肢体缺血病因相比，动脉瘤病（OR，38.35；95%CI，3.54，42.45）和创伤性损伤（OR，108.08；95%CI，8.21，159.06）是截肢的最强预测因素。多变量模型确定了终末期肾病（OR，9.2；95%CI，1.8-46.3）、缺血程度（IIb 级或更高与 IIa 级；OR，3.5；95%CI，1.2-10.6）和年龄（每增加 10 岁，OR 为 1.5；95%CI，1.1-2.0）是围手术期死亡率的独立预测因素。
急性肢体缺血的紧急血管重建与较高的发病率和死亡率相关。患有终末期肾病且严重威胁肢体的老年患者尤其有围手术期死亡的高风险，可能不是肢体挽救的理想人选。
