Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy.
Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy.
Eur J Vasc Endovasc Surg. 2023 Jun;65(6):878-886. doi: 10.1016/j.ejvs.2023.03.043. Epub 2023 Apr 5.
Chronic limb threatening ischaemia (CLTI) involving the infragenicular arteries is treated by distal angioplasty or pedal bypass; however, this is not always possible, due to chronically occluded pedal arteries (no patent pedal artery, N-PPA). This pattern represents a hurdle to successful revascularisation, which must be limited to the proximal arteries. The aim of the study was to analyse the outcome of patients with CLTI and N-PPA after a proximal revascularisation.
All patients with CLTI submitted to revascularisation in a single centre (2019 - 2020) were analysed. All angiograms were reviewed to identify N-PPA, defined as total obstruction of all pedal arteries. Revascularisation was performed with proximal surgical, endovascular, and hybrid procedures. Early and midterm survival, wound healing, limb salvage, and patency rates were compared between N-PPA and patients with one or more patent pedal artery (PPA).
Two hundred and eighteen procedures were performed. One hundred and forty of 218 (64.2%) patients were male, mean age 73.2 ± 10.6 years. The procedure was surgical in 64/218 (29.4%) cases, endovascular in 138/218 (63.3%), and hybrid in 16/218 (7.3%). N-PPA was present in 60/218 (27.5%) cases. Eleven of 60 (18.3%) cases were treated surgically, 43/60 (71.7%) by endovascular and 6/60 (10%) by hybrid procedures. Technical success was similar in the two groups (N-PPA 85% vs. PPA 82.3%, p = .42). At a mean follow up of 24.5 ± 10.2 months, survival (N-PPA 93.7 ± 3.5% vs. PPA 95.3 ± 2.1%, p = .22) and primary patency (N-PPA 53.1 ± 8.1% vs. PPA 55.2 ± 5%, p = .56) were similar. Limb salvage was significantly lower in N-PPA patients (N-PPA 71.4 ± 6.6% vs. PPA 81.5 ± 3.4%, p = .042); N-PPA was an independent predictor of major amputation (hazard ratio [HR] 2.02, 1.07 - 3.82, p = .038) together with age > 73 years (HR 2.32, 1.17 - 4.57, p = .012) and haemodialysis (2.84, 1.48 - 5.43, p = .002).
N-PPA is not uncommon in patients with CLTI. This condition does not hamper technical success, primary patency, and midterm survival; however, midterm limb salvage is significantly lower than in patients with PPA. This should be considered in the decision making process.
涉及膝下动脉的慢性肢体威胁性缺血（CLTI）通过远端血管成形术或足背旁路治疗；然而，由于慢性闭塞的足背动脉（无通畅的足背动脉，N-PPA），这并不总是可行的。这种模式代表了成功再血管化的障碍，必须将其限制在近端动脉。本研究的目的是分析 CLTI 合并 N-PPA 患者在近端再血管化后的结果。
分析了 2019 年至 2020 年在单一中心接受再血管化治疗的所有 CLTI 患者。所有血管造影均进行复查以识别 N-PPA，定义为所有足背动脉完全阻塞。再血管化采用近端手术、血管内和杂交手术进行。比较 N-PPA 患者与存在 1 条或多条通畅足背动脉（PPA）患者的早期和中期生存率、伤口愈合、肢体存活率和通畅率。
共进行了 218 例手术。218 例患者中 140 例（64.2%）为男性，平均年龄 73.2±10.6 岁。64/218（29.4%）例为手术治疗，138/218（63.3%）例为血管内治疗，16/218（7.3%）例为杂交治疗。60/218（27.5%）例存在 N-PPA。11/60（18.3%）例接受手术治疗，43/60（71.7%）例接受血管内治疗，6/60（10%）例接受杂交治疗。两组的技术成功率相似（N-PPA 85% vs. PPA 82.3%，p=0.42）。平均随访 24.5±10.2 个月时，生存率（N-PPA 93.7±3.5% vs. PPA 95.3±2.1%，p=0.22）和原发性通畅率（N-PPA 53.1±8.1% vs. PPA 55.2±5%，p=0.56）相似。N-PPA 患者的肢体存活率明显较低（N-PPA 71.4±6.6% vs. PPA 81.5±3.4%，p=0.042）；N-PPA 是主要截肢的独立预测因素（风险比[HR]2.02，1.07-3.82，p=0.038），与年龄>73 岁（HR 2.32，1.17-4.57，p=0.012）和血液透析（2.84，1.48-5.43，p=0.002）相关。
N-PPA 在 CLTI 患者中并不少见。这种情况不会妨碍技术成功率、原发性通畅率和中期生存率；然而，中期肢体存活率明显低于 PPA 患者。在决策过程中应考虑到这一点。
