基于全球血管指南分类为旁路首选类别的慢性肢体缺血威胁性患者中旁路手术与血管内治疗的治疗结局。
Treatment outcomes between bypass surgery and endovascular therapy in patients with chronic limb-threatening ischemia classified as bypass-preferred category based on Global Vascular Guidelines.
机构信息
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan.
出版信息
J Vasc Surg. 2023 Aug;78(2):475-482.e1. doi: 10.1016/j.jvs.2023.04.006. Epub 2023 Apr 17.
OBJECTIVE
The aim of this study was to examine outcomes between bypass surgery and endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI), classified as bypass-preferred according to the Global Vascular Guidelines (GVG).
METHODS
We retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) Stage 3 to 4 and Global Limb Anatomical Staging System (GLASS) Stage III, which is classified as bypass-preferred category by the GVG between 2015 and 2020. The endpoints were limb salvage and wound healing.
RESULTS
We analyzed 301 patients and 339 limbs following 156 bypass surgeries and 183 EVTs. The 2-year limb salvage rates were 92.2% in the bypass surgery group and 76.3% in the EVT group, respectively (P < .01). The 1-year wound healing rates were 86.7% in the bypass surgery group and 67.8% in the EVT group (P < .01). Multivariate analysis shows decreased serum albumin level (P < .01), increased wound grade (P = .04), and EVT (P < .01) were risk factors for major amputation. Decreased serum albumin level (P < .01), increased wound grade (P < .01), GLASS infrapopliteal grade (P = .02), inframalleolar (IM) P grade (P = .01), and EVT (P < .01) were risk factors for impaired wound healing. Subgroup analysis of limb salvage in patients after EVT, decreased serum albumin level (P < .01), increased wound grade (P = .03), increased IM P grade (P = .04), and congestive heart failure (P < .01) were risk factors for major amputation. According to scoring by existence of these risk factors, 2-year limb salvage rates following EVT were 83.0% and 42.8% for the total score of 0 to 2 and of 3 to 4, respectively (P < .01).
CONCLUSIONS
Bypass surgery provides better limb salvage and wound healing in patients with WIfI Stage 3 to 4 and GLASS Stage III, which is classified as bypass-preferred category by the GVG. In patients after EVT, serum albumin level, wound grade, IM P grade, and congestive heart failure were related to major amputation. Although bypass surgery may be considered as initial revascularization procedure in patients classified as bypass-preferred category, in case that EVT has to be selected, relatively acceptable outcomes can be expected in patients with less of these risk factors.
目的
本研究旨在探讨根据全球血管指南（GVG）分类为旁路首选的慢性肢体缺血性疾病（CLTI）患者中旁路手术与血管内治疗（EVT）之间的结局。
方法
我们回顾性分析了 2015 年至 2020 年间，Wound、Ischemia、and foot Infection（WIfI）3 至 4 期和 Global Limb Anatomical Staging System（GLASS）III 期接受下肢血运重建的 CLTI 患者的多中心数据，该患者根据 GVG 被归类为旁路首选类别。终点是肢体挽救和伤口愈合。
结果
我们分析了 301 例患者和 339 条肢体，其中 156 例行旁路手术，183 例行 EVT。旁路手术组 2 年肢体存活率为 92.2%，EVT 组为 76.3%（P<.01）。旁路手术组 1 年伤口愈合率为 86.7%，EVT 组为 67.8%（P<.01）。多变量分析显示，血清白蛋白水平降低（P<.01）、伤口分级增加（P=0.04）和 EVT（P<.01）是主要截肢的危险因素。血清白蛋白水平降低（P<.01）、伤口分级增加（P<.01）、GLASS 腘下分级（P=0.02）、胫后（IM）P 分级（P=0.01）和 EVT（P<.01）是伤口愈合不良的危险因素。EVT 后患者的肢体挽救亚组分析显示，血清白蛋白水平降低（P<.01）、伤口分级增加（P=0.03）、IM P 分级增加（P=0.04）和充血性心力衰竭（P<.01）是主要截肢的危险因素。根据这些危险因素的存在进行评分，EVT 后 2 年的肢体存活率分别为总分为 0 至 2 分的 83.0%和 42.8%，总分为 3 至 4 分的 83.0%和 42.8%（P<.01）。
结论
在 WIfI 3 至 4 期和 GLASS III 期患者中，旁路手术提供了更好的肢体挽救和伤口愈合，这些患者根据 GVG 被归类为旁路首选类别。在 EVT 后患者中，血清白蛋白水平、伤口分级、IM P 分级和充血性心力衰竭与主要截肢有关。尽管在被归类为旁路首选类别的患者中，可以考虑旁路手术作为初始血运重建程序，但如果必须选择 EVT，则具有较少这些危险因素的患者可以获得相对可接受的结果。
Zotero 插件