Kim Young, Loanzon Roberto S, Southerland Kevin W, Long Chandler A, Williams Zachary F, Mohapatra Abhisekh
Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC.
Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC.
Ann Vasc Surg. 2024 Jan;98:124-130. doi: 10.1016/j.avsg.2023.08.041. Epub 2023 Oct 17.
Single segment, greater saphenous vein (GSV) conduit is considered the optimal bypass conduit among patients undergoing bypass surgery for peripheral artery disease (PAD). While this data has been extrapolated to patients undergoing bypass for popliteal artery aneurysms (PAAs), the pathophysiology of PAA is inherently different when compared to PAD, and the impact of conduit type on long-term outcomes after open repair of PAA remains unclear.
A multicenter database of five regional hospitals was retrospectively reviewed for all patients with PAA undergoing open surgical repair. Data were collected on demographic information, operative details, medications, and postoperative outcomes. Kaplan-Meier curves were used to compare freedom from major adverse limb events (MALE) following GSV versus prosthetic bypass. Cox proportional hazards model was used to identify patient-level characteristics associated with MALE, which was defined as major ipsilateral limb amputation or reintervention for graft patency.
From 1999 to 2020, a total of 101 patients with PAA underwent open exclusion and bypass surgery. Median follow-up period was 4.2 years (interquartile range, 1.3-7.4 years), and complete data were available for 99 (98.0%) patients. The majority of patients were male (99.0%) and Caucasian (93.9%). Only 11.1% of procedures were emergent, with the remainder (88.9%) being elective. All patients underwent medial exposure with a below-knee popliteal bypass target (100%). Bypass conduits included GSV (69.7%), prosthetic conduit (28.3%), and 2 (2.0%) alternative conduits (one spliced arm vein, one cryopreserved vein). Patients undergoing prosthetic bypass were older (72 vs. 66 years, P = 0.001) and had similar rates of medical comorbidities. Compared with the GSV group, patients with prosthetic conduits were more frequently placed on postoperative anticoagulation (60.7% vs. 23.2%, P < 0.001). Conduit type did not impact postoperative complication rates (P = NS each). MALE rates were low overall (19.2% at 2 years), and similar when stratified by conduit type (log rank P = 0.47). On multivariable analysis, emergent bypass was associated with MALE (hazard ratio [HR] 5.73, 95% confidence interval [CI] 2.07-15.85, P < 0.001). Prosthetic conduit usage (HR 1.00, 95% CI, 0.40-2.51, P = 0.99) and postoperative anticoagulation (HR 1.02, 95% CI 0.42-2.50, P = 0.97) were not associated with MALE.
Open repair of PAA is associated with excellent long-term outcomes. Prosthetic bypass is a comparable alternative to autogenous conduit for below-knee popliteal bypass targets, and lack of suitable GSV should not prohibit open surgical repair when indicated.
在接受外周动脉疾病（PAD）搭桥手术的患者中，单节段大隐静脉（GSV）导管被认为是最佳的搭桥导管。虽然该数据已外推至接受腘动脉瘤（PAA）搭桥手术的患者，但与PAD相比，PAA的病理生理学本质上有所不同，并且导管类型对PAA开放修复术后长期结局的影响仍不清楚。
回顾性分析五家地区医院的多中心数据库中所有接受PAA开放手术修复的患者。收集患者的人口统计学信息、手术细节、用药情况及术后结局。采用Kaplan-Meier曲线比较使用GSV与人工血管搭桥后主要不良肢体事件（MALE）的发生率。采用Cox比例风险模型确定与MALE相关的患者水平特征，MALE定义为同侧主要肢体截肢或因移植物通畅进行再次干预。
1999年至2020年，共有101例PAA患者接受了开放结扎和搭桥手术。中位随访期为4.2年（四分位间距，1.3 - 7.4年），99例（98.0%）患者有完整数据。大多数患者为男性（99.0%）和白种人（93.9%）。仅11.1%的手术为急诊手术，其余（88.9%）为择期手术。所有患者均采用内侧入路，以膝下腘动脉搭桥为目标（100%）。搭桥导管包括GSV（69.7%）、人工血管导管（28.3%）和2例（2.0%）其他导管（1例拼接臂静脉，1例冷冻保存静脉）。接受人工血管搭桥的患者年龄较大（72岁对66岁，P = 0.001），且合并症发生率相似。与GSV组相比，使用人工血管导管的患者术后更常接受抗凝治疗（60.7%对23.2%，P < 0.001）。导管类型不影响术后并发症发生率（各P = 无统计学意义）。总体MALE发生率较低（2年时为19.2%），按导管类型分层时相似（对数秩检验P = 0.47）。多变量分析显示，急诊搭桥与MALE相关（风险比[HR] 5.73，95%置信区间[CI] 2.07 - 15.85，P < 0.001）。使用人工血管导管（HR = 1.00，95% CI，0.40 - 2.51，P = 0.99）和术后抗凝（HR = 1.02，95% CI 0.42 - 2.50, P = 0.97）与MALE无关。
PAA的开放修复与良好的长期结局相关。对于膝下腘动脉搭桥目标，人工血管搭桥是自体导管的可比替代方案，当有指征时，缺乏合适的GSV不应妨碍开放手术修复。
