Konstantinou Nikolaos, Argyriou Angeliki, Dammer Felicitas, Bisdas Theodosios, Chlouverakis Gregory, Torsello Giovanni, Tsilimparis Nikolaos, Stavroulakis Konstantinos
Department of Vascular Surgery, University Hospital LMU Munich, Munich, Germany.
Department of Vascular Surgery, Marien Hospital Herne, Herne, Germany.
J Endovasc Ther. 2023 Nov 27:15266028231210232. doi: 10.1177/15266028231210232.
To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI).
This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs).
In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27).
Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy.
Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.
报告急性肢体缺血（ALI）患者的手术治疗（ST）、杂交治疗（HT）和血管内治疗（ET）的疗效。
这是一项对2010年4月至2020年4月期间在2个三级中心接受治疗的所有连续性ALI患者进行的回顾性比较研究。截肢和/或死亡（无截肢生存；AFS）是主要的复合终点。此外，还分析了随访期间的死亡率、大截肢率和再次干预情况。采用比例风险模型识别混杂因素，结果以风险比（HR）和95%置信区间（CIs）表示。
在研究期间共治疗了395例患者（平均年龄=71.1±13.6岁；51.1%为女性）。150例患者（38%）首选手术治疗，98例接受HT治疗（24.8%），147例接受ET治疗（37.2%）。Rutherford IIa级是ET组最常见的临床表现（50.3%），而Rutherford IIb级在ST组（54%）和HT组（48%）中最常见（p<0.001）。值得注意的是，与ET组（53.7%）相比，ST组和HT组中更多患者出现新发病变（分别为79.3%和64.3%；p<0.001）。中位随访时间为20个月（范围=0-111个月）。在多变量分析中，与ST组相比，ET组在随访期间显示出显著更好的AFS（HR=1.89，95%CI=1.2-2.9，p<0.001）和HT组（HR=1.73，95%CI=1.1-3.1，p<0.001）。与ST组相比，ET组随访期间的死亡率也显著更低（HR=2.21，95%CI=1.31-3.74，p=0.003）和HT组（HR=2.04，95%CI=1.17-3.56，p=0.012）。与ST组相比，血管内治疗的截肢率更低（HR=2.27，95%CI=1.19-4.35，p=0.013），但与HT组相当（HR=2.00，95%CI=0.98-4.06，p=0.055）。各组之间的再次干预率无显著差异（ET组与ST组：HR=1.52，95%CI=0.99-2.31，p=0.053；ET组与HT组：HR=1.3，95%CI=0.81-2.07，p=0.27）。
与开放手术和杂交治疗相比，ALI的血管内治疗与改善的AFS和相当的再次干预率相关。
急性下肢缺血的治疗仍然是临床医生面临的挑战，并具有较高的发病率和死亡率。血管内血运重建被认为是许多患者的一线治疗方法，杂交治疗也越来越普遍，然而数据仅限于旧试验、小样本系列或随访时间短的研究。我们在此展示了我们10年来使用所有可用设备和技术进行开放手术、血管内和杂交急性肢体缺血治疗的经验，并比较了它们的结果。
