编辑推荐——接受血管内治疗与开放手术血运重建的急性下肢缺血患者临床结局比较：日本的一项大规模分析
Editor's Choice - Comparison of Clinical Outcomes in Patients with Acute Lower Limb Ischaemia Undergoing Endovascular Therapy and Open Surgical Revascularisation: A Large Scale Analysis in Japan.
作者信息
Ozawa Takaaki, Yanishi Kenji, Fujioka Ayumu, Seki Tomotsugu, Zen Kan, Matoba Satoaki
机构信息
Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
出版信息
Eur J Vasc Endovasc Surg. 2024 Dec;68(6):748-756. doi: 10.1016/j.ejvs.2024.08.039. Epub 2024 Aug 30.
OBJECTIVE
The recommended revascularisation methods for acute limb ischaemia (ALI), which is caused by embolism and atherosclerotic thrombosis, include endovascular therapy (EVT) and open surgical revascularisation (OSR); however, treatment choices based on patient characteristics remain controversial. This retrospective analysis from the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination database (April 2012 to March 2020) evaluated differences in clinical outcomes and identified prognostic predictors in patients with ALI.
METHODS
This study analysed 10 977 patients with lower limb ALI. EVT was defined as catheter directed thrombolysis, percutaneous thrombectomy, or percutaneous angioplasty with balloon dilatation and or stenting. OSR was defined as Fogarty thrombectomy, bypass surgery, or thromboendarterectomy. The EVT and OSR groups were compared after propensity score matching (PSM) considering ten clinical covariables.
RESULTS
The EVT group had more patients at higher risk of atherosclerotic disease than the OSR group. The OSR group had more patients at a higher risk of embolism, including atrial fibrillation and atrial flutter, than the EVT group. In the EVT group, 20.4% of patients underwent catheter directed thrombolysis using urokinase, the only thrombolytic agent available in Japan that is covered under insurance. After PSM, in hospital mortality (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.11 - 1.59; p = .002), major amputation rate (OR 1.43, 95% CI 1.19 - 1.72; p < .001), major amputation and or death rate (OR 1.42, 95% CI 1.24 - 1.62; p < .001), and total hospitalisation cost (1.16 vs. 0.97 million yen; p < .001) were statistically significantly more common in the EVT group. In interaction analyses, peripheral artery disease (PAD) was a factor responsible for reducing OSR efficacy in terms of major amputation and or death rate (with PAD, OR 0.94, 95% CI 0.68 - 1.29; without PAD, OR 1.56, 95% CI 1.34 - 1.82; p = .004).
CONCLUSION
In Japan, EVT was a less effective primary treatment for patients with ALI than OSR, except for those with PAD.
目的
急性肢体缺血（ALI）由栓塞和动脉粥样硬化血栓形成引起，推荐的血运重建方法包括血管内治疗（EVT）和开放手术血运重建（OSR）；然而，基于患者特征的治疗选择仍存在争议。这项来自日本全心脏和血管疾病诊断程序组合数据库（2012年4月至2020年3月）的回顾性分析评估了ALI患者临床结局的差异，并确定了预后预测因素。
方法
本研究分析了10977例下肢ALI患者。EVT定义为导管定向溶栓、经皮血栓切除术或经皮球囊扩张和/或支架置入的经皮血管成形术。OSR定义为Fogarty血栓切除术、旁路手术或血栓内膜切除术。在考虑十个临床协变量的倾向评分匹配（PSM）后，对EVT组和OSR组进行比较。
结果
与OSR组相比，EVT组中动脉粥样硬化疾病风险较高的患者更多。与EVT组相比，OSR组中包括心房颤动和心房扑动在内的栓塞风险较高的患者更多。在EVT组中，20.4%的患者使用尿激酶进行导管定向溶栓，尿激酶是日本唯一一种纳入医保的溶栓药物。PSM后，EVT组的住院死亡率（优势比[OR]1.33，95%置信区间[CI]1.11 - 1.59；p = .002）、大截肢率（OR 1.43，95%CI 1.19 - 1.72；p < .001）、大截肢和/或死亡率（OR 1.42，95%CI 1.24 - 1.62；p < .001）以及总住院费用（116万日元对97万日元；p < .001）在统计学上显著更常见。在交互分析中，外周动脉疾病（PAD）是导致OSR在大截肢和/或死亡率方面疗效降低的一个因素（有PAD，OR 0.94，95%CI 0.68 - 1.29；无PAD，OR 1.56，95%CI 1.34 - 1.82；p = .004）。
结论
在日本，对于ALI患者，除了患有PAD的患者外，EVT作为主要治疗方法的效果不如OSR。
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