Hobson R W, Lynch T G, Jamil Z, Karanfilian R G, Lee B C, Padberg F T, Long J B
J Vasc Surg. 1985 Jan;2(1):174-85. doi: 10.1067/mva.1985.avs0020174.
Aggressive revascularization of the ischemic lower extremity in atherosclerotic occlusive disease by femoropopliteal (FP) and femorotibial (FT) bypass or profundaplasty (P), as indicated, has been advocated by some authors for all patients. Others have recommended primary amputation, particularly for tibial occlusive disease. To clarify this clinical dilemma, we reviewed the results of 547 procedures performed during the last 5 years: revascularization in 375 (69%) instances and below-knee amputation (BKA) in 172 (31%) cases. Bypass procedures were used in 246 cases: FP in 155 (64%) and FT in 91 (37%). Reversed autogenous saphenous vein (ASV) was used preferentially in 125 (51%) cases, whereas polytetrafluoroethylene (PTFE) was used in 121 (49%) cases. P was performed in 129 instances accompanied by inflow procedures in 92 (71%) of these cases. Cumulative limb salvage (LS) exceeded bypass patency in all categories and resulted in 2- and 5-year LS rates of 83% and 81% for FP with the use of ASV and 52% and 35% for PTFE. The LS rate for FT was 53% and 47%, respectively, for ASV and 20% and 15% for PTFE. Rest pain was successfully relieved by P in 99 cases (77%), whereas healing occurred in only 51% of cases with tissue loss. The perioperative mortality rate for revascularization was 3%; 42% of the group died during follow-up, death usually resulting from complications of atherosclerosis. Of the 172 BKAs, primary healing occurred in 80%, but the perioperative mortality rate was 13%. FP and FT bypasses are preferred procedures if ASV is available, whereas use of PTFE should be limited to FP bypasses only. Rest pain is relieved by P but tissue loss should prompt consideration for bypass. BKA should be considered in cases of severe tibial disease only in the absence of a suitable ASV, as the perioperative mortality rate is high and ultimate rehabilitation (64%) is limited.
一些作者主张，对于所有患有动脉粥样硬化闭塞性疾病的患者，应根据情况积极采用股腘（FP）和股胫（FT）旁路移植术或股深动脉成形术（P）对缺血性下肢进行血运重建。另一些人则建议进行一期截肢，特别是对于胫动脉闭塞性疾病。为了阐明这一临床困境，我们回顾了过去5年中进行的547例手术的结果：375例（69%）进行了血运重建，172例（31%）进行了膝下截肢（BKA）。246例采用了旁路手术：155例（64%）为FP，91例（37%）为FT。125例（51%）优先使用了自体大隐静脉（ASV）反转，而121例（49%）使用了聚四氟乙烯（PTFE）。129例进行了P手术，其中92例（71%）同时进行了流入道手术。所有类别中肢体挽救（LS）的累积率均超过了旁路通畅率，使用ASV的FP的2年和5年LS率分别为83%和81%，使用PTFE的分别为52%和35%。FT使用ASV的LS率分别为53%和47%，使用PTFE的分别为20%和15%。99例（77%）患者的静息痛通过P手术成功缓解，而组织缺损患者中只有51%实现了愈合。血运重建的围手术期死亡率为3%；该组42%的患者在随访期间死亡，死亡通常由动脉粥样硬化并发症导致。在172例BKA中，80%实现了一期愈合，但围手术期死亡率为13%。如果有ASV，FP和FT旁路移植术是首选手术，而PTFE的使用应仅限于FP旁路移植术。P手术可缓解静息痛，但出现组织缺损时应考虑进行旁路手术。仅在没有合适的ASV且胫动脉疾病严重的情况下才应考虑BKA，因为围手术期死亡率高且最终康复率（64%）有限。
