Bloch Randall A, Caron Elisa, Prushik Scott G, Shean Katie E, Conrad Mark F
Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA.
Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA.
J Vasc Surg. 2025 Sep;82(3):941-951.e1. doi: 10.1016/j.jvs.2025.03.193. Epub 2025 Mar 26.
Although the Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia trial demonstrated superiority of bypass with single-segment great saphenous vein for chronic limb-threatening ischemia (CLTI), an endovascular-first approach remains appropriate for patients lacking single-segment great saphenous vein, those who are high risk for open surgery, and most patients with Global Limb Anatomic Staging System stage I disease. Isolated popliteal artery disease is an anatomically challenging disease pattern for which evidence to drive operative decisions is lacking. The objective of this study was to compare endovascular therapies (EVTs) for isolated popliteal artery disease with CLTI.
All isolated popliteal EVT performed for CLTI were identified within the Vascular Quality Initiative database from 2017 to 2022 and those with available long-term follow-up data were included. The main exposure was type of EVT and the primary end point was limb salvage.
There were 3330 EVT isolated to the popliteal segment, of which 881 (26.5%) were plain balloon angioplasty, 927 (27.8%) were special balloon angioplasty (drug coated, cutting, lithotripsy), 835 (25.1%) included stents, and 687 (20.6%) included atherectomy. Atherectomy as part of the endovascular treatment strategy was associated with higher 1-year freedom from major amputation when compared against all other interventions combined (94.7% vs 89.2%; adjusted hazard ratio [HR] for amputation, 0.632; P = .022), as well as plain balloon angioplasty alone (94.7% vs 88.3%; adjusted HR for amputation, 0.502; P = .003) and special balloon angioplasty alone (94.7% vs 87.4%; adjusted HR for amputation, 0.456; P < .001). Although including atherectomy and stent as part of the endovascular treatment resulted in equivalent 1-year freedom from major amputation (94.7% vs 92.1%; P = .201), this result was driven by greater use of atherectomy in patients with diabetes. When selecting only for patients with diabetes, atherectomy with or without other EVTs demonstrated greater 1-year freedom from major amputation than stenting (univariate, 93.4% vs 86.1%; adjusted HR for amputation, 0.541; P = .019).
Atherectomy as a part of an endovascular treatment strategy may be associated with improved limb salvage compared with other EVTs among patients with CLTI requiring interventions limited to the popliteal artery.
尽管“严重肢体缺血患者最佳血管内治疗与最佳手术治疗”试验表明，采用单段大隐静脉旁路术治疗慢性肢体威胁性缺血（CLTI）具有优势，但对于缺乏单段大隐静脉的患者、开放手术高风险患者以及大多数全球肢体解剖分期系统I期疾病患者，血管内优先治疗方法仍然适用。孤立性腘动脉疾病是一种解剖结构复杂的疾病模式，目前缺乏指导手术决策的证据。本研究的目的是比较用于治疗CLTI的孤立性腘动脉疾病的血管内治疗（EVT）。
在血管质量改进数据库中识别出2017年至2022年期间所有为治疗CLTI而进行的孤立性腘动脉EVT，并纳入有可用长期随访数据的患者。主要暴露因素是EVT的类型，主要终点是肢体挽救。
共有3330例孤立性腘动脉段EVT，其中881例（26.5%）为单纯球囊血管成形术，927例（27.8%）为特殊球囊血管成形术（药物涂层、切割、碎石），835例（25.1%）包括支架置入，687例（20.6%）包括旋切术。与所有其他干预措施联合使用相比，旋切术作为血管内治疗策略的一部分，1年免于大截肢的比例更高（94.7%对89.2%；截肢调整风险比[HR]为0.632；P = 0.022），与单纯单纯球囊血管成形术相比（94.7%对88.3%；截肢调整HR为0.502；P = 0.003）以及与单纯特殊球囊血管成形术相比（94.7%对87.4%；截肢调整HR为0.456；P < 0.001）。尽管将旋切术和支架置入作为血管内治疗的一部分，1年免于大截肢的比例相当（94.7%对92.1%；P = 0.201），但这一结果是由于糖尿病患者更多地使用了旋切术。仅选择糖尿病患者时，无论是否联合其他EVT，旋切术1年免于大截肢的比例均高于支架置入术（单因素分析，93.4%对86.1%；截肢调整HR为0.541；P = 0.019）。
对于需要仅限于腘动脉干预的CLTI患者，旋切术作为血管内治疗策略的一部分，与其他EVT相比，可能与更好的肢体挽救效果相关。
