Nehler M R, Moneta G L, Yeager R A, Edwards J M, Taylor L M, Porter J M
Department of Surgery, Oregon Health Sciences University, Portland.
J Vasc Surg. 1994 Oct;20(4):558-63; discussion 563-5. doi: 10.1016/0741-5214(94)90280-1.
Current information concerning the results of surgical revision of threatened infrainguinal vein grafts is largely limited to in situ conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow arteries. To assess the results of operative revision of infrainguinal reversed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft surveillance.
All patients who underwent surgical revision of a threatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular registry. Data were analyzed for type of vein used, date of original reversed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, patient risk factors, operative techniques and complications, and long-term assisted primary graft patency and limb salvage.
Ninety-six patients with 100 infrainguinal reversed vein grafts (69) femoral-popliteal, 31 femoral-tibial) underwent 117 surgical vein graft revisions or inflow procedures during the study period. Eighty-one percent of the original reversed vein grafts consisted of a single segment of greater saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision was performed in 85 grafts, two revisions in 13 grafts, and three revisions in two grafts. There were nine (8%) isolated inflow procedures, eight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts, and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the above. Median time to primary graft revision after initial graft implantation was 15 months (range 2 days to 316 months). Mean time to secondary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 years, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 years, respectively.
Although surgical revision of reversed vein graft requires much use of alternative vein sources, these procedures can be performed with minimum mortality and provide excellent assisted primary graft patency and limb salvage.
目前有关濒临失败的腹股沟下静脉移植物手术翻修结果的信息主要局限于原位血管。腹股沟下静脉移植物可能因移植物本身的病变或相邻流入或流出动脉的严重狭窄而受到威胁。为了评估腹股沟下逆向静脉移植物手术翻修的结果，我们回顾了通过术后临床和血管实验室移植物监测计划确定的濒临失败的腹股沟下逆向静脉移植物的手术翻修经验。
通过查阅我们的血管登记资料，确定了1987年1月至1993年4月期间所有接受濒临失败但仍通畅的腹股沟下逆向静脉移植物手术翻修的患者。分析了所用静脉的类型、原始逆向静脉移植物的日期、导致逆向静脉移植物翻修的临床和血管实验室检查结果、术前血管造影结果、患者风险因素、手术技术和并发症，以及长期辅助原发性移植物通畅率和肢体挽救情况。
在研究期间，96例患者的100条腹股沟下逆向静脉移植物（69条股-腘静脉，31条股-胫静脉）接受了117次手术静脉移植物翻修或流入道手术。81%的原始逆向静脉移植物由单一段大隐静脉组成。所有翻修的移植物在移植物本身或近端或远端动脉中至少有50%的狭窄。85条移植物进行了单次翻修，13条移植物进行了两次翻修，两条移植物进行了三次翻修。有9例（8%）单纯流入道手术，8例（7%）静脉补片血管成形术，62例（53%）间置静脉移植物，29例（25%）静脉移植物延伸至新的远端吻合部位。其余9例（8%）手术包括上述方法的组合。初次移植物植入后至初次移植物翻修的中位时间为15个月（范围2天至316个月）。初次翻修后至二次翻修的平均时间为21个月。手术死亡率为0.9%。因狭窄病变而翻修的原始移植物的累积辅助原发性通畅率在1年、3年和5年分别为99%、96%和92%。肢体挽救率在1年、3年和5年分别为99%、97%和97%。
虽然逆向静脉移植物的手术翻修需要大量使用替代静脉来源，但这些手术可以在最低死亡率的情况下进行，并能提供出色的辅助原发性移植物通畅率和肢体挽救率。
