显微镜辅助的足部搭桥术是挽救缺血性足部的一种有效且低风险的手术。

Gloviczki P, Bower T C, Toomey B J, Mendonca C, Naessens J M, Schabauer A M, Stanson A W, Rooke T W

Division of Vascular Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905.

Am J Surg. 1994 Aug;168(2):76-84. doi: 10.1016/s0002-9610(94)80040-5.

BACKGROUND

The aim of this study was to determine the current operative risks of the pedal bypass procedure, its durability, and the factors affecting long-term outcome.

METHODS

We prospectively observed 96 patients who consecutively underwent 100 pedal bypasses using autogenous vein grafts for chronic critical ischemia. Of the 100 limbs, 91 had ischemic ulcers or gangrene, and 9 produced rest pain only. Sixty-four patients were diabetic, 21 had renal failure, and 36 had coronary artery disease. Nonreversed saphenous vein grafts were used most frequently (68 translocated, 13 in situ), followed by composite (13) and reversed vein grafts (6). Fifty-two long grafts originated from the iliac or femoral arteries, and 48 short grafts originated from the popliteal or tibial arteries. For the 100 procedures, 102 distal anastomoses were performed--68 to the dorsalis pedis, 8 to the distal posterior tibial, 10 to the common plantar, 2 to the medial plantar, 9 to the lateral plantar, 4 to the lateral tarsal, and 1 to the first dorsal metatarsal arteries--with the aid of an operating microscope.

RESULTS

No patient died during the perioperative period. Two had hemodynamically insignificant myocardial infarctions. Wound complications developed in 12 patients--infection in 7 and hematoma in 5. There were 10 early graft failures, 6 of which could be salvaged, and 96 grafts were patent at dismissal. Mean follow-up was 2.1 years (range 1 month to 6.4 years). Postoperative surveillance identified 33 failed or failing grafts, 16 of which were successfully revised. At 3 years, cumulative primary and secondary patency rates were 60% and 69%, respectively. Factors correlating with increased secondary patency were intraoperative flow rate > or = 50 mL/min (P = 0.004) and diabetes (P < 0.05). Major amputations were performed on 17 limbs. The cumulative foot salvage rate at 3 years was 79%.

CONCLUSION

Pedal bypass is a safe, effective, and durable procedure. It should be considered even for high-risk patients with critical limb ischemia before major amputation is contemplated.

背景

本研究旨在确定足部搭桥手术当前的手术风险、其耐久性以及影响长期预后的因素。

方法

我们前瞻性观察了96例连续接受100次自体静脉移植进行慢性严重缺血足部搭桥手术的患者。在这100条肢体中，91条有缺血性溃疡或坏疽，9条仅有静息痛。64例患者患有糖尿病，21例患有肾衰竭，36例患有冠状动脉疾病。最常使用非翻转大隐静脉移植（68例移位，13例原位），其次是复合移植（13例）和翻转静脉移植（6例）。52条长移植血管起源于髂动脉或股动脉，48条短移植血管起源于腘动脉或胫动脉。对于这100例手术，在手术显微镜辅助下进行了102次远端吻合——68次吻合至足背动脉，8次吻合至胫后动脉远端，10次吻合至足底总动脉，2次吻合至足底内侧动脉，9次吻合至足底外侧动脉，4次吻合至跗外侧动脉，1次吻合至第一跖背动脉。

结果

围手术期无患者死亡。2例发生血流动力学无显著意义的心肌梗死。12例患者出现伤口并发症——7例感染，5例血肿。有10例早期移植血管失败，其中6例可挽救，出院时96条移植血管通畅。平均随访2.1年（范围1个月至6.4年）。术后监测发现33条移植血管失败或即将失败，其中16条成功修复。3年时，原发性和继发性通畅率分别为60%和69%。与继发性通畅率增加相关的因素是术中流速≥50 mL/分钟（P = 0.004）和糖尿病（P < 0.05）。17条肢体进行了大截肢。3年时足部挽救累积率为79%。