Jacobs M J, Reul G J, Gregoric I D, Ubbink D T, Tordoir J H, Kitslaar P J, Reneman R S
Division of Vascular Surgery, Academic Hospital Maastricht, The Netherlands.
J Vasc Surg. 1993 Jul;18(1):1-8; discussion 8-9. doi: 10.1067/mva.1993.41521.
In patients with critical limb ischemia, poor distal arterial runoff, and absence of autogenous veins, the use of an artificial graft and an arteriovenous fistula might be a valuable option. However, in these patients little information is available regarding preoperative and postoperative microcirculatory hemodynamics after this type of intervention.
With the use of intravital capillary microscopy, we studied the effect of distal revascularization on the microcirculation in 26 patients with critical limb ischemia. All patients had had failed vascular reconstructive operations, and artificial grafts were required because of the absence of autogenous veins. Patients were prospectively investigated and divided into two groups: 12 patients received a femorocrural bypass with polytetrafluoroethylene grafts, and 14 patients underwent the same procedure with the creation of an arteriovenous fistula at the site of the distal anastomosis and ligation of the proximal vein. Red blood cell velocity was measured before and after arterial occlusion to determine microcirculatory hemodynamic alterations.
Immediate postoperative graft patency was achieved in all 26 patients. The 1-year cumulative graft patency rate was 64% in the group that had creation of an arteriovenous fistula, which was significantly higher (p < 0.01) compared with that in the group in which a fistula was not created (21%). The 1-year cumulative foot salvage rate was 72% in the patients with an arteriovenous fistula and 43% in the patients without a fistula (p < 0.05). Red blood cell velocity increased similarly in both groups after the bypass procedure. Peak and time to peak red blood cell velocity also improved significantly in both groups; however, comparing both groups, peak and time to peak red blood cell velocity were significantly better (p < 0.05) in the patients with an arteriovenous fistula and remained significantly higher during the follow-up period.
In conclusion, creation of an adjunctive arteriovenous fistula at the distal anastomosis of a prosthetic graft appears to improve microcirculatory hemodynamics in the nutritional capillary vascular bed. Improved graft patency and foot salvage rates suggest that this procedure benefits patients with critical limb ischemia who have no usable veins.
在严重肢体缺血、远端动脉血流不佳且缺乏自体静脉的患者中，使用人工血管移植物和动静脉瘘可能是一种有价值的选择。然而，对于这类患者在这种干预措施前后的术前和术后微循环血流动力学情况，几乎没有相关信息。
我们使用活体毛细血管显微镜，研究了26例严重肢体缺血患者远端血管重建对微循环的影响。所有患者的血管重建手术均失败，且因缺乏自体静脉而需要人工血管移植物。对患者进行前瞻性研究并分为两组：12例患者接受了聚四氟乙烯移植物的股腘动脉旁路移植术，14例患者接受了相同手术，并在远端吻合口处创建动静脉瘘并结扎近端静脉。在动脉闭塞前后测量红细胞速度，以确定微循环血流动力学改变。
26例患者术后均立即实现了移植物通畅。创建动静脉瘘的组1年移植物累积通畅率为64%，与未创建瘘的组（21%）相比显著更高（p < 0.01）。有动静脉瘘的患者1年足部挽救率为72%，无瘘的患者为43%（p < 0.05）。旁路手术后两组红细胞速度均有相似增加。两组的红细胞速度峰值和达峰时间也均有显著改善；然而，比较两组，有动静脉瘘的患者红细胞速度峰值和达峰时间显著更好（p < 0.05），且在随访期间仍显著更高。
总之，在人工血管移植物的远端吻合口处创建辅助性动静脉瘘似乎可改善营养性毛细血管床的微循环血流动力学。移植物通畅率和足部挽救率的提高表明，该手术对没有可用静脉的严重肢体缺血患者有益。
