Sullivan T R, Welch H J, Iafrati M D, Mackey W C, O'Donnell T F
Department of Surgery, New England Medical Center.
J Vasc Surg. 1996 Dec;24(6):909-17; discussion 917-9. doi: 10.1016/s0741-5214(96)70036-8.
Patients who have failing infrainguinal bypass grafts or failed grafts reopened with lytic therapy represent a group at high risk of subsequent failure. Previous studies suggest that vein patch angioplasty and jump grafting may be less durable than interposition grafting as a method of correcting graft lesions. Our objective was to assess the value of various technical strategies for graft revision in a series of autogenous infrainguinal bypass grafts and to assess how these variables might affect cumulative graft patency (CGP) rates.
We retrospectively reviewed the clinical course, anatomic sites of revision, and type of revision performed on 67 grafts in 58 patients who underwent at least one revision from 1991 to 1995. Results were assessed with regression analysis and Kaplan-Meier estimates of CGP rates (p < 0.05 was considered significant).
Sixty-seven vein grafts underwent revision of 112 anatomical sites in 95 operations. Forty-nine of 67 grafts were single-segment greater saphenous vein grafts and 18 were composite (> 1 segment) grafts, with an overall 5-year CGP rate of 72%. No difference was observed between the 4-year CGP rate in grafts with hemodynamically significant distal anastomotic stenoses repaired primarily with jump grafts (n = 20, 71% CGP rate) and those with stenoses found only in the graft body (n = 41, 89% CGP rate). Vein patch angioplasty was used primarily, but not exclusively, for focal graft body stenoses (n = 35), whereas interposition grafts (n = 11) were reserved for more diffuse strictures; no significant difference in 3-year CGP rates was observed (94% and 73%, respectively).
Using an appropriate revision strategy that favors vein patch angioplasty for graft body lesions and jump grafts for distal anastomotic lesions, acceptable assisted patency rates can be achieved in grafts that are at risk for repeated failure.
下肢旁路移植血管功能衰竭或通过溶栓治疗重新开通的移植血管患者是后续移植失败风险较高的群体。既往研究表明，作为纠正移植血管病变的一种方法，静脉补片血管成形术和跳跃式移植可能不如间置移植持久。我们的目的是评估一系列自体下肢旁路移植血管中各种移植血管修复技术策略的价值，并评估这些变量如何影响累积移植血管通畅率（CGP）。
我们回顾性分析了1991年至1995年期间接受至少一次修复的58例患者67条移植血管的临床病程、修复的解剖部位和修复类型。结果采用回归分析和CGP率的Kaplan-Meier估计进行评估（p<0.05被认为具有统计学意义）。
67条静脉移植血管在95次手术中对112个解剖部位进行了修复。67条移植血管中，49条为单段大隐静脉移植血管，18条为复合（>1段）移植血管，总体5年CGP率为72%。主要采用跳跃式移植修复血流动力学显著的远端吻合口狭窄的移植血管（n=20，CGP率71%）与仅在移植血管体部发现狭窄的移植血管（n=41，CGP率89%）的4年CGP率之间未观察到差异。静脉补片血管成形术主要但并非仅用于移植血管体部局灶性狭窄（n=35），而间置移植（n=11）则用于更弥漫性狭窄；3年CGP率未观察到显著差异（分别为94%和73%）。
采用合适的修复策略，对于移植血管体部病变采用静脉补片血管成形术，对于远端吻合口病变采用跳跃式移植，可以在有反复失败风险的移植血管中实现可接受的辅助通畅率。
