Schneider D B, Schneider P A, Reilly L M, Ehrenfeld W K, Messina L M, Stoney R J
Department of Surgery, University of California, San Francisco, 94143, USA.
J Vasc Surg. 1998 Feb;27(2):276-84; discussion 284-6. doi: 10.1016/s0741-5214(98)70358-1.
Recurrent visceral ischemia after a failed visceral revascularization occurs in up to one third of patients, yet no comprehensive report has described the management of this problem. The purpose of this study was to examine the presentation, surgical management, and outcome of patients with recurrent visceral ischemia.
Between 1959 and 1997, 109 patients underwent primary visceral revascularization at the University of California, San Francisco. Nineteen patients (17.4%) had recurrent visceral ischemia (12 chronic visceral ischemia, seven acute visceral ischemia). Fourteen additional patients with recurrent chronic visceral ischemia were referred after failed primary revascularization (two patients underwent multiple operations before referral). Thirty visceral reoperations were performed for recurrent visceral ischemia in 24 patients (10 patients with recurrence at University of California, San Francisco, 14 referred patients). Symptom-free and overall survival rates were determined by life table analysis.
Of seven patients (6.4%) who had recurrent acute visceral ischemia, six (85.7%) died of bowel infarction. Twelve patients (11%) had recurrent chronic visceral ischemia. Patients with recurrent chronic visceral ischemia received their diagnoses earlier and lost less weight than at their initial presentation (p = 0.004 and 0.001, respectively). Recurrent ischemia was associated with younger age, greater weight loss, and modification of surgical technique at the time of initial operation (p = 0.5, 0.009, and 0.02, respectively). For 20 (90.9%) of the 22 first reoperations, antegrade aortovisceral bypass (n = 10) or transaortic visceral endarterectomy (n = 10) was used. Multiple techniques (four antegrade bypass, two retrograde bypass, one endarterectomy, one anastomotic revision) were used in the eight second or third reoperations. Postoperative mortality and complication rates were 6.7% and 33.3%, respectively. Symptoms recurred in six of 22 patients (27.3%) after the first reoperation, three of whom were cured or improved after additional reoperations. The life table symptom-free survival rate after reoperation was 77.3% and 62.8% at 1 and 5 years, respectively. The life table overall survival rate after reoperation was 74.6% at 5 years.
Recurrent visceral ischemia is not uncommon after primary visceral revascularization. These results show that reoperation for recurrent chronic visceral ischemia can be accomplished safely and effectively with established revascularization techniques. Furthermore, after repeat visceral revascularization patients achieve durable relief of symptoms and have life expectancy rates comparable with those of patients who undergo primary visceral revascularization.
内脏血管重建失败后复发性内脏缺血在多达三分之一的患者中出现，但尚无全面报告描述该问题的处理方法。本研究的目的是检查复发性内脏缺血患者的临床表现、手术处理及预后。
1959年至1997年间，109例患者在加利福尼亚大学旧金山分校接受了初次内脏血管重建术。19例患者（17.4%）出现复发性内脏缺血（12例慢性内脏缺血，7例急性内脏缺血）。另外14例复发性慢性内脏缺血患者在初次血管重建失败后前来就诊（2例患者在就诊前接受了多次手术）。24例患者（加利福尼亚大学旧金山分校10例复发患者，14例转诊患者）因复发性内脏缺血接受了30次内脏再次手术。通过寿命表分析确定无症状生存率和总生存率。
7例（6.4%）出现复发性急性内脏缺血的患者中，6例（85.7%）死于肠梗死。12例患者（11%）出现复发性慢性内脏缺血。复发性慢性内脏缺血患者比初次就诊时更早得到诊断且体重减轻更少（分别为p = 0.004和0.001）。复发性缺血与年龄较轻、体重减轻较多以及初次手术时手术技术的改变有关（分别为p = 0.5、0.009和0.02）。在22例首次再次手术中的20例（90.9%）中，采用了顺行主动脉内脏旁路术（n = 10）或经主动脉内脏内膜切除术（n = 10）。在8例第二次或第三次再次手术中采用了多种技术（4例顺行旁路术、2例逆行旁路术、1例内膜切除术、1例吻合口修复术）。术后死亡率和并发症发生率分别为6.7%和33.3%。22例患者中有6例（27.3%）在首次再次手术后症状复发，其中3例在再次手术后治愈或改善。再次手术后1年和5年的寿命表无症状生存率分别为77.3%和62.8%。再次手术后5年的寿命表总生存率为74.6%。
初次内脏血管重建术后复发性内脏缺血并不少见。这些结果表明，采用既定的血管重建技术，复发性慢性内脏缺血再次手术可安全有效地完成。此外，再次内脏血管重建术后患者症状得到持久缓解，预期寿命与接受初次内脏血管重建术的患者相当。
