Surgical or endovascular revascularization in patients with critical limb ischemia: Influence or diabetes mellitus on clinical outcome
Surgical or endovascular revascularization in patients with critical limb ischemia: Influence or diabetes mellitus on clinical outcome
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DOI：
10.1016/j.jvs.2006.12.022
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发表时间：
2007-04-01
影响因子：
4.3
通讯作者：
Baumgartner, Iris
中科院分区：
文献类型：
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作者：
Dick, Florian;Diehm, Nicolas;Baumgartner, Iris
目的：糖尿病合并慢性重度肢体缺血（CLI）患者的最佳血运重建策略尚不清楚。本研究评估了针对糖尿病患者进行血管内优先与手术优先血管重建术分层的疗效。这项前瞻性队列研究在一家三级转诊中心进行了为期1年的随访，对383例（45.7%患有糖尿病）426例肢体慢性CLI患者进行了连续系列研究。干预措施为血管内（PTA组，207条肢体）或手术（SURG组，85条肢体）血运重建术。未行血管重建的保守治疗患者（非REVASC队列，108条肢体）作为参考。主要的结局指标是持续的临床成功，定义为没有大截肢或重复目标肢体血运重建术（TER）的生存，以及根据卢瑟福分类的临床症状的分类上升。非糖尿病患者血运重建的持续临床成功率显著优于糖尿病患者（风险比[HR]， 0.48； 95%可信区间[CI]， 0.29至0.72;P = 0.001 [SURG队列]；HR, 0.53; 95% CI， 0.35至0.78;P = 0.002 [PTA队列]）（HR, 0.78; 95% CI， 0.44至1.43,P = 0.45 [SURG队列]；HR, 0.83; 95% CI， 0.55至1.27,P = 0.40 [PTA队列]）。重复TER显著提高了临床成功率，糖尿病患者和非糖尿病患者的临床成功率相等（HR, 1.02; 95% CI, 0.7 ~ 1.4）。在多变量分析中，治疗成功不受初始血运重建模式的影响，无论是糖尿病患者还是非糖尿病患者。累计1年死亡率为30.4%，糖尿病患者的死亡率有上升趋势（HR, 1.45; 95% CI, 0.98 ~ 2.17; P = 0.064）。在治疗队列中，残肢保留率相似，对于糖尿病也是如此（HR, 1.04; 95% CI, 0.62 - 1.75）。结论：糖尿病合并慢性CLI患者早期血运重建获益。为了达到这一目的，可能需要多次血运重建手术，因此必须密切监测。初始血运重建方式的选择似乎不影响临床成功。
Objective: The optimal revascularization strategy in diabetic patients with chronic critical limb ischemia (CLI) is unclear. This study assessed the efficacy of tailored endovascular-first vs surgical-first revascularization stratified for the presence of diabetes.Methods. This prospective cohort study, with 1-year follow up, was conducted in a tertiary referral center in a consecutive series of 383 patients (45.7% had diabetes) presenting 426 limbs with chronic CLI. Interventions were endovascular (PTA cohort, 207 limbs) or surgical (SURG cohort, 85 limbs) revascularization. Conservatively treated patients without revascularization (NON REVASC cohort, 108 limbs) were used as a reference. The main outcome measures were sustained clinical success, defined as survival without major amputation or repeated target extremity revascularization (TER), and a categoric upward shift in clinical symptoms according to the Rutherford classification.Results. Sustained clinical success of revascularization was significantly better in nondiabetic patients (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.29 to 0.72; P =.001 [SURG cohort]; HR, 0.53; 95% CI, 0.35 to 0.78; P =.002 [PTA cohort]) compared with diabetic patients (HR, 0.78; 95% CI, 0.44 to 1.43, P =.45 [SURG cohort]; HR, 0.83; 95% CI, 0.55 to 1.27, P =.40 [PTA cohort]). Repeated TER significantly improved clinical success, which became equivalent between diabetic and nondiabetic patients (HR, 1.02; 95% CI, 0.7 to 1.4). In multivariate analysis, treatment success was not influenced by mode of initial revascularization, neither in diabetic nor in nondiabetic patients. Cumulative 1-year mortality was 30.4%, with a trend of increased mortality in patients with diabetes (HR, 1.45; 95% CI, 0.98 to 2.17; P =.064). Limb salvage rates were similar in treatment cohorts, also if stratified for diabetes (HR, 1.04; 95% CI, 0.62 to 1.75).Conclusion: Diabetic patients with chronic CLI benefit from early revascularization. To achieve this benefit, multiple revascularization procedures may be required, and close surveillance is therefore mandatory. Choice of initial revascularization modality seems not to influence clinical success.