Disparity in outcomes of surgical revascularization for limb salvage: race and gender are synergistic determinants of vein graft failure and limb loss.
Disparity in outcomes of surgical revascularization for limb salvage: race and gender are synergistic determinants of vein graft failure and limb loss.
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DOI：
10.1161/circulationaha.108.810341
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发表时间：
2009-01-06
期刊：
影响因子：
37.8
通讯作者：
Conte MS
中科院分区：
文献类型：
--
作者：
Nguyen LL;Hevelone N;Rogers SO;Bandyk DF;Clowes AW;Moneta GL;Lipsitz S;Conte MS
静脉旁路手术是治疗冠状动脉和外周循环中动脉粥样硬化闭塞性疾病的有效方法;然而，长期结果受到移植物通畅性进行性磨损的限制。严重肢体缺血患者的静脉旁路移植失败会导致发病、肢体丧失和额外的资源使用。尽管已知技术因素对手术血运重建的成功至关重要，但患者特异性风险因素尚未明确定义。特别是，种族/种族和性别与外周血管旁路手术结局的关系一直存在争议。我们分析了通过转染III（PREVENT III）进行的体外静脉移植工程项目随机试验数据库，其中包括83个北美中心专门为严重肢体缺血进行的1404例下肢静脉移植手术。试验设计包括对旁路移植物的强化超声监测和1年的临床随访。多变量模型（考克斯比例风险和倾向评分）用于检查人口统计学变量与临床终点的关系，包括围手术期（30天）事件和1年结局（静脉移植物通畅率、保肢和患者生存率）。最终倾向评分模型调整了16个协变量（包括机构类型、技术因素、选定的合并症和预防性药物），以检查种族、性别和结局之间的相关性。在参加PREVENT III的249名黑人患者中，118名为女性，131名为男性。黑人男性早期移植失败的风险增加（30天失败的风险比[HR]为2.832; 95%置信区间[CI]为1.393至5.759; P = 0.0004），即使分析仅限于排除高风险静脉管道。1年时，黑人患者的二期通畅率（HR，1.49; 95% CI，1.08 - 2.06; P = 0.016）和保肢率（HR，2.02; 95% CI，1.27 - 3.20; P = 0.003）降低。倾向评分模型表明，黑人女性处于最不利的地位，1年时移植物通畅性丧失（HR，2. 02，二期通畅; 95% CI，1. 27 - 3. 20; P = 0. 003）和大截肢（HR，2. 38; 95% CI，1. 18 - 4. 83; P = 0. 016）的风险增加。不同种族/性别组的围手术期死亡率和1年死亡率相似。黑人和女性是静脉搭桥保肢术后不良结局的危险因素。移植失败和肢体丧失在黑人患者中更常见，黑人妇女是一个特别高的风险群体。这些数据表明，在这一人群中，静脉移植的生物学反应可能发生改变;然而，需要进一步研究来确定这些观察到的结果差异的机制。
Vein bypass surgery is an effective therapy for atherosclerotic occlusive disease in the coronary and peripheral circulations; however, long-term results are limited by progressive attrition of graft patency. Failure of vein bypass grafts in patients with critical limb ischemia results in morbidity, limb loss, and additional resource use. Although technical factors are known to be critical to the success of surgical revascularization, patient-specific risk factors are not well defined. In particular, the relationship of race/ethnicity and gender to the outcomes of peripheral bypass surgery has been controversial. We analyzed the Project of Ex Vivo Vein Graft Engineering via Transfection III (PREVENT III) randomized trial database, which included 1404 lower extremity vein graft operations performed exclusively for critical limb ischemia at 83 North American centers. Trial design included intensive ultrasound surveillance of the bypass graft and clinical follow-up to 1 year. Multivariable modeling (Cox proportional hazards and propensity score) was used to examine the relationships of demographic variables to clinical end points, including perioperative (30-day) events and 1-year outcomes (vein graft patency, limb salvage, and patient survival). Final propensity score models adjusted for 16 covariates (including type of institution, technical factors, selected comorbidities, and adjunctive medications) to examine the associations between race, gender, and outcomes. Among the 249 black patients enrolled in PREVENT III, 118 were women and 131 were men. Black men were at increased risk for early graft failure (hazard ratio [HR], 2.832 for 30-day failure; 95% confidence interval [CI], 1.393 to 5.759; P=0.0004), even when the analysis was restricted to exclude high-risk venous conduits. Black patients experienced reduced secondary patency (HR, 1.49; 95% CI, 1.08 to 2.06; P=0.016) and limb salvage (HR, 2.02; 95% CI, 1.27 to 3.20; P=0.003) at 1 year. Propensity score models demonstrate that black women were the most disadvantaged, with an increased risk for loss of graft patency (HR, 2.02 for secondary patency; 95% CI, 1.27 to 3.20; P=0.003) and major amputation (HR, 2.38; 95% CI, 1.18 to 4.83; P=0.016) at 1 year. Perioperative mortality and 1-year mortality were similar across race/gender groups. Black race and female gender are risk factors for adverse outcomes after vein bypass surgery for limb salvage. Graft failure and limb loss are more common events in black patients, with black women being a particularly high-risk group. These data suggest the possibility of an altered biological response to vein grafting in this population; however, further studies are needed to determine the mechanisms underlying these observed disparities in outcome.