Long-term outcomes and predictors of iliac angioplasty with selective stenting
Long-term outcomes and predictors of iliac angioplasty with selective stenting
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DOI：
10.1016/j.jvs.2005.05.002d
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发表时间：
2005-09-01
影响因子：
4.3
通讯作者：
Ahn, SS
中科院分区：
文献类型：
--
作者：
Kudo, T;Chandra, FA;Ahn, SS
目的：总结11年来应用选择性支架成形术治疗髂动脉闭塞性疾病的经验，评价其安全性、近远期通畅率、临床成功率和预测危险因素。方法：自1993年8月至2004年11月，对104例患者的151处病变(149处狭窄，2处闭塞)进行了经皮血管腔内成形术(PTA)。这些患者有慢性肢体缺血，描述为残疾跛行(美国血管外科学会临床2级或3级)76例(50%)，休息疼痛(4级)38例(25%)，溃疡/坏疽(5级)37例(25%)。46条肢体(30%)同时行腹股沟下血管内成形术(36条，24%)或开放手术(10条，6%)。34条肢体(23%)因原发性PTA失败而放置了一个或多个支架，包括残余狭窄(>；=30%)、平均压力差(>；=5 mm Hg)或夹层(支架组)，而117条肢体(77%)仅接受PTA(PTA组)。治疗的受累动脉包括28支(19%)髂总动脉、31支(20%)髂外动脉和92支(61%)两支动脉。按跨大西洋社会共识(TASC)分类，A型39条(26%)，B型71条(47%)，C型36条(24%)，D型5条(3%)。总并发症发生率为0。7%(1例腹股沟血肿)。平均随访21个月(中位数为10个月；范围为1至94个月)。在117例PTA患者中，只有9例(8%)因复发狭窄而再次置入支架。根据TASC分类(Mann-Whitney U test[M-W]，P<；0.0001)和解剖位置(M-W，P=0.0019)，支架组的髂骨病变比PTA组更严重、更广泛。技术成功率为99%，初步临床成功率为99%。总体而言，1年、3年和5年的累积初级通畅率分别为76%、59%和49%(Kaplan-Meier[K-M])。术后7年的累积辅助一次通畅率为98%，二次通畅率为99%(K-M)。在原发性髂动脉成形术/支架失败的患者中，随后的髂内血管内手术的平均次数为每条肢体1.4次。1年、3年和5年的临床持续改善率分别为81%、67%和53%(K-M)。术后7年肢体保留率为93%(K-M)。在151个髂骨病变中研究的15个预测变量中，不良结局的显著独立预测因素是：吸烟史(P=.0074)、TASC C/D型病变(P=.0001)和同侧股浅动脉狭窄(P=.0002)；慢性肾功能衰竭合并血液透析(P=.014)；溃疡/坏疽作为PTA的指征(P<；同侧股浅动脉狭窄(P=.0001)和狭窄程度(P=.034)，以继续改善临床症状(K-M检验和Cox回归模型)。结论：虽然一次通畅率不高，但辅助一次通畅率和二次通畅率在没有一次支架置入的情况下很好。总体而言，70%的髂骨病变仅用PTA治疗是成功的。本研究的结果表明，选择性支架置入术在髂动脉成形术后提供了令人满意的辅助一期和二期远期通畅。TASC C/D型髂骨病变、同侧股浅动脉狭窄、溃疡/坏疽、吸烟史、慢性肾功能衰竭合并血液透析的患者，在血管内血管重建术后应仔细观察。这些危险因素可以被认为是初次支架置入术的适应症，尽管还需要进一步的研究来证实这一点。
Objective: To review our 11-year experience of iliac angioplasty with selective stenting and to evaluate the safety, short- and long-term patency, clinical success rates, and predictive risk factors in patients with iliac artery occlusive disease.Methods: From August 1993 to November 2004, 151 iliac lesions (149 stenoses, 2 occlusions) in 104 patients were treated by percutaneous transluminal angioplasty (PTA). The patients had chronic limb ischemia described as disabling claudication (the Society for Vascular Surgery clinical category 2 or 3) in 76 (50%), rest pain (category 4) in 38 (25%), and ulcer/gangrene (category 5) in 37 (25%). Forty-six limbs (30%) were treated with concomitant infrainguinal endovascular (36, 24%) or open procedures (10, 6%). Thirty-four limbs (23%) had one or more stents placed for primary PTA failure, including residual stenosis (>= 30%), mean pressure gradient (>= 5 mm Hg), or dissection (stent group); whereas, 117 limbs (77%) underwent PTA alone (PTA group). The affected arteries treated were 28 (19%) common iliac, 31 (20%) external iliac, and 92 (61%) both arteries. According to TransAtlantic Inter-Society Consensus (TASC) classification, 39 limbs (26%) were in type A, 71 (47%) in type B, 36 (24%) in type C, and 5 (3%) in type D. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed.Results: There was no perioperative death. Total complication rate was 0. 7% (one groin hematoma). The mean follow-up was 21 months (median, 10; range, 1 to 94 months). Only 9 (8%) of 117 of the PTA group had subsequent stent placement for recurrent stenosis. The iliac lesions were more severe and extensive in the stent group than those in the PTA group according to TASC classification (Mann-Whitney U test [M-W], P < .0001) and anatomic location (M-W, P = .0019). The technical success rate was 99%, and the initial clinical success rate was 99%. Overall, the cumulative primary patency rates at 1, 3, and 5 years were 76%, 59%, and 49% (Kaplan-Meier [K-M]). The cumulative assisted primary and secondary patency rates at 7 years were 98% and 99% (K-M). The mean number of subsequent iliac endovascular procedures was 1.4 per limb in patients with primary failure of iliac angioplasty/stenting. The continued clinical improvement rates at 1, 3, and 5 years were 81%, 67%, and 53% (K-M). The limb salvage rates at 7 year were 93% (K-M). Of 15 predictor variables studied in 151 iliac lesions, the significant independent predictors for adverse outcomes were smoking history (P = .0074), TASC type C/type D lesions (P = .0001), and stenotic ipsilateral superficial femoral artery (P = .0002) for the primary patency rates; chronic renal failure with hemodialysis (P = .014), ulcer/gangrene as an indication for PTA (P < .0001), and stenotic ipsilateral superficial femoral artery (P = .034) for the continued clinical improvement (K-M, log-rank test and Cox regression model).Conclusions: Although the primary patency rates were not high, the assisted primary and secondary patency rates were excellent without primary stenting. Overall, > 70% of iliac lesions were treated successfully with PTA alone. The results of this study show that selective stenting offers satisfactory assisted primary and secondary long-term patency after iliac angioplasty. Patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/ gangrene, smoking history, and chronic renal failure with hemodialysis should be followed carefully after endovascular iliac revascularization. These risk factors could be considered indications for primary stenting, although further studies are needed to confirm this.