Predicting Functional Status Following Amputation After Lower Extremity Bypass
Predicting Functional Status Following Amputation After Lower Extremity Bypass
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DOI：
10.1016/j.avsg.2011.07.014
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发表时间：
2012-01-01
影响因子：
1.5
通讯作者：
Cronenwett, Jack L.
中科院分区：
文献类型：
--
作者：
Suckow, Bjoern D.;Goodney, Philip P.;Cronenwett, Jack L.
背景：一些因严重肢体缺血而行下肢旁路手术的患者最终需要截肢。这些患者截肢后的功能结果尚不清楚。因此，我们试图描述LEB术后截肢患者的功能结局，并描述与下肢截肢后在家独立行走相关的术前和围手术期因素。方法：在2003年1月至2008年12月期间接受LEB手术的3198例患者中，我们研究了436例随后接受膝上（AK）、膝下（BK）或轻微（前脚或脚趾）同侧或对侧截肢的患者。我们的主要结果测量包括“良好的功能结果”，定义为在家中生活和独立行走。我们计算了患者特征、主要结局指标以及总生存率之间的单因素和多因素相关性。结果：在436例LEB术后一年内截肢的患者中，436例中有224例（51.4%）有轻微截肢，436例中有105例（24.1%）有BK截肢，436例中有107例（24.5%）有AK截肢。大多数AK截肢（107例中有75例，72.8%）和BK截肢（105例中有72例，70.6%）发生在搭桥血栓形成的情况下，而几乎所有轻微截肢（224例中有200例，89.7%）发生在未闭搭桥的情况下。通过1年的生命表分析，我们发现功能预后良好的存活患者比例因截肢的存在和程度而异（功能预后良好的存活患者比例为88%未截肢，81%轻度截肢，55% BK截肢，45% AK截肢，p = 0.001）。在长期随访分析中，与LEB术后未截肢的患者相比，轻度截肢患者的生存率略低（81%对88%，p = 0.02）。重度截肢患者的生存率与未截肢患者相比无显著差异（BK截肢87%，p = 0.14， AK截肢89%，p = 0.27）；然而，这部分分析受到样本量的限制（n = 212）。在多变量分析中，我们发现，尽管进行了下肢截肢，但最可能保持活动和独立生活的患者是术前生活在家中的患者（风险比[HR]: 6.8, 95%可信区间[CI]: 0.94-49, p = 0.058）和术前使用他汀类药物的患者（风险比：1.6,95% CI: 1.2-2.1, p = 0.003），而一些合并症的存在表明患者不太可能获得良好的功能结局：0.6, 95% CI: 0.5-0.9, p = 0.003)，透析（HR: 0.5, 95% CI: 0.3-0.9, p = 0.02）和充血性心力衰竭（HR: 0.5, 95% CI: 0.3-0.8, p = 0.005）。结论：术后任何级别的截肢都会影响LEB手术后的功能结局，并且截肢的程度与功能结局的影响直接相关。根据术前患者的特征，可以确定接受LEB的患者，即使最终需要进行大截肢，也最有可能或最不可能获得良好的功能结果。这些发现可能有助于对不适合进行下肢搭桥手术的患者进行患者教育和手术决策。
Background: Some patients who undergo lower extremity bypass (LEB) for critical limb ischemia ultimately require amputation. The functional outcome achieved by these patients after amputation is not well known. Therefore, we sought to characterize the functional outcome of patients who undergo amputation after LEB, and to describe the pre- and perioperative factors associated with independent ambulation at home after lower extremity amputation.Methods: Within a cohort of 3,198 patients who underwent an LEB between January, 2003 and December, 2008, we studied 436 patients who subsequently received an above-knee (AK), below-knee (BK), or minor (forefoot or toe) ipsilateral or contralateral amputation. Our main outcome measure consisted of a "good functional outcome," defined as living at home and ambulating independently. We calculated univariate and multivariate associations among patient characteristics and our main outcome measure, as well as overall survival.Results: Of the 436 patients who underwent amputation within the first year following LEB, 224 of 436 (51.4%) had a minor amputation, 105 of 436 (24.1%) had a BK amputation, and 107 of 436 (24.5%) had an AK amputation. The majority of AK (75 of 107, 72.8%) and BK amputations (72 of 105, 70.6%) occurred in the setting of bypass graft thrombosis, whereas nearly all minor amputations (200 of 224, 89.7%) occurred with a patent bypass graft. By life-table analysis at 1 year, we found that the proportion of surviving patients with a good functional outcome varied by the presence and extent of amputation (proportion surviving with good functional outcome 88% no amputation, 81% minor amputation, 55% BK amputation, and 45% AK amputation, p = 0.001). Among those analyzed at long-term follow-up, survival was slightly lower for those who had a minor amputation when compared with those who did not receive an amputation after LEB (81 vs. 88%, p = 0.02). Survival among major amputation patients did not significantly differ compared with no amputation (BK amputation 87%, p = 0.14, AK amputation 89%, p = 0.27); however, this part of the analysis was limited by its sample size (n = 212). In multivariable analysis, we found that the patients most likely to remain ambulatory and live independently despite undergoing a lower extremity amputation were those living at home preoperatively (hazard ratio [HR]: 6.8, 95% confidence interval [CI]: 0.94-49, p = 0.058) and those with preoperative statin use (HR: 1.6, 95% CI: 1.2-2.1, p = 0.003), whereas the presence of several comorbidities identified patients less likely to achieve a good functional outcome: coronary disease (HR: 0.6, 95% CI: 0.5-0.9, p = 0.003), dialysis (HR: 0.5, 95% CI: 0.3-0.9, p = 0.02), and congestive heart failure (HR: 0.5, 95% CI: 0.3-0.8, p = 0.005).Conclusions: A postoperative amputation at any level impacts functional outcomes following LEB surgery, and the extent of amputation is directly related to the effect on functional outcome. It is possible, based on preoperative patient characteristics, to identify patients undergoing LEB who are most or least likely to achieve good functional outcomes even if a major amputation is ultimately required. These findings may assist in patient education and surgical decision making in patients who are poor candidates for lower extremity bypass.