Surgical implications of early failed endovascular intervention of the superficial femoral artery.
Surgical implications of early failed endovascular intervention of the superficial femoral artery.
复制标题
股浅动脉血管内介入早期失败的手术意义。
DOI：
10.1016/j.jvs.2007.11.044
复制
发表时间：
2008
影响因子：
4.3
通讯作者：
Spence M. Taylor
中科院分区：
文献类型：
--
作者：
Charles S. Joels;J. York;C. Kalbaugh;D. Cull;E. Langan;Spence M. Taylor
研究背景：人们普遍认为，使用假体材料的腹股沟下旁路手术失败会严重影响动脉血流，这可能会限制未来的血运重建。众所周知，早期静脉移植物血栓形成的不良后果是有限的，但外周血管成形术失败对远端血管系统的影响研究甚少。本研究的目的是确定股浅动脉介入治疗后早期失败是否会影响随后的血管重建选择。METHODS在1998年7月1日至2006年6月30日期间，276例患者接受了股浅动脉血管内介入治疗。由3名主治血管外科医生以设盲方式对介入治疗前和早期失败（≤200天）后的血管造影片进行前瞻性分析，以确定是否进行手术的最佳远端旁路部位。使用多名评分者的Fleiss广义κ评估了血管造影评分的评分者间可靠性。潜在远端吻合部位被分类为膝上腘、膝下腘、胫骨或无适当部位。对每例患者（3名评估者中的2名）确定了一致的分类。在276名接受股浅动脉血管内介入治疗的患者中，23名患者的24条肢体出现早期失败。20例患者（60%男性;平均年龄65.3 ± 11.3岁）的21条肢体的血管造影记录可用，其中60%患有严重肢体缺血，40%患有跛行，65%患有糖尿病。6条肢体（28.6%）的远端旁路部位发生改变; 4条从腘动脉到胫骨，2条从膝上到膝下腘动脉。评定者间可靠性为0.54（中度/良好）。对这些早期失败进行的手术为经皮腔内血管成形术±支架（n = 14）、腹股沟下旁路（n = 5）和未治疗（n = 1）。只有0.4%（1 276）的患者需要主要截肢，由于早期失败的股浅动脉intervention.CONCLUSIONSEARLY失败后，孤立的血管内介入治疗的股浅动脉是罕见的，并改变了远端目标在30%的早期失败的患者，如果开放旁路计划。如有必要，大多数患者可以通过重复血管成形术进行挽救，而截肢的需要非常罕见。本研究中的早期失败结果支持对下肢缺血（尤其是跛行）患者的股浅动脉进行更广泛的血管内介入治疗。晚期血管内失败的影响以及疾病进展的影响需要进一步研究。
BACKGROUNDIt is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options.METHODSBetween July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (≤200 days) was performed in a blinded fashion by three attending vascular surgeons to determine the optimal distal bypass site if an operation were to be performed. Inter-rater reliability of the angiogram scores was assessed using the Fleiss generalized κ for multiple raters. Potential distal anastomotic sites were classified as above knee popliteal, below knee popliteal, tibial, or no adequate site. A consensus classification was determined for each patient (2 of 3 raters).RESULTSOf the 276 patients who underwent endovascular intervention of the superficial femoral artery, early failure was noted in 24 limbs in 23 patients. Angiographic records were available for 21 limbs in 20 patients (60% men; mean age, 65.3 ± 11.3 years), of which 60% had critical limb ischemia, 40% had claudication, and 65% had diabetes. The distal bypass site was altered in six limbs (28.6%); four from popliteal to tibial and two from above knee to below knee popliteal. Inter-rater reliability was 0.54 (moderate/good). The procedures performed on these early failures were percutaneous transluminal angioplasty ± stent (n = 14), infrainguinal bypass (n = 5), and no treatment (n = 1). Only 0.4% (1 of 276) of patients required major limb amputation due to early failure of a superficial femoral artery intervention.CONCLUSIONSEarly failure after isolated endovascular intervention of the superficial femoral artery is infrequent and alters the distal target in 30% of early-failure patients if open bypass is planned. Salvage with repeat angioplasty, if necessary, can be accomplished in most patients, and the need for limb amputation is exceedingly rare. The early failure results in this study support a more liberal application of endovascular intervention to the superficial femoral artery in patients with lower extremity ischemia, especially claudication. The repercussions of late endovascular failure as well as the effects of disease progression need further study.