Comparison of Graft Patency, Limb Salvage, and Antithrombotic Therapy Between Prosthetic and Autogenous Below-Knee Bypass for Critical Limb Ischemia
Comparison of Graft Patency, Limb Salvage, and Antithrombotic Therapy Between Prosthetic and Autogenous Below-Knee Bypass for Critical Limb Ischemia
复制标题
DOI：
10.1016/j.avsg.2013.01.019
复制
发表时间：
2013-11-01
影响因子：
1.5
通讯作者：
Goodney, Philip P.
中科院分区：
文献类型：
--
作者：
Suckow, Bjoern D.;Kraiss, Larry W.;Goodney, Philip P.
背景：自体静脉是膝下血管重建的首选管道。然而，许多人认为，人工移植物可以表现良好的下肢旁路与连续抗血栓治疗。因此，我们比较了膝下假体与自体静脉旁路移植术治疗严重肢体缺血的结果，以及在两种情况下使用连续性抗血栓治疗的结果。利用新英格兰血管研究组的登记研究（2003-2009年），我们研究了1227例因严重肢体缺血接受膝下旁路手术的患者，其中223例接受了膝下腘动脉（70%）或更远靶点（30%）的人工血管移植。我们使用倾向匹配来识别接受单段大隐静脉的患者队列，但在特征、移植来源/目标和抗血栓治疗方案方面与假体队列保持相似。主要结果指标为1年内移植物通畅率和主要肢体截肢。次要结局为出血并发症（再次手术或输血）和死亡率。结果：人工管道组比大隐静脉组更容易使用华法林（57%比24%，P < 0.001）。倾向评分匹配后，我们发现人工和单段隐静脉移植物之间的一期移植物通畅率（72% vs. 73%，P=0.81）或大截肢率（17% vs. 13%，P=0.31）无显著差异。在对胫骨和腘动脉移植物的亚组分析中，我们注意到假体和静脉管道的一期通畅率和截肢率相当。尽管总体1年人工移植物通畅率从51%（阿司匹林+氯吡格雷）到78%（阿司匹林+华法林）不等，但抗血栓治疗的一期通畅率或大截肢率无显著差异（分别为P=0.32和0.17）。此外，出血并发症和1年死亡率的发生率并没有不同的管道类型或抗血栓治疗方案的倾向matchedanalysis.Conclusions：虽然规模有限，我们的研究表明，适当的患者选择和抗血栓治疗，1年的结果为膝下假体旁路移植术可以与大隐静脉管道。
Background: The autogenous vein is the preferred conduit in below-knee vascular reconstructions. However, many argue that prosthetic grafts can perform well in crural bypass with adjunctive antithrombotic therapy. We therefore compared outcomes of below-knee prosthetic versus autologous vein bypass grafts for critical limb ischemia and the use of adjunctive antithrombotic therapy in both settings.Methods: Utilizing the registry of the Vascular Study Group of New England (2003-2009), we studied 1227 patients who underwent below-knee bypass for critical limb ischemia, 223 of whom received a prosthetic graft to the below-knee popliteal artery (70%) or more distal target (30%). We used propensity matching to identify a patient cohort receiving single-segment saphenous vein yet had remained similar to the prosthetic cohort in terms of characteristics, graft origin/target, and antithrombotic regimen. Main outcome measures were graft patency and major limb amputation within 1 year. Secondary outcomes were bleeding complications (reoperation or transfusion) and mortality. We performed comparisons by conduit type and by antithrombotic therapy.Results: Patients receiving prosthetic conduit were more likely to be treated with warfarin than those with greater saphenous vein (57% vs. 24%, P < 0.001). After propensity score matching, we found no significant difference in primary graft patency (72% vs. 73%, P=0.81) or major amputation rates (17% vs. 13%, P=0.31) between prosthetic and single-segment saphenous vein grafts. In a subanalysis of grafts to tibial versus popliteal targets, we noted equivalent primary patency and amputation rates between prosthetic and venous conduits. Whereas overall 1-year prosthetic graft patency rates varied from 51% (aspirin + clopidogrel) to 78% (aspirin + warfarin), no significant differences were seen in primary patency or major amputation rates by antithrombotic therapy (P=0.32 and 0.17, respectively). Further, the incidence of bleeding complications and 1-year mortality did not differ by conduit type or antithrombotic regimen in the propensity-matched analysis.Conclusions: Although limited in size, our study demonstrates that, with appropriate patient selection and antithrombotic therapy, 1-year outcomes for below-knee prosthetic bypass grafting can be comparable to those for greater saphenous vein conduit.