Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program
Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program
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DOI：
10.1016/j.jvs.2016.01.011
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发表时间：
2016-06-01
影响因子：
4.3
通讯作者：
Conte, Michael S.
中科院分区：
文献类型：
--
作者：
Causey, Marlin W.;Ahmed, Ayman;Conte, Michael S.
目的：晚期肢体缺血的临床决策和准确的结局比较需要改进的分期系统。血管外科学会下肢危险肢体分类系统（伤口范围、缺血和足部感染[WIfI]）旨在根据三个主要因素-伤口范围、缺血和足部感染对肢体结局进行分层。开发了项目或体外静脉移植物工程通过转染III（PREVENT）III（PIII）风险评分，以根据手术血运重建后的预期无截肢生存率（AFS）对患者进行分层。本研究的目的是前瞻性地评估肢体和患者为基础的分期预测结果的住院患者在截肢prevention programme.Methods：本研究进行了回顾性分析，前瞻性收集的登记数据的连续患者的肢体威胁的条件承认一个完全集成的血管/足科服务超过16个月的时间。入院后，使用WIfI系统对肢体风险进行分层，使用PIII分类对患者风险进行分类。评估患者的围手术期和出院后结果，并分析其与入院时分期的关系。有174个肢体受到威胁（143例住院患者）按WIfI分期分层（1%-12%，2%-28%，3%-24%，4%-28%，5%-3%，未分期-5%）和PIII风险（34%低风险，49%中度风险和17%高风险）。糖尿病和终末期肾病与WIfI分期（P = 0.006和P = 0.018）和PIII风险（P = 0.003和P <0.001）相关。围手术期（30天）事件包括3%的死亡率、8%的主要不良心血管事件和2.4%的大截肢。有119条肢体（71%）接受了血运重建，包括108例腹股沟下重建（血管内或开放血运重建）。血运重建率随WIfI分期增加（P <0.001），与足病手术次数、小截肢和初始住院时间相关（均P <0.001）。WIfI分期增加与主要不良肢体事件（P = 0.018）、保肢率降低（P = 0.037）和AFS降低（P = 0.048）相关。相反，PIII风险类别与死亡率（P < .001）和AFS（P < .001）相关。在腹股沟下重建手术中，血管内（46%）和外科（54%）干预的分布相似。自体静脉搭桥术最好无严重肢体不良事件（P = .025），在最严重威胁的肢体中，手术血运重建与保肢改善相关（WIfI 4期：开放旁路术的保肢率为95%，血管内旁路术的保肢率为68%; P = 0.026）。在因肢体威胁性疾病住院并接受多学科截肢预防小组治疗的患者中，PIII风险与死亡率相关，而WIfI分期强烈预测初始住院时间，和关键的中期肢体结果。手术血运重建在风险最大的肢体（WIfI 4期）中表现最好，自体静脉旁路是开放旁路的首选管道。这些数据支持使用WIfI和PIII作为补充分期工具在慢性肢体威胁性缺血的管理。
Objective: Clinical decision making and accurate outcomes comparisons in advanced limb ischemia require improved staging systems. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (Wound extent, Ischemia, and foot Infection [WIfI]) was designed to stratify limb outcomes based on three major factors-wound extent, ischemia, and foot infection. The Project or Ex-Vivo vein graft Engineering via Transfection III (PREVENT) III (PIII) risk score was developed to stratify patients by expected amputation-free survival (AFS) after surgical revascularization. This study was designed to prospectively assess limb and patient-based staging for predicting outcomes of hospitalized patients in an amputation prevention program.Methods: This study undertook a retrospective analysis of prospectively gathered registry data of consecutive patients with limb-threatening conditions admitted to a fully integrated vascular/podiatry service over a 16-month period. Upon admission, limb risk was stratified using the WIfI system and patient risk was categorized using PIII classification. Patients were assessed for perioperative and postdischarge outcomes, and their relationship to staging at admission was analyzed.Results: There were 174 threatened limbs (143 hospitalized patients) stratified by WIfI stage (1%-12%, 2%-28%, 3%-24%, 4%-28%, 5%-3%, unstaged-5%) and PIII risk (34% low, 49% moderate, and 17% high risk). Diabetes and end-stage renal disease were associated with WIfI stage (P = .006 and P = .018) and PIII risk (P = .003 and P < .001). Perioperative (30-day) events included 3% mortality, 8% major adverse cardiovascular events and 2.4% major amputation. There were 119 limbs (71%) that underwent revascularization, including 108 infrainguinal reconstructions (endovascular or open revascularization). Rate of revascularization increased with WIfI stage (P < .001), concomitant with the number of podiatric procedures, minor amputations, and initial hospital duration of stay (all P < .001). Increased WIfI stage was associated with major adverse limb events (P = .018), reduced limb salvage (P = .037), and decreased AFS (P = .048). In contrast, PIII risk category was associated with mortality (P < .001) and AFS (P < .001). Among infrainguinal reconstruction procedures, there was a similar distribution of endovascular (46%) and surgical (54%) interventions. Freedom from major adverse limb events was best for autogenous vein bypass (P = .025), and surgical revascularization was associated with improved limb salvage among the most severely threatened limbs (WIfI stage 4: 95% limb salvage for open bypass vs 68% limb salvage for endovascular; P = .026).Conclusions: Among patients hospitalized with limb-threatening conditions and treated by a multidisciplinary amputation prevention team, PIII risk correlates with mortality whereas WIfI stage strongly predicts initial hospital duration of stay, and key mid-term limb outcomes. Surgical revascularization performed best in the limbs at greatest risk (WIfI stage 4), and autogenous vein bypass was the preferred conduit for open bypass. These data support the use of WIfI and PIII as complementary staging tools in the management of chronic limb-threatening ischemia.