Contemporary outcomes of endovascular interventions for acute limb ischemia
Contemporary outcomes of endovascular interventions for acute limb ischemia
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DOI：
10.1016/j.jvs.2013.10.054
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发表时间：
2014-04-01
影响因子：
4.3
通讯作者：
Chaer, Rabih A.
中科院分区：
文献类型：
--
作者：
Byrne, Raphael M.;Taha, Ashraf G.;Chaer, Rabih A.
目的：根据20多年前发表的研究，溶栓治疗急性肢体缺血（ALI）已成为一线治疗方法。本研究的目的是评估使用当代溶栓药物和血管内techniques.Methods治疗急性肺损伤患者的结果：确定2005年至2011年期间治疗的下肢急性肺损伤患者，并对其记录进行回顾性分析。所有患者均通过导管直接溶栓（CDT）和/或药物机械溶栓（PMT）给予组织纤溶酶原激活剂，并辅以其他辅助血管内或外科干预措施进行治疗。获得了整个系列的手术成功率、溶栓持续时间以及30天和长期结局，并在CDT组和PMT组之间进行了比较。保肢和生存率进行了评估，使用时间到事件的方法，包括Kaplan-Meier估计和考克斯比例风险models.Results：共154肢治疗147例患者出现ALI（卢瑟福I级，9.7%，IIa级，70.1%，IIb级，20.1%）。平均随访时间为15.20个月（范围：0.56-56.84个月）。介入适应症包括栓塞（14.3%）、血栓旁路（36.4%）、血栓支架（26.6%）、自体动脉血栓形成（24.0%）和血栓腘动脉瘤（3.2%）。83.8%的病例获得了技术成功，30天死亡率为5.2%。手术并发症包括全身出血（5.2%）、穿刺部位血肿（4.5%）、急性肾衰竭（1.9%）和远端栓塞（9.7%）。平均径流评分从干预前的13.42下降到干预后的7.43。89.0%的患者需要辅助血运重建术，包括血管内（68.8%）、混合（9.1%）或开放（11.0%）。只有3.2%的患者需要筋膜切开术。大截肢的总体发生率为15.0%（仅CDT为18.1%，PMT为11.3%; P = NS）。考克斯比例风险模型预测肢体丧失的因素包括终末期肾病（风险比[HR]，8.563; P <0.001）和踏板流出不良，改善的踏板流出增加了保护作用（HR，0.205;一个踏板流出血管P <0.001; HR，0.074; P < .001 for >=两个踏板流出血管）。性别、吸烟、糖尿病、Rutherford评分、径流评分、血栓性腘动脉瘤和PMT不是肢体丧失的显著预测因素。PMT的使用是技术成功的一个重要预测因素（比值比，2.67; P = .046）。结论：血管内治疗与溶栓使用组织纤溶酶原激活剂仍然是一种有效的治疗选择，患者出现轻度或中度下肢ALI，与同等的好处来自CDT或PMT。终末期肾病或足流出道不良的患者肢体缺失的风险增加，可能受益于替代血运重建策略。
Objective: Thrombolysis as a treatment for acute limb ischemia (ALI) has become a first-line therapy based on studies published over 2 decades ago. The purpose of this study was to assess outcomes of patients treated for ALI using contemporary thrombolytic agents and endovascular techniques.Methods: Consecutive patients with ALI of the lower extremities treated between 2005 and 2011 were identified, and their records were retrospectively reviewed. All patients were treated with tissue plasminogen activator delivered via catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombolysis (PMT), with other adjunctive endovascular or surgical interventions. Procedural success, thrombolysis duration, and 30-day and long-term outcomes were obtained for the whole series and were also compared between the CDT and PMT groups. Limb salvage and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models.Results: A total of 154 limbs were treated in 147 patients presenting with ALI (Rutherford class I, 9.7%; class IIa, 70.1%; class IIb, 20.1%). The mean follow-up was 15.20 months (range, 0.56-56.84 months). Indications for intervention included embolization (14.3%), thrombosed bypass (36.4%), thrombosed stent (26.6%), native artery thrombosis (24.0%), and thrombosed popliteal aneurysm (3.2%). Technical success was achieved in 83.8% of cases, with a 30-day mortality rate of 5.2%. Procedural complications included systemic bleeding (5.2%), access site hematoma (4.5%), acute renal failure (1.9%), and distal embolization (9.7%). The mean runoff score decreased from 13.42 preintervention to 7.43 postintervention. Adjuvant revascularization procedures were required in 89.0% of patients and were endovascular (68.8%), hybrid (9.1%), or open (11.0%). Only 3.2% of patients required a fasciotomy. The overall rate of major amputation was 15.0% (18.1% for CDT only, 11.3% for PMT; P = NS). Predictors of limb loss by Cox proportional hazards models included end-stage renal disease (hazard ratio [HR], 8.563; P < .001) and poor pedal outflow, with an incremental protective effect for improved pedal outflow (HR, 0.205; P < .001 for one pedal outflow vessel; HR, 0.074; P < .001 for >= two pedal outflow vessels). Gender, smoking, diabetes, Rutherford score, runoff score, thrombosed popliteal aneurysm, and PMT were not significant predictors of limb loss. The use of PMT was a significant predictor of technical success (odds ratio, 2.67; P = .046).Conclusions: Endovascular therapy with thrombolysis using tissue plasminogen activator remains an effective treatment option for patients presenting with mild or moderate lower extremity ALI, with equal benefit derived with CDT or PMT. Patients with end-stage renal disease or poor pedal outflow have an increased risk of limb loss and may benefit from alternative revascularization strategies.