經皮意向式管腔外血管重塑術對慢性嚴重肢體缺血有益


  July 27, 2004 - 根據8月號放射學(Radiology)期刊刊載的一項回朔性研究結果顯示,經皮意向式管腔外血管重塑術(PIER)對患有慢性嚴重肢體缺血病患是有益的。
  
  夏洛特斯維維吉尼亞大學健康科學中心David J. Spinosa醫師與他的同事們表示,PIER是一種新興有潛力的治療,可用於嚴重肢體缺血(CCLI)患者挽救其腿之阻塞血管;最近PIER已經被主張作為一種暫時性經皮繞道手術,且有潛力可成為治療動脈阻塞與CCLI患者的第一選擇。
  
  為了賦予腿部連續動脈血流來挽救肢體,研究人員針對40位不適合作鼠蹊內動脈繞道手術(IABS)的病患進行50次PIER手術,其中男性22位,女性18位,平均年齡為69歲(年齡介於44至87歲),包括24位(60%)糖尿病患、17位(42%)腎臟病患、與26位(66%)冠狀動脈疾病病患。
  
  在44條以PIER治療的腿阻塞血管中,37條(84%)牽涉到脛骨血管,包括15條只有脛骨血管,以及22條包括脛骨與上股骨動脈(SFA)以及/或是膕血管。有40條(91%)腿阻塞血管發生組織喪失、4條(9%)腿阻塞血管靜止時會疼痛。平均追蹤時間為7.8個月(從1至24個月)。
  
  PIER成功地治療38條腿阻塞血管中66條鼠蹊內動脈部份(29條上股骨動脈與37條脛動脈)。根據修正後Rutherford測量流出的動脈指數,脛動脈阻塞病患平均流出指數為5.3(範圍3-8),而上股骨動脈以及/或是脛動脈阻塞的是6.6(範圍3-9)。
  
  4位(10%)病患發生重大的併發症,而另外4位(10%)發生輕微的併發症,30日內的死亡率為2.5%;PIER手術後12個月,Kaplan-Meier分析顯示肢體挽救率為66%,肢體存活率為71%,而不需截肢的存活率為48%。
  
  這項試驗的限制包括回溯性試驗設計、缺乏手術控制組、僅為單一機構的經驗、有限的解剖暢通性數據與期中追蹤。
  
  研究人員表示,雖然仍需要更多的經驗來確定PIER是否應該作為CCLI患者的首選治療,但我們受到初步經驗的鼓舞,而這個經驗也支持其他試驗的結果;研究人員認為,PIER是個有效的經皮技術,將可使用於組織喪失、其他重大疾病、有限天生適合IABS的靜脈、之前進行IABS失敗的CCLI患者。

Percutaneous Intentional Extra

By Laurie Barclay, MD
Medscape Medical News

July 27, 2004 — Percutaneous intentional extraluminal revascularization (PIER) is useful for patients with chronic critical limb ischemia (CCLI), according to the results of a retrospective study published in the August issue of Radiology.

"[PIER] is emerging as a potential treatment that can be used for limb salvage in patients with CCLI," write David J. Spinosa, MD, from the University of Virginia Health Science Center in Charlottesville, and colleagues. "Recently PIER has been advocated as a temporary percutaneous bypass procedure and potentially could be considered the technique of first choice for treatment of patients with arterial occlusions and CCLI."

To create continuous arterial flow to the foot for limb salvage, 50 PIER procedures were attempted in 40 patients with CCLI who were poor candidates for infrainguinal arterial bypass surgery (IABS). There were 22 men and 18 women with a median age of 69 years (range, 44-87 years), including 24 (60%) with diabetes, 17 (42%) with renal disease, and 26 (66%) with coronary artery disease.

Of 44 limbs treated with PIER, 37 (84%) involved tibial vessels, including 15 in tibial vessels only, and 22 in tibial and superior femoral artery [SFA] and/or popliteal vessels. Tissue loss occurred in 40 limbs (91%), and rest pain in four limbs (9%). Median follow-up was 7.8 months (range, 1-24 months).

PIER treatment was successful in 66 infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb). Of 37 tibial occlusions, 35 (95%) were longer than 10 cm, as were 24 (83%) of 29 SFA and/or popliteal occlusions. Based on modified Rutherford weighting of run-off arteries, median run-off scores were 5.3 (range, 3-8) for patients with tibial occlusions and 6.6 (range, 3-9) for patients with SFA and/or popliteal occlusions.

Major complications occurred in four patients (10%), and minor complications in an additional four (10%). The 30-day mortality rate was 2.5%. Twelve months after PIER, Kaplan-Meier analysis showed that the limb salvage rate was 66%, the survival rate was 71%, and the amputation-free survival rate was 48%.

Limitations of this study include retrospective design, lack of a surgical control group, experience limited to a single institution, limited anatomic patency data, and midterm follow-up.

"[PIER] is a useful percutaneous technique that is used for limb salvage in patients with [CCLI] who have tissue loss, substantial comorbidities, limited suitable native veins for IABS, previous failed IABS, and/or high surgical risk," the authors write. "Although more experience is needed to determine if PIER should become a first-line treatment for patients with CCLI, we are encouraged by our initial experience, which supports the results of others."

Radiology. 2004;232:499-507

Reviewed by Gary D. Vogin, MD

    
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