杂交手术治疗TASC D型下肢动脉硬化闭塞症的临床分析

Hybrid surgical and endovascular therapy in TASC type D atherosclerotic occlusive disease： a retrospective analysis of 48 cases

目的 评价杂交手术治疗TASC D型下肢动脉硬化闭塞症的临床疗效.方法 回顾性分析2006年1月至2009年12月间采用杂交手术治疗的46例TASC D型下肢动脉硬化闭塞症患者（共48条患肢）的临床资料.其中男性32条患肢,女性16条患肢;年龄54～85岁,平均67岁.根据临床症状进行Fontaine分级,根据开放手术与腔内治疗部位的相对关系进行分组,采用Kaplan-Meier生存曲线比较不同分级、分组患者间一期通畅率的差异,分析影响一期通畅率的危险因素.结果 所有患者手术均获成功.术后41条患肢（85.4%）临床症状明显改善,平均踝肱指数0.63±0.18,高于术前的0.24±0.13（P＜0.05）;平均间歇性跛行距离从术前（87±48）m提高至（247±62）m（P＜0.05）.平均随访27.1个月,一期通畅率为79.2%,辅助一期通畅率为83.3%,二期通畅率为95.8%.生存分析显示FontaineⅡ级患者一期通畅率明显高于Ⅲ、Ⅳ级（P均＜0.05）;当对开放手术治疗动脉段的远近端都进行腔内干预时,其一期通畅率要低于仅在其近端或远端一侧干预者（P值均＜0.05）.Cox回归分析发现糖尿病和高血脂是影响术后一期通畅率的独立因素（P=0.013、0.008）.结论 杂交手术是治疗TASC D型下肢动脉硬化闭塞症的有效方法,适用于高危重症患者.

Objective To retrospectively analyze 4-year results after hybrid （combined surgicalendovascular） therapy in patients with complex peripheral TASC type D atherosclerotic occlusive disease. Methods From January 2006 to December 2009, 48 lower limbs in 46 patients with TASC type D atherosclerotic occlusive disease were treated by hybrid surgical and endovascular therapy. There were 32 male and 16 female, age ranged from 54 to 85 years with an average of 67 years. The early clinical results were determined by ankle brachial index （ABI） and intermittent claudication distance. Patency analyses were performed using Kaplan-Meier life tables. Univariate and multivariate analyses were used to assess the influence of various risk factors on primary patency. Results All lower limbs underwent successful hybrid surgical and endovascular therapy. The average ABI before and after hybrid therapy were 0. 63± 0. 18 and 0. 24 ± 0. 13 （ P 〈 0. 05 ）. The average intermittent claudication distance significantly increased from （ 87 ± 48） m to （247 ± 62） m （P 〈0. 05）. The mean duration of follow-up was 21.7 months （ranging I to 46 months）. Over all, the primary patency rates, primary assisted pateney rates and second patency rates were 79.2%, 83.3% and 95.8% respectively. The primary patency rate for intermittent clandication was significantly higher than that for critical limb ischemia （ P 〈 0. 05 ）. Primary patency rates were lower in patients who underwent open surgery with both proximal and distal endoluminal procedures when compared with endovascular reconstruction proximal or distal to the site of open reconstruction （ P 〈 0. 05 ）. The presence of diabetes and dyslipidaemia were independent predictors of decreased primary patency rate （P = 0. 013 and P = 0. 008, respectively）. Conclusions Hybrid procedures provide an effective treatment management of selected patients with multilevel lower extremity arterial disease.