足动脉血管成形术治疗下肢动脉硬化闭塞症合并足部缺血性溃疡的效果及溃疡愈合影响因素的分析

Analysis of the therapeutic effect on foot arterial angioplasty in the treatment of lower limb arteriosclerosis obliterans complicated with ischemic ulcer and influencing factors of ulcer healing

目的探讨足动脉血管成形术(PAA)治疗下肢动脉硬化闭塞症合并足部缺血性溃疡患者的近期疗效,并分析影响溃疡愈合的因素。方法回顾性队列研究。纳入2018年1月—2022年3月蚌埠医学院第一附属医院收治的下肢动脉硬化闭塞症合并有足部缺血性溃疡的患者43例(43肢),均行常规膝下腔内治疗,打通膝下病变血管。依据是否行PAA治疗分组:PAA组20例(20肢),男12例、女8例,年龄59~77(68.4±3.8)岁;未行PAA治疗的常规组23例(23肢),男14例、女9例,年龄58~80(67.3±8.3)岁。观察项目:(1)通过术后6个月随访,比较2组患者的踝肱指数(ABI)、疼痛视觉模拟评分法(VAS)评分、溃疡愈合情况、一期通畅率、再狭窄率、截肢率及生存情况;(2)按患者术后6个月溃疡愈合和溃疡未愈合进行分组,采用单因素及多因素二元logistic回归分析影响患者溃疡愈合的独立危险因素。结果PAA组18例患者手术成功,常规组22例手术成功,纳入统计学分析。2组患者性别、年龄、既往史、创面感染、足弓类型、膝下受累血管等基线资料差异均无统计学意义(P值均>0.05)。(1)2组患者术前ABI及疼痛VAS评分差异均无统计学意义(P值均>0.05),术后6个月均较术前有明显改善,PAA组ABI明显高于常规组(0.66±0.08与0.57±0.07)、疼痛VAS评分低于常规组[2(1.00,2.00)分与2(1.75,3.00)分],差异均有统计学意义(t=3.92、Z=-2.02,P值均<0.05);2组患者均未出现溃疡复发、大截肢、严重并发症及死亡。术后6个月,PAA组的溃疡愈合率、免于小截肢率分别为15/18和18/18,明显高于常规组的45.5%(10/22)和72.7%(16/22),差异均有统计学意义(P值均<0.05);2组患者膝下动脉的一期通畅率、再狭窄率、通畅血管类型比较,差异均无统计学意义(P值均>0.05)。(2)单因素分析及多因素二元logistic回归分析显示,创面感染[比值比(OR)=15.196、95%可信区间(CI)1.331~173.178]、PAA治疗(OR=0.079、95%CI 0.103~0.613)、糖化血红蛋白>7%(OR=12.553、95%CI 1.734~90.885)均为影响溃疡愈合的独立危险因素(P值均<0.05)。结论PAA对于下肢动脉硬化闭塞症合并缺血性溃疡的治疗安全有效,是溃疡愈合的保护因素,较常规腔内治疗有明显优势,术后随访6个月达到较高的溃疡愈合率和免于小截肢率,具有临床推广价值。

Objective This study aimed to explore the short-term efficacy of pedal artery angioplasty(PAA)in the treatment of lower extremity arteriosclerosis obliterans complicated with foot ischemic ulcer and its effect on ulcer healing.Methods The retrospective cohort study was conducted.Forty-three patients(43 limbs)with arteriosclerosis obliterans of lower extremities complicated with foot ischemic ulcer who were admitted in the First Affiliated Hospital of Bengbu Medical College from January 2018 to March 2022 were treated with routine subknee intracavitary treatment to open the diseased vessels under the knee.Whether they were treated with PAA or not,the patients were divided into two groups.A total of 20 limbs were included in the PAA group with 12 males and 8 females,aged 59 to 77 years old,and 23 limbs were included in the conventional group with 14 males and 9 females,aged 58 to 80 years old.The observation indicators were as follows:(1)the ankle-brachial index(ABI),pain visual analogue scale(VAS)score,ulcer healing,primary patency rate,restenosis rate,amputation rate,and survival were compared between the two groups after 6-month follow-up.(2)The patients were divided into two groups in accordance with ulcer healing and non-healing six months after operation.Univariate and multivariate logistic regression analyses were used to analyze the independent risk factors of ulcer healing.Results The operation was successful in 18 cases in PAA group and 22 cases in the conventional group.No significant difference in gender,age,past history,wound infection,type of foot arch,and vessels involved below the knee was observed between the two groups(all P values>0.05).(1)In addition,no significant difference in ABI and VAS scores was found between the two groups before operation(all P values>0.05).Six months after the operation,the ABI score in PAA group was significantly higher than that in the conventional group(0.66±0.08 vs 0.57±0.07),whereas the VAS score in PAA group was lower than that in the conventional group(2[1.00,2.00]vs 2[1.75,3.00]).The differences were statistically significant(t=3.92,Z=-2.02;all P values<0.05)No ulcer recurrence,major amputation,serious complications,and death were observed in both groups.Six months after the operation,the ulcer healing rate and exemption from the small amputation rate in PAA group were 15/18 and 18/18,respectively,which were significantly higher than those in the conventional group(45.5%[10/22]and 72.7%[16/22]).The differences were statistically significant(all P values<0.05).No significant difference in the primary patency rate,restenosis rate,and patency type of inferior knee artery was found between the two groups(all P values>0.05).(2)Univariate analysis and multivariate logistic regression analysis showed that wound infection(odds ratio[OR]=15.196,95%confidence interval[CI]1.331-173.178),PAA treatment(OR=0.079,95%CI 0.103-0.613),and HbA1c>7%(OR=12.553,95%CI 1.734-90.885)were independent risk factors affecting ulcer healing(all P values<0.05).Conclusion PAA is safe and effective for the healing of lower limb arteriosclerosis obliterans complicated with ischemic ulcer,and it has evident advantages over conventional intracavitary therapy.Six months after operation,the ulcer healing rate reaches a higher level and higher rate of avoiding small amputation,which is of clinical significance.