目的:在慢性威胁肢体缺血(CLTI)的治疗中,伤口完全愈合是一个重要的目标。虽然足部灌注状态似乎对伤口愈合很重要,《全球血管指南》(GVG)的全球肢体解剖分期系统(GLASS)由于缺乏足够的证据证明其重要性,因此在分期过程中未纳入足动脉状态.本研究旨在阐明搭桥手术后踏板灌注状态的重要性。
方法:在2014年至2018年的153例CLTI患者中,有117例CLTI四肢有伤口并有足够的踏板血管造影数据。他们分为两组,根据术后6个月的伤口状态;早期伤口愈合组(EWG,N=78),术后6个月内伤口完全愈合,和长时间愈合或未愈合的伤口组(PWG,N=39),在6个月内未能实现伤口愈合。与伤口愈合相关的各种因素,包括伤口,缺血,和足部感染(WIfI)分类,术中移植流,和踏板血管造影数据,进行了分析。关于踏板血管造影数据,除了GLASS踝下/踏板疾病描述符(IPD),新形成的与伤口位置相关的踏板循环状态分类系统包括:踏板循环状态分为两组,分别为伤口的可视化动脉灌注(可视化灌注)和伤口的非可视化动脉灌注(非可视化灌注).
结果:单因素分析显示术前白蛋白(比值比[OR],0.47;95%置信区间[CI],0.24-0.94;P=.027),较高的WIfI临床分期(OR,3.88;95CI,1.74-10.1;P=.0005),更高的IPD(或,2.16;95CI,1.16-4.02;P=.012),和伤口的非可视化灌注(OR,5.74:95CI,2.45-14.0;P<0.0001)对于延长的伤口愈合具有重要意义。多因素分析显示WIfI分期较高(OR,5.04;95CI,1.74-14.6;P=.0029)和伤口的非可视化灌注(OR,4.34;95CI,1.71-11.0;P=.0021)为显著,而IPD没有被检测为显著的。关于脚的血液供应,尽管IPD-P2的移植物流量明显低于IPD-P0/P1,但无论伤口的血管造影循环状态如何,移植物流量都相似。这表明伤口的血液供应分布比伤口愈合的足部血液供应总量更重要。
结论:WIfI临床分期和踏板循环环境是影响搭桥手术后伤口愈合的重要因素。包括灌注状态的踏板解剖分类系统对于CLTI治疗中的决策将是重要的。
OBJECTIVE: In the treatment of chronic limb-threatening ischemia (CLTI), complete wound healing is an important goal. Although foot perfusion status seems to be important for wound healing, the global limb anatomic staging system (GLASS) of the Global Vascular Guidelines (GVG) does not include pedal artery status for the staging process due to the lack of sufficient evidence of its importance. This study aimed to clarify the importance of pedal perfusion status after bypass surgery.
METHODS: Among the 153 CLTI cases that underwent bypass distal to popliteal arteries from 2014 to 2018, 117 CLTI limbs with wounds and with sufficient pedal angiographic data were enrolled. They were classified into two groups, based on the wound status 6 months postoperatively; early wound healing group (EWG, N=78), which achieved complete wound healing within 6 months postoperatively, and prolonged healing or unhealed wounds group (PWG, N=39), which failed to achieve wound healing within 6 months. Various factors associated with wound healing, including the wound, ischemia, and foot infection (WIfI) classification, intraoperative graft flow, and pedal angiographic data, were analyzed. Regarding pedal angiographic data, in addition to the GLASS inframalleolar/pedal disease descriptor (IPD), newly formed classification system of the pedal circulation status in association with the location of wounds was included: pedal circulation status was classified into two groups as visualized arterial perfusion towards wounds (visualized perfusion) and non-visualized arterial perfusion towards wounds (non-visualized perfusion).
RESULTS: Univariate analysis showed preoperative albumin (Odds ratio [OR], 0.47; 95% confidence interval [CI], 0.24-0.94; P=.027), higher WIfI clinical stage (OR, 3.88; 95%CI, 1.74-10.1; P=.0005), higher IPD (OR, 2.16; 95%CI, 1.16-4.02; P=.012), and non-visualized perfusion to wounds (OR, 5.74: 95%CI, 2.45-14.0; P < .0001) as significant for prolonged wound healing. Multivariate analysis showed higher WIfI stage (OR, 5.04; 95%CI, 1.74-14.6; P=.0029) and non-visualized perfusion to wounds (OR, 4.34; 95%CI, 1.71-11.0; P=.0021) as significant, while IPD was not detected as significant. Regarding blood supply to the foot, although graft flow was significantly lower in IPD-P2 than IPD-P0/P1, graft flow was similar regardless of the status of angiographic circulation to wounds, suggesting that distribution of blood supply to the wound would be more important than total amount of blood supply to the foot for wound healing.
CONCLUSIONS: WIfI clinical stage and pedal circulatory environment were important factors for wound healing after bypass surgery. Pedal anatomical classification system including perfusion status would be important for decision making in CLTI treatment.