■本文旨在比较斑块切除术加球囊血管成形术(BA)与单用BA治疗膝下动脉疾病的有效性和安全性。
■根据纳入和排除标准,PubMed,Embase,我们在CochraneLibrary数据库中搜索了在2022年11月之前比较斑块切除术加血管成形术和仅血管成形术治疗膝下动脉病变的研究.终点包括技术成功,初级通畅,临床驱动的靶病变血运重建(CD-TLR),围手术期并发症,远端栓塞,目标截肢,和全因死亡率。
■十项研究符合我们荟萃分析的要求,包括斑块切除加BA组的7723例患者和单独BA组的2299例患者。荟萃分析显示,在12个月的随访中,斑块切除术加BA与CD-TLR降低(比值比[OR]:0.51,95%置信区间[CI]:0.34,0.78,p=0.002)和目标肢体大截肢(OR:0.43,95%CI:0.19,1.01,p=0.05)相关。在技术成功方面没有发现统计学上的显著差异,初级通畅,围手术期并发症,远端栓塞,或全因死亡率。亚组分析发现,6个月和12个月的原发性通畅率较高(6个月:OR:2.26,95%CI:1.11,4.60,p=0.02;12个月:OR:2.38,95%CI:1.16,4.86,p=0.02),12个月时CD-TLR(OR:0.45,95%CI:0.25,0.82,p=0.009)和目标截肢(OR:0.43,95%CI:0.19,1.01,p=0.05)的发生率较低。
■这项荟萃分析表明,与单独的BA相比,动脉粥样硬化切除术加BA可以减少CD-TLR的需要和在12个月的随访中治疗膝下动脉闭塞性病变的目标肢体大截肢的发生率,即使技术成功没有显著优势,初级通畅,围手术期并发症,远端栓塞,或全因死亡率。为了更进一步,动脉粥样硬化切除术加DCB显示主要通畅的显著好处,CD-TLR,和目标肢体大截肢率,但粥样斑块切除术加POBA没有。然而,由于本文的局限性,需要更多的随机对照试验(RCT)来证实这些结论.
结论:根据我们的研究,动脉粥样硬化切除术结合BA具有较高的主要通畅率的优势,降低CD-TLR和目标肢体显著截肢率治疗膝下动脉闭塞性病变,这可能会取代目前主流的手术方法---BA。对于临床医生来说,虽然手术可能需要更长的时间,它将显著改善患者的预后和生活质量,对膝下动脉疾病患者的治疗具有重要意义。根据膝下动脉疾病的特点,本研究探讨了斑块切除联合BA治疗膝下动脉病变的可行性。此外,我们发现斑块切除联合DCB有较好的临床疗效,这应该是本研究的创新之处。
UNASSIGNED: The article aimed to compare the efficiency and safety of atherectomy plus balloon angioplasty (BA) with BA alone for the treatment of infrapopliteal arterial disease.
UNASSIGNED: According to the inclusion and exclusion criteria, PubMed, Embase, and Cochrane Library database were searched for studies comparing atherectomy plus angioplasty and angioplasty alone in treating infrapopliteal artery lesions until November 2022. The endpoints included technical success, primary patency, clinically-driven target lesion revascularization (CD-TLR), periprocedural complications, distal embolization, target limb major amputation, and all-cause mortality.
UNASSIGNED: Ten studies met the requirements of our meta-analysis, including 7723 patients in the atherectomy plus BA group and 2299 patients in the BA alone group. The meta-analysis showed that atherectomy plus BA was associated with reduced CD-TLR (odds ratio [OR]: 0.51, 95% confidence interval [CI]: 0.34, 0.78, p=0.002) and target limb major amputation (OR: 0.43, 95% CI: 0.19, 1.01, p=0.05) at 12-month follow-up. No statistically significant difference was found in technical success, primary patency, periprocedural complications, distal embolization, or all-cause mortality. Subgroup analysis found a higher rate of primary patency at 6 and 12 months (6 months: OR: 2.26, 95% CI: 1.11, 4.60, p=0.02; 12 months: OR: 2.38, 95% CI: 1.16, 4.86, p=0.02), and lower rates of CD-TLR (OR: 0.45, 95% CI: 0.25, 0.82, p=0.009) and target limb major amputation (OR: 0.43, 95% CI: 0.19, 1.01, p=0.05) at 12 months in patients treated with atherectomy plus drug-coated balloon (DCB) but not in patients treated with atherectomy plus plain old balloon angioplasty (POBA).
UNASSIGNED: This meta-analysis suggests that compared with BA alone, atherectomy plus BA may reduce the need for CD-TLR and the incidence of target limb major amputation at 12-month follow-up in the treatment of infrapopliteal artery occlusive lesions, even though there are no significant advantages in technical success, primary patency, periprocedural complications, distal embolization, or all-cause mortality. To go further, atherectomy plus DCB shows significant benefits in primary patency, CD-TLR, and target limb major amputation rate but atherectomy plus POBA does not\'. However, due to the limitations of this article, more randomized controlled trials (RCTs) are needed to confirm these conclusions.
CONCLUSIONS: According to our research, atherectomy combined with BA has the advantages of higher primary patency rate, lower CD-TLR and target limb significant amputation rate in treating infrapopliteal artery occlusive lesions, which may replace the current mainstream surgical method ---BA alone. For the clinician, although the surgery may take longer, it will significantly improve the prognosis and quality of life of patients and hold considerable significance for the management of patients with infrapopliteal arterial disease. Based on the characteristics of infrapopliteal artery disease, this study explored the feasibility of atherectomy combined with BA for infrapopliteal artery disease. Moreover, we found that atherectomy combined with DCB had better clinical efficacy, which should be the innovation of this study.