经皮肺动脉瓣球囊成形术治疗肺动脉瓣狭窄16例体会

目的　评价经皮肺动脉瓣球囊成形术对肺动脉瓣狭窄的治疗效果。临床资料　我院自1998年9月～2 0 0 4年7月共完成16例肺动脉瓣狭窄球囊扩张,女8例,男8例,年龄2～5 8岁,单纯PS9例,合并房缺1例,术前经病史、体格检查、超声心动图等检查确诊。其中术前经多普勒超声估测跨瓣压差。方法　经皮Seldinger穿刺右股静脉成功后,常规行右心导管检查,测跨瓣压差。用6F猪尾巴导管行右室造影:测量肺动脉瓣环直径来选择球囊大小。前7例用J型钢丝经右心导管送至左上或下肺动脉远端,后9例用左房钢丝盘在扩张的肺动脉内。用扩张管扩张皮下及股静脉,前14例用Inoue左房室瓣球囊,后2例用自制肺动脉瓣球囊,参照造影影像定位,将球囊前囊打起,后撤至肺动脉瓣口上,将后囊打起,腰部消失反复扩张2～3次,听诊杂音,撤出左房钢丝,用球囊连续测压,测术后跨瓣压,再次右室造影(取左侧位)。结果　16例患者手术均获成功,术前跨瓣压差2 5～110mmHg,术后跨瓣压12～4 2mmHg ,术前多普勒超声估测跨瓣压差2 4～112mmHg,术后估测跨瓣压差15～4 0mmHg ,其中以重度狭窄者扩张效果最好,有1例术后跨瓣压差为0。但重度狭窄...     

超声心动图在肺动脉分支狭窄支架植入术中的应用

目的:评价超声心动图在肺血管分支狭窄支架植入术中的应用价值。方法:回顾性分析13例肺血管分支狭窄支架植入患者术前、术中及术后随访的的超声心动图诊断资料。结果:13例患者术前超声诊断均正确,术前超声测量狭窄段血管内径为(0.49±0.19)cm,心血管造影测量狭窄段内径为(0.54±0.25)cm,二者间高度相关(P<0.01,r=0.94);术前超声估测跨狭窄段压差为(62.25±26.41)mmHg,心导管所测压差为(45.73±32.03)mmHg,二者间高度相关(P<0.05,r=0.88)。13例患者共植入16根血管支架,术后即刻超声估测压差为(22.44±14.49)mmHg,较术前明显下降(P<0.01)。术后1个月随访,14根支架效果良好,2根支架发生异位,滑脱入右心室。结论:超声心动图在肺动脉分支狭窄的术前诊断、支架植入术中监测、术后即刻效果判断及随访中起重要作用,是一种有效的监测手段。     

经皮球囊肺动脉瓣成形术的临床应用

目的:观察经皮球囊成形术治疗肺动脉瓣狭窄的疗效和安全性。方法:男性4例,女性2例,年龄8～19岁,平均11.7岁,均行经皮肺动脉瓣球囊成形术治疗。结果:肺动脉至右心室平均收缩压差由术前9.1kPa降至术后3.6kPa。结论:经皮肺动脉瓣球囊成形术是治疗肺动脉瓣狭窄的首选方法。     

肺动脉狭窄的介入治疗

对肺动脉狭窄的治疗一直是临床上比较棘手的问题 ,外科手术效果不理想 ,且手术本身可引起受治动脉的进一步扭曲。 2 0世纪 80年代 ,球囊扩张术和支架置入术相继用于肺动脉狭窄的治疗 ,并取得了良好的临床效果。笔者对肺动脉狭窄的病因、血管成形术的机制、疗效、并发症等进行综述。一、肺动脉狭窄的病因可分为先天性、获得性和外科术后 ,大多数先天性肺动脉狭窄是先天性心脏病 (简称先心病 )伴肺循环发育不良的结果 ,如Ｆａｌｌｏｔ四联症、肺动脉闭锁、三尖瓣闭锁伴肺动脉狭窄或闭锁等。另一种先天性狭窄 ,尤其在左肺动脉 ,是由于动脉导管…     

球囊扩张成形术在小儿食管狭窄中的应用

目的 总结球囊扩张成形术在小儿食管狭窄治疗中的应用,评价其安全性、有效性和影响疗效的因素.方法 回顾性分析30例小儿食管狭窄行球囊扩张成形术的临床资料,其中先天性食管闭锁术后吻合口狭窄20例,先天性食管下段狭窄5例,误服强碱食管腐蚀伤后狭窄5例.按扩张次数将患儿分为3组,A组18例,行1次球囊扩张,均为先天性食管闭锁术后吻合口狭窄患儿;B组7例,行2～3次球囊扩张,主要为先天性食管狭窄和先天性食管闭锁术后吻合口狭窄患儿;C组5例,行4～6次球囊扩张,为食管化学性烧灼伤患儿.扩张前行上消化道造影检查,明确病灶部位及狭窄程度,分别使用不同规格球囊进行扩张;扩张后复查造影进行对照分析了解扩张效果,分析各组间病因、食管狭窄长度和狭窄食管直径对扩张效果的影响.结果 30例患儿共接受62次扩张,平均每例扩张2.1次(1～6次).27例患儿扩张后呕吐症状明显改善,体重明显增加;3例化学性烧灼伤患儿疗效不佳,转而进行手术治疗,全部患儿未发生穿孔、呕血或黑便等并发症.A、B、C3组患儿食管扩张前狭窄段平均直径分别为:4.0 mm(3.0 ～ 5.0),4.3 mm(2.5 ～ 6.0)和4.4 mm(4.0～5.0),平均狭窄段长度分别为(1.18±0.59)cm,(1.53±0.49)cm和(7.50±2.89)cm.3组扩张成功率分别为18/18、7/7和2/5.C组患儿食管狭窄段长度显著大于其他两组,P＜ 0.05.C组患儿扩张有效率显著低于A、B组(P＜ 0.01).结论 球囊扩张成形术治疗小儿食管狭窄操作简便,安全有效,可以有效地解除患儿的食管狭窄症状,是治疗小儿食管狭窄的首选方法.食管闭锁术后吻合口狭窄和先天性食管狭窄患儿扩张有效率高;化学性烧灼伤患儿需要反复多次扩张和再手术.     

67例二尖瓣球囊成形术临床分析

经皮二尖瓣球囊成形术治疗二尖瓣狭窄67例,63例成功(94%),术后左房平均压由24+8mmHg 降至15+7mmHg(P<0.001);跨瓣压差由21±9mmhg 降至10±8mmhg(P<0.001);左房内径由49±7mmhg 降至43±7mmhg(P<0.001)二尖瓣口面积由1.1cm±0.2cm 增至2.1cm±0.3cm(P<0.001);心输出量由5.7±1.4升/分增至6.3±1.6升/分(P<0.001)。MR 系影响 PTMV 术的效果的重要因素,术中产生 MR 主要决定二尖瓣病理形态结构,与采用球囊类型无关。术后近期及远期疗效稳定。国产球囊可与进口球囊相媲美。     

先天性食管闭锁手术后吻合口狭窄的介入治疗

目的 报道13例先天性食管闭锁术后食管吻合口狭窄婴儿使用球囊扩张术治疗。方法 13例患儿均为食管闭锁术后吻合口狭窄,年龄为3～10个月,球囊扩张前均先行食管吞钡检查,显示狭窄段内径仅1～3mm。采用球囊导管分次扩张。所用球囊直径6～12mm。结果 每例经2～3次扩张,13例共进行球囊扩张30次,扩张后疗效明显,保持临床无症状期6～30个月,无食管穿孔并发症。结论 球囊扩张术简单、安全、有效,为婴儿先天性食管闭锁手术后吻合口狭窄的首选疗法。     

常见先天性心脏病介入治疗中国专家共识四、经皮球囊肺动脉瓣与主动脉瓣成形术

经皮球囊肺动脉瓣成形术已成为肺动脉瓣狭窄的首选治疗方法,先天性主动脉瓣狭窄亦可通过球囊扩张方法得到缓解.典型肺动脉瓣狭窄跨瓣压差≥ 40 mmHg,主动脉瓣狭窄跨瓣压差≥ 60 mmHg是球囊成形术的适应证.球囊成形术成功的关键在于谨慎选择合适的患者,熟练地掌握操作方法,严格挑选球囊的类型、大小和长度,避免损伤腱索和瓣...     

介入治疗移植肾动脉狭窄

目的探讨移植肾动脉狭窄(TRAS)的介入治疗。方法21例TRAS患者从肾移植到出现肾动脉狭窄症状平均6．6个月(3～15个月)，记录经皮血管成形术(PTA)前后血压变化和肌酐水平。经对侧股动脉或左肱动脉入路，使用普通球囊导管(5F，直径4～6mm，长度20～30mm)和微球囊导管(2．6F，直径3mm，长度36mm)分别对21例TRAS行PTA术，其中5例放置支架。结果21例TRAS患者共行32次PTA(行1次PTA13例，2次5例，3次3例)，其中22次经对侧股动脉，10次经左肱动脉穿刺插管。PTA治疗前肾动脉狭窄率为79％～97％，PTA后狭窄率降为10％～30％。PTA前收缩压150～210mmHg(1mmHg=0．133kPa)，平均170mmHg，舒张压90～145mmHg，平均120mmHg；PTA后收缩压降为100～190mmHg，平均135mmHg，舒张压降为80～125mmHg，平均85mmHg。首次PTA后再狭窄率38％，再次PTA后狭窄率14％。32次PTA共使用普通球囊导管25个，微球囊导管7个。5个支架4个为自膨式支架，1个为球囊扩张式。术后随访3～60个月(平均23个月)。21例中最终治愈6例，改善8例，好转5例，无效2例。除1例肱动脉入路发生术后穿刺点血肿外无其他并发症。结论TRAS的PTA治疗安全有效，配合肱动脉入路和微球囊导管有助于提高手术成功率；合理选用支架能降低再狭窄率。     

再次球囊扩张术治疗风湿性左房室瓣狭窄的疗效评价

目的　评价左房室瓣球囊扩张术(PBMV)后再狭窄的病例再次作球囊扩张术的临床效果。方法　5 0 1例接受球囊扩张术的患者,分为首次球囊扩张组(45 3例)及再次球囊扩张组(48例) ,球囊扩张前后用超声及导管测左房室瓣口面积(MVA)、左房前后径(LAD)、左房压(LAP) ,比较两组患者这些参数在PBMV前后的变化情况。结果　首次球囊扩张组与再次球囊扩张组PBMV后MVA分别由术前的(0 .86±0 .2 5 )、(1.0 9±0 .2 6 )cm2 增加至(1.87±0 .2 7)、(1.86±0 .30 )cm2 ;LAD分别由(46 .0 9±7.5 7)、(49.74±9.88)mm减少至(41.6 4±7.97)、(45 .4 1±8.4 4 )mm ;LAP分别由(2 9.2 6±6 .6 4 )、(30 .5 2±5 .2 8)mmHg下降至(16 .14±5 .13)、(2 2 .35±7.83)mmHg(P均<0 .0 0 1) ;再次球囊扩张组较首次球囊扩张组术后MVA增加的幅度(术前术后的差值)小(0 .72±0 .2 2vs 0 .99±0 .2 7,P <0 .0 0 1) ;左房压下降的幅度则较低(8.33±4 .17vs 13.0 7±5 .77,P <0 .0 0 1) ;两组各种并发症及总的并发症均未见统计学差异。结论　球囊扩张术后再狭窄的患者,再次作球囊扩张术仍然是安全有效的,但效果不如首次扩张组     

Caring for the major trauma victim: the role for radiology

Two innovations have improved the care of the major trauma victim in the past 20 years. Both depend on active radiologist participation. The first has been the progressive nationwide development of the Emergency Medical Service System, which identifies trauma centers by a process of categorization, regionalization, and verification. The hospital must be staffed and equipped to perform computed tomography, angiography, and sonography. Trauma centers effectively reduce morbidity and mortality of the accident patient. The second innovation has been the intensive use of computed tomography (CT) for immediate patient evaluation. CT surpasses other imaging methods in examination for craniocerebral, abdominal, spinal, pelvic, and facial trauma. In craniocerebral trauma, the precise diagnosis afforded by CT reduces the fatality rate by permitting early surgical intervention. In abdominal trauma, CT examination supports nonoperative management of hemodynamically stable patients with solid organ injury. In spinal, pelvic, and facial injuries, CT provides diagnostic information not available with conventional radiography.     

Alternative models for estimating the radiotherapy retreatment dose for the spinal cord

Abstract

Purpose: To review the available experimental animal and patient data on response of the spinal cord to re-irradiation in order to identify appropriate data sets to investigate the clinical potential of models that would allow evaluation of the increase in the retreatment dose with elapsed time from the initial exposure.

Materials/methods: Analysis of published data on irradiated rat and primate spinal cord identified results for the rat cervical spinal cord that could be compared, where the development of myelopathy was caused by selective white matter necrosis. This data, although limited, provide some important insights. Two models, derived from simple differential equations, provide a time- and dose-dependency for recovery and could be fitted to these data. These models predict the remaining tolerance, in a phase space above the line that connects the 100% biological effectiveness (BED_TOL) tolerance dose of the first and second treatment courses when these are plotted together. A third, much simpler, linear model, assumed that recovery was time but not initial dose dependent.

Results: The experimental results showed a non-linear time dependency for the change in biological effectiveness (BED) of the re-irradiation dose. Comparison of the three different models paid particular attention to changes in the re-irradiation dose, when the initial radiation dose was either low or high. For each model, cautious data interpretations were also introduced to reduce the effects of the near completeness of recovery with time derived from the important experiments with primates, which include few data points. Model 1 predicts the least recovery following low initial doses, but with greater recovery following larger initial doses. Model 2 allowed no further irradiation after an initial full tolerance dose, but also greater than expected recovery following the use of smaller priming doses. Model 3 gives unrealistically high doses when used after an initial full tolerance irradiation dose.

Conclusions: These results show that it is possible to model these time-dependent relationships for the spinal cord and that Model 1 is probably the most realistic, especially when it is used conservatively. To give greater confidence as to which of the three presented methods is best, further experiments and/or more analysis of human data are necessary. In the meantime clinicians will need to exert caution and judgement as to the choice of the re-irradiation BED, bearing in mind the other clinical factors that influence radio-tolerance. Further research is necessary to provide the safest recommendations and best clinical outcomes. Some suggestions as to what needs to be done are given.     

Caring for the dancer: special considerations for the performer and troupe

The needs of a dancer patient can be daunting to the uninitiated physician. A dancer's technique, environment, and mentality are unique among athletes. Compared with popular team sports, like football or basketball, physicians are often unfamiliar with dancers' injuries and requirements to facilitate a safe, timely return to dance. The goal of this article is to help foster better communication between dancers and the medical community by describing dance epidemiology, dance basics including technique and characteristics, and some specific dance injuries.     

Planning for the Mercy Center for Breast Health

During the last months of 2000, administrators at the Mercy San Juan Medical Center in Carmichael, Calif., convened a steering committee to plan the Mercy Center for Breast Health. The Steering Committee was composed of the director of ancillary and support services, the oncology clinical nurse specialist, the RN manager of the oncology nursing unit, the RN surgery center manager, and me, the manager of imaging services. The committee was responsible for creating a new business with five specific objectives: to position the Center as a comprehensive diagnostic and resource center for women; to generate physician referrals to the Breast Center through various vehicles; to create awareness of the Breast Center's capabilities among area radiologists; to create awareness of the Breast Center among employees of six sister facilities; to create "brand awareness" for the Mercy Center for Breast Health among referring physicians and patients who could use competing centers in the area. The Steering Committee's charter was to design a center with a feminine touch and ambience and to provide a "one-stop shopping" experience for patients. A major component of the Breast Center is the Dianne Haselwood Resource Center, which provides patients with educational support and information. The Steering Committee brought its diverse experience and interests to bear on arranging for equipment acquisition, information and clerical systems, staffing, clinic office design, patient care and marketing. Planning the Mercy Center for Breast Health has been a positive challenge that brought together many elements of the organization and people from different departments and specialties to create a new business venture. Our charge now is to grow and to live up to our vision of offering complete breast diagnostic, education and support services in one location.