微创技术结合外科手术治疗重症下肢缺血

目的 探讨术中血管微创治疗技术结合外科手术治疗重症下肢缺血的初步临床经验。方法 1999年7月至2000年10月,采用术中同时行髂动脉腔内微创治疗技术(球囊扩张和支架植入)结合肢体远端动脉重建术治疗广泛多节段动脉硬化闭塞症15例(20条肢体)。结果 术中17条髂动脉微创介入治疗均获成功,11条肢体同时行股-腘动脉人工血管旁路术,3条肢体行股-股-腘动脉人工血管旁路系列转流术,5条肢体行股深动脉成形术。其中有1条肢体股-腘动脉旁路术失败。本组患者无重要脏器并发症和手术死亡。平均随访时间8个月(1-16个月),髂动脉腔内支架通畅率100％,3条股-股动脉耻骨上人工血管转流均通畅,而股-腘动脉人工血管通畅率78．6％,截肢率10．0％。结论 术中髂动脉腔内微创介入治疗技术同时结合远端动脉重建术是治疗广泛多节段动脉硬化闭塞症的害全右特肯沸．     

多节段动脉硬化闭塞症的外科治疗

目的　探讨下肢多节段动脉硬化闭塞症外科治疗的临床经验。　方法　术中行髂动脉腔内微创技术 (球囊扩张和支架植入 ) ,并同时行肢体远端动脉重建术治疗广泛多节段动脉硬化闭塞症 47例 ( 5 8条肢体 )。　结果　术中 5 3条髂动脉球囊扩张和支架植入均获成功 ,微创治疗技术成功率 10 0 % ;同时行远端动脉重建 5 8条肢体 ,其中包括 :股 -动脉人工血管旁路术 40条肢体 ;深动脉内膜剥脱或补片扩大成形术 18条肢体。股 -动脉人工血管旁路术后踝肱指数平均 0 .77± 0 .13 ( 0 .5～ 1.2 ) ,与术前相比有显著性差异 (P <0 .0 1)。股深动脉扩大成形术后踝肱指数 0 .41± 0 .15 ( 0 .2～ 0 .5 6) ,与术前相比有提高 (P <0 .0 5 )。死亡 1例 (占 2 .1% ) ,其余无严重并发症。平均随访 2 1( 3～ 42 )个月 ,髂动脉支架一期通畅率为 98.1% ( 5 1 5 2 ) ,二期通畅率为 10 0 % ( 5 2 5 2 ) ,股 -动脉人工血管一期通畅率为 87.2 % ( 3 4 3 9) ,二期通畅率为 94.9% ( 3 7 3 9)。截肢率 3 .4% ( 2 5 8)。　结论　术中髂动脉腔内微创介入治疗结合远端动脉重建术是治疗严重多节段动脉硬化闭塞症安全、有效方法     

下肢多节段动脉硬化闭塞症的联合治疗

目的探讨下肢多节段动脉硬化闭塞症治疗方法及临床疗效。方法2004年3月至2005年11月,采用髂动脉球囊扩张和支架植入结合动脉旁路术、股深动脉成形术或自体骨髓干细胞移植术治疗下肢多节段动脉硬化闭塞症17例(19条肢体),术前踝肱指数(ABI)为(0.26±0.13),术前常规行血管彩超及CTA检查评价下肢动脉病变情况。结果髂动脉球囊扩张和支架植入19条,股深动脉成形11条,股-动脉人工血管转流术12条,自体骨髓干细胞移植3条,均获得成功。均未出现严重并发症。术后ABI(0.64±0.17)(P<0.05,t检验),随访期间,4例残余间歇性跛行,3例术后3个月行干细胞移植术后症状明显好转。结论多方法联合是治疗多节段多平面下肢动脉硬化闭塞症的有效方法;股深动脉的病变范围与手术治疗效果密切相关;术前正确评价股深动脉的通畅程度十分重要。     

骼动脉支架结合股深动脉成形术治疗高危重症下肢缺血的临床研究

目的探讨术中髂动脉支架植入结合股深动脉成形术治疗高危重症下肢缺血的初步临床经验.方法1999年7月至2001年5月,采用术中髂动脉球囊扩张和支架植入结合股深动脉成形术治疗高危重症多节段动脉硬化闭塞症9例(13条肢体),其中男性7例,女性2例,平均年龄76岁,均以静息痛为主诉.术前踝肱指数为0.22±0.17.结果髂动脉球囊扩张和支架植入10条,股深动脉成形11条,股-股动脉人工血管转流术3条,均获得成功.无重要脏器并发症和手术死亡.术后踝肱指数0.41±0.15,与术前相比有提高(P＜0.05).平均随访11个月(1-23个月),患者症状较术前明显改善,均无静息痛,仅3例残余有轻度间歇性跛行.结论髂动脉球囊扩张和支架植入结合股深动脉成形术是治疗高危重症多节段动脉硬化闭塞症的安全、有效方法     

股深动脉成形联合髂动脉支架治疗高危重症下肢缺血18例

目的：探讨股深动脉成形联合髂动脉支架植入治疗高危、重症下肢动脉闭塞缺血的效果。方法：对18例（26条肢体）重症、高危下肢动脉广泛闭塞患者采用术中髂动脉球囊扩张和支架植入联合股深动脉成形术治疗。通过观察患肢间歇性跛行距离,踝肱指数等指标改善情况进行评估。结果：髂动脉球囊扩张和支架植入20条肢体、股深动脉成形22条肢体、股-股动脉人工血管转流6条肢体均获得成功,平均随访（16±8.5）个月（3～26个月）,踝肱指数明显提高,静息痛均消失。结论：股深动脉成形联合髂动脉支架植入是治疗高危、重症下肢动脉硬化闭塞症的安全、有效方法。     

血管腔内介入联合外科手术治疗下肢多节段动脉硬化闭塞症

目的: 探讨下肢多节段动脉硬化闭塞症的治疗手段及临床疗效。方法:2004年3月—2006年1月，采用髂动脉球囊扩张和支架植入结合动脉旁路术、股深动脉成形术治疗下肢多节段动脉硬化闭塞症21例(24条患肢)。24条患肢行髂动脉球囊扩张和支架植入术，其中12条患肢加行股深动脉成形术，14条患肢加行股-腘动脉人工血管转流术。结果:手术均获得成功，未出现严重并发症。术后踝肱指数0.63 ±0.18与术前0.24±0.13相比有明显提高（P<0.05）。平均随访13个月(1~23个月)。与术前相比患者症状明显改善，仅4例残余有间歇性跛行（跛行距离300~500m），其中3例术后3个月行干细胞移植术后症状明显好转，跛行距离加大（>1 000m）。结论:髂动脉腔内介入结合动脉旁路术、股深动脉成形术是治疗多节段多平面下肢动脉硬化闭塞症的有效方法。手术创伤小，操作方便。手术方式灵活，尤适用于高危重症患者。     

血管腔内介入联合外科手术治疗下肢多节段动脉硬化闭塞症

目的：探讨下肢多节段动脉硬化闭塞症的治疗手段及临床疗效。方法：采用下肢动脉球囊扩张、支架植入结合动脉旁路术、股深动脉成形及原位大隐静脉动脉化,治疗下肢多节段动脉硬化闭塞症31例（36条患肢）,行髂动脉支架植入球囊扩张术33条患肢;股总动脉支架植入球囊扩张术3条患肢,23条患肢行股一胭动脉人工血管旁路术,12条患肢行股深动脉成形术,6条行原位的大隐静脉动脉化。结果：手术均获得成功,未出现严重并发症。术后踝肱指数（0．65±0．18）与术前（0．25±0．11）相比较有明显提高（P〈0．05）。平均随访14个月（2～24个月）,与术前相比,患者术后症状明显好转,跛行距离加大（〉1000m）。结论：下肢动脉腔内介入结合动脉旁路术、股深动脉成形术、大隐静脉动脉化等是治疗多节段多平面下肢动脉硬化闭塞症的有效方法。     

腹腔镜下左髂总动脉-股动脉人工血管旁路移植治疗髂外动脉闭塞症一例

目的总结腹腔镜下人工血管旁路移植治疗髂外动脉闭塞症的手术技巧和临床效果。方法 2011年12月,收治1例57岁髂外动脉硬化闭塞症男性患者。患者双下肢间歇性跛行;下肢动脉造影示左髂外动脉闭塞,右髂总动脉狭窄;心电图示窦性心律,完全性右束支传导阻滞,ST段改变;踝肱指数(ankle brachial index,ABI):左侧0.59,右侧0.54。于全麻下行腹腔镜下左髂总动脉-股动脉人工血管旁路移植术。结果术后人工血管通畅,吻合口无漏血,患者跛行症状明显改善。术后1周左侧ABI增加至1.09;术后1个月血管造影显示血管通畅。结论腹腔镜下主-髂动脉重建既保留开腹动脉旁路移植效果好的特点,又具有腔内支架成形创伤小、术后恢复快的优点。     

多节段下肢动脉硬化闭塞症介入治疗及手术治疗体会

目的 总结一侧髂动脉闭塞合并下肢动脉长段闭塞患者治疗的临床效果.方法 对于一侧髂动脉同时合并下肢动脉长段闭塞的多节段下肢动脉硬化闭塞症患者,间歇跛行距离小于50m或有静息痛者采用髂动脉支架或联合血管旁路术治疗下肢动脉硬化闭塞症32例.结果 行髂动脉病变段球囊扩张及内置支架术29例36枚支架,3例髂动脉介入治疗失败,行股浅动脉病变段支架置入3例,行股-腘动脉膝上血管旁路术13例,行膝下血管旁路术2例,3例髂动脉支架治疗失败者2例行股-股动脉耻骨上旁路术,1例放弃治疗.介入治疗及手术治疗均取得成功.随访3～36个月,3例患者因肿瘤或急性心肌梗塞死亡,大部分患者临床症状消失.1例股浅动脉支架1个月后闭塞,后因肢体严重缺血截肢.3例股-腘旁路血管闭塞,1例接受取栓手术好转,1例截肢,1例无静息痛间歇跛行距离大于50m应用药物治疗.结论 支架置入或联合血管旁路术是治疗多节段下肢动脉硬化闭塞症的安全有效方法 .     

下肢动脉硬化闭塞症血管介入联合外科手术疗效观察

目的探讨下肢动脉硬化闭塞症的治疗方法及临床疗效。方法采用骼、股、腘动脉球囊扩张术+支架植入术结合动脉旁路术、股深动脉成形术治疗下肢动脉硬化闭塞症26例(30条患肢)。8条患肢行骼动脉球囊扩张+支架植入术,其中12条患肢加行股深动脉成形术,6条患肢加行股-腘动脉人工血管转流术,4条肢体行膝下球囊扩张术。结果手术均获得成功,未出现严重并发症。术后踝肱指数0.65±0.19与术前0.23±0.12相比有明显提高(P<0.05)。平均随访12个月(1～23个月)。与术前相比患者症状明显改善,仅4例残余有间歇性跛行(跛行距离300 m),其中1例术后3个月外院行干细胞移植术后症状明显好转,跛行距离>1 000 m。结论骼、股、腘动脉球囊扩张、膝下球囊扩张术+支架植入结合动脉旁路术、股深动脉成形术、股-腘动脉人工血管转流术是治疗下肢动脉硬化闭塞症的有效方法。手术创伤小,操作方便。手术方式灵活,尤适用于高危重症患者。     

Semiclosed transfemoral iliac endarterectomy with an oscillating ring stripper

The technique of endarterectomy for the removal of occlusive atherosclerotic lesions of the aorta and iliac arteries has been utilized successfully in the revascularization of ischemic limbs since its introduction in 1951. The oscillating loop endarterectomy device (Amsco-Hall arterial oscillator) has proven to be useful for endarterectomy of segmental occlusive disease as a substitute for bypass with prosthetic graft. For our elderly debilitated patients, we have adopted a new technique of semiclosed transfemoral iliac endarterectomy for management of occlusive external iliac disease with a patent common iliac artery. We report seven patients treated during May 1987 through May 1988 for external iliac artery occlusion by transfemoral oscillating loop endarterectomy. At 12 months for follow-up review, the cumulative limb salvage rate was 80% with no perioperative mortality. One patient required above-knee amputation eight months following endarterectomy to control forefoot sepsis. Two patients required subsequent leg bypass procedures to achieve full healing of foot level amputation. One patient required dilatation of residual stenosis at the iliac bifurcation by percutaneous balloon angioplasty. Semiclosed transfemoral endarterectomy with the Amsco-Hall oscillating loop device remains an attractive option to the vascular surgeon for recanalization of the iliac artery without the need for an extensive retroperitoneal dissection.     

经皮腔内血管成形术治疗髂-股动脉狭窄或闭塞

目的探讨经皮腔内血管成形术（PTA）及血管内支架植入术治疗髂-股动脉狭窄或闭塞的应用价值。方法 66例髂-股动脉狭窄或闭塞患者,患肢均有不同程度的缺血症状,均采用PTA和（或）支架植入术进行介入治疗,分别于治疗前、后测定踝/肱指数（ABI）。结果 66例患者成功完成介入治疗,共植入支架73枚,其中髂动脉植入27枚,股浅动脉植入32枚,髂-股动脉植入14枚,无严重并发症发生。术后患者患肢缺血症状明显减轻或消失。ABI由术前0.39±0.12上升至0.72±0.15,术后随访3～24个月（平均15个月）,10例患者因复发而再次接受介入治疗。结论 PTA及血管内支架植入术,因其创伤小、可重复性高、疗效显著等特点已成为治疗髂-股动脉狭窄或闭塞的有效手段。     

Long-term results of combined iliac balloon angioplasty and distal surgical revascularization.

Long-term results of combined use of iliac artery percutaneous transluminal angioplasty (PTA) and distal surgical revascularization for the management of multilevel occlusive disease were evaluated over a 12-year period. A total of 79 combined procedures were performed in 75 patients. All patients had tandem occlusive disease, with the inflow lesion felt to preclude a distal revascularization procedure alone. Revascularization was performed for incapacitating claudication in 17 (22%) and limb salvage indications in 62 (78%) cases. A mean resting iliac artery pressure gradient of 29 +/- 11 mmHg pre-PTA was reduced to 0.9 +/- 0.4 post-PTA. Major complications of PTA occurred in five (6%) cases, but four were successfully corrected at the time of the distal surgical procedure without alteration of the operative plan. Infrainguinal operations included 55 femoropopliteal or tibial bypass grafts, 18 femorofemoral grafts, and 6 profundaplasties. Mean follow-up was 43 months. By life table analysis, the 5-year primary patency rate of the distal surgical procedures was 76%; a secondary patency of 88% at 5 years was achieved by various means of reintervention. Mean pretreatment ankle/brachial index of 0.31 +/- 0.14 increased to 0.80 +/- 0.16 after operation (p less than 0.0001). The 5-year limb salvage rate was 90%. There were no operative deaths. We conclude that in carefully selected patients, combined use of iliac PTA and distal surgical reconstruction is effective and durable, safely reducing the extent of surgical intervention while reliably increasing the comprehensiveness of revascularization.     

Long-term results of femoro-femoral crossover bypass after endovascular aortouniiliac repair of abdominal aortic and aortoiliac aneurysms

Aortouniiliac stent grafts allow the endovascular treatment of complex anatomy aortoiliac aneurysms. The main drawback is the need for femoro-femoral crossover bypass, with its complications and its patency limitations. However, some authors have shown good results of femoro-femoral crossover bypass in aneurysmal disease. In this article, initial and long-term results of our experience in femoro-femoral crossover bypass revascularization after endovascular aortouniiliac stent grafts repair of aortoiliac aneurysms is reported. Prospective collection, intention-to-treat, and retrospective analysis maintained database. Femoro-femoral crossover bypass patency assessment of all patients treated between January 1999 and September 2002, compared patients with or without associated occlusive arterial disease. Urgent indications were excluded. In total of 52 patients, with a mean age 72.6 years, 30.8% of patients were identified with associated occlusive arterial disease. Initial systemic and local, access site, complications were 7.7% and 7.7%, respectively, no early thrombosis or death is reported. Primary patency was 90.9% at 54 months, 66 months assisted primary and secondary patency were 97.7% and 100%, respectively. The 48-month survival rate was 84.2%. No significant differences between patients with or without associated occlusive arterial disease were found. Femoro-femoral crossover bypass after aortouniiliac stent grafts treatment of aortoiliac aneurysms shows excellent initial and long-term patency and low complication rate.     

Long-term outcomes and predictors of iliac angioplasty with selective stenting: is primary stenting necessary?

Percutaneous transluminal angioplasty (PTA) has become one of the initial treatment options in patients with iliac artery occlusive disease. Stents have been recommended to correct procedural complications and improve long-term patency. Many series advocate routine stent placement after an otherwise uncomplicated PTA (primary stenting) in an attempt to prevent recurrent disease. Currently, many physicians in the United States seem to use stents in the iliac artery more liberally, even on a routine basis. There is little evidence to support this practice, however. It is still unclear whether a stent should be inserted primarily or selectively. This article provides the data from an 11-year experience of angioplasty with selective stenting for iliac artery occlusive lesions and reviews the current literatures on the iliac artery stent placement.     

Long-term effects of combined iliac dilatation and distal arterial surgery

PURPOSE: When standard aortofemoral surgical procedure is combined with lower extremity vascular surgery, problems related with the hospital stay, morbidity, mortality and the cost of treatment will exist. The number of reports relating to combined iliac artery PTA and distal bypass surgery is limited. After the development of stenting procedures, the results of arterial system plasty have much more improved. This report reviews our preliminary experience with iliac artery angioplasty with distal bypass procedures. PATIENTS AND METHODS: A total of 41 patients have undergone combined iliac artery dilatation and distal arterial revascularization. Angioplastic procedures were performed in the angiography suite and distal surgery was carried out at the same day or the day after. Of all patients, 29 underwent percutaneous transluminal angioplasty (PTA) and 12 underwent combined PTA and stent placement. Ipsilateral femoropopliteal bypass was performed as a distal revascularization procedure in all patients. RESULTS: Mean systolic iliac artery pressure gradients improved from 34.7+/-8.6 mmHg to 3.9+/-3.2 mmHg after angioplastic procedures (P < 0.0001). Six patients needed reangioplasty because of restenosis in the follow-up period. Thrombectomy was performed on 1 patient in the early postoperative period and re-do femoropopliteal bypass was performed on two patients in the 2nd and 23rd months. Three minor wound infections were successfully treated with antibiotics and local care. Mean follow-up was 21.4 months (range 1-48 months).By life-table analyses, the overall 4-year cumulative primary patency of combined procedures was 78.1%. CONCLUSION: The results show that the combined procedure is a suitable method for the treatment of patients with multiple stenotic lesions at the iliac and distal arterial levels. We believe that the combined use of PTA and distal vascular surgery by an experienced surgical team will give beneficial results and a highly satisfactory outcome in this group of patients.     

Immediate post-operative urokinase infusion: extending the limits of limb salvage surgery

We report the case of a 74-year-old woman with multi-level arterial occlusive disease and severe ischemia of the right lower extremity who underwent a re-operative femoro-femoral and a right femoro-popliteal bypass graft. Her right foot remained non-viable post-operatively despite patent grafts. She then underwent a 12-hour infusion of urokinase through a percutaneously placed popliteal artery catheter during that first post-operative day, with salvage of the right leg.     

Combined iliac angioplasty and infrainguinal revascularization surgery are effective in diabetic patients with multilevel arterial disease

The success of percutaneous transluminal angioplasty (PTA) in the treatment of common and external iliac atherosclerotic lesions has been established for the general population. However, several studies have suggested that the presence of diabetes may reduce the effectiveness of iliac angioplasty, particularly in the setting of limb-threatening ischemia requiring concomitant lower extremity revascularization. This study compared the results of iliac artery PTA performed in conjunction with infrainguinal bypass for limb-threatening ischemia for diabetic (DM) and nondiabetic (non-DM) patients. Between 1991 and 2000, 159 PTA were performed in 126 patients (DM = 99/79%, non-DM = 27/21%) in conjunction with subsequent infrainguinal bypass for limb-threatening ischemia (gangrene = 42%, ulcer = 36%, rest pain = 22%). These patients were followed prospectively using a computerized vascular registry. Stents were placed in 34 (21.4%) cases for suboptimal angioplasty results. In this study the combined use of standard surgical and endoluminal modalities for the treatment of multilevel arterial occlusive disease resulted in excellent cumulative patency and limb salvage rates. The presence of diabetes did not alter these favorable results. Multimodal vascular therapy may be used effectively in diabetic patients with limb-threatening ischemia due to multiple levels of arterial occlusion. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

Duplex selection facilitates single point-of-service endovascular and surgical management of aortoiliac occlusive disease

We attempted to optimize management of aortoiliac occlusive disease by using duplex imaging to aid in selection of favorable lesions for percutaneous transluminal angioplasty (PTA)/stenting, by avoiding nontherapeutic arteriography, and by providing single point-of-service care in which endovascular and open surgical reconstruction were combined. One-hundred consecutive patients with symptomatic (91 claudication, 9 limb threat) inflow occlusive disease based on clinical examination and physiologic testing underwent physician-directed duplex scanning of the infrarenal aorta through the femoral bifurcation. Iliac lesions suited to endovascular intervention were defined as focal (length <5 CM), high-grade stenoses with a peak velocity >300 cm/sec and velocity ratio >2 by duplex and were differentiated from unfavorable (diffuse/long iliac stenosis, occlusions, aneurysms, femoral occlusive disease) inflow lesions. Patients with favorable iliac lesions according to duplex were considered candidates for PTA/stenting in an endo-capable operating room, without prior diagnostic angiography. On the basis of duplex imaging, 38 patients possessed endovascularly favorable iliac lesions, 58 patients had unfavorable aortoiliofemoral disease, and 4 obese patients had inadequate studies. Duplex interpretation correctly classified disease distribution/severity in 92% of 50 patients who subsequently underwent intraoperative or diagnostic arteriography. Thirty-one of the 45 (69%) total interventions performed in this patient group were based on duplex findings alone. Of 29 patients with favorable lesions by duplex scanning who had intervention, 25 (86%) received iliac PTA/stenting, while 4 patients required inflow surgical reconstruction for nonfocal iliac disease demonstrated on operative arteriography. Duplex imaging correctly identified the need for concomitant outflow reconstruction/bypass in 11 of the 25 (44%) patients treated by iliac PTA/stenting. Primary and assisted patency rates of iliac PTA/stenting were 83% and 100% at 24 months by life-table analysis. Duplex imaging in patients with symptomatic aortoiliac occlusive disease can provide sufficient information to permit endovascular and surgical intervention without formal diagnostic arteriography in most patients.