Comparison of outcomes for balloon angioplasty,atherectomy, and stenting in the treatment of infrapopliteal disease for chronic limb-threatening ischemia

ObjectiveWe evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI).MethodsAll index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS.ResultsThe 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P < .001).ConclusionsStenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment.     

膝下血管成形术治疗重症肢体缺血的临床疗效

目的评价膝下经皮腔内血管成形术(PTA)治疗重症肢体缺血(CLI)的临床疗效。方法回顾性分析48例(50条患肢)接受膝下PTA治疗的下肢CLI患者,统计PTA的技术成功率、围术期并发症、PTA术后的缺血症状缓解情况、治疗血管的通畅情况和大截肢情况。结果共针对64条膝下动脉施行PTA,技术成功率为85.94%(55/64);围术期并发症发生率为12.50%(6/48)。平均随访(16.25±2.65)个月;PTA术后1、3、6、12、24、36个月的1期血管通畅率分别为92.0%、85.7%、79.0%、75.8%、59.8%、29.9%;保肢率分别为92.0%、92.0%、89.7%、86.4%、82.1%、72.9%。50条患肢中,1、3、6个月时的缺血症状缓解率分别为42.00%(21/50)、70.21%(33/47)和86.36%(38/44)。结论膝下PTA治疗CLI技术可行,安全性高,能有效缓解CLI的静息痛症状、促进肢体溃疡的愈合,避免大截肢的发生。     

腔内斑块切除在缺乏流出道的股腘动脉狭窄病变中的应用

目的:探讨腔内斑块切除治疗缺乏流出道的股腘动脉狭窄病变的疗效。方法:2014年7月—2015年6月笔者对所在单位21例以重度间歇跛行为主要症状、缺乏远端流出道的股腘动脉狭窄患者进行腔内斑块切除术,并进行随访。结果:与术前比较,患者术后3、6、12个月跛行距离均明显且逐渐增加(均P0.05);术后2d与3、6、12个月踝肱指数均明显增加(均P0.05);术后3个月无靶血管再狭窄,术后6个月发现靶血管再狭窄1例(1/21),术后12个月发现靶血管再狭窄2例(2/21),均为中度再狭窄。结论:腔内斑块切除术治疗缺乏流出道的股腘动脉狭窄病变具有较好的近期疗效。     

直接斑块切除术治疗股腘动脉闭塞性病变

目的 评价SilverHawk直接斑块切除术治疗股腘动脉闭塞性病变的临床疗效及其安全性.方法 应用SilverHawk直接斑块切除术治疗11例下肢缺血共18个病变,其中完全闭塞9个,平均病变数(1.6±1.1)个,平均狭窄程度96%±14%,平均长度(3.4±2.2)cm.间歇性跛行4例(Rutherford分级:3),重症下肢缺血7例(Rutherford分级:4).按TASC(TransAtlantic Inter-Society Consensus)股腘动脉病变分型:B型7例,C型1例(支架内闭塞),D型3例.平均踝肱指数(ankle brachial index,ABI)0.5±0.4.除临床症状外,还采用彩超或CT血管成像(CT angiography,CTA)方法对管腔通畅情况进行评估随访.结果 9个完全闭塞病变均经腔内开通成功.其中1例(支架内闭塞)先行预扩,经过平均(8±3)min斑块切除后,18个病变管腔均技术成功(残余狭窄＜50%),平均残余狭窄15%±7%.临床症状均消失或明显改善;Rutherford分级:9例为0,2例为1;平均ABI1.07±0.12.平均随访(9±4)个月,Rutherford分级稳定无变化,平均ABI 0.93±0.14,管腔均通畅.结论 SilverHawk直接斑块切除术是治疗下肢缺血性病变的一种安全有效的新方法.

Abstract：

Objective To evaluate the clinical safety and efficacy of SilverHawk directional atherectomy for femoropopliteal occlusive lesions. Methods Eighteen ischemia occlusive lesions in 11 patients of the lower extremity were treated with SilverHawk directional atherectomy. The mean lesion number was 1.6 ± 1. 1 per patient. The mean lesion length was ( 3.4 ± 2. 2 ) cm. The average degree of diameter stenosis was 96％ ± 14％. 9 lesions were totally occlusive. Clinical symptoms included claudication in 4 cases ( Rutherford classes: 3) and critical limb ischemia ( Rutherford classes: 4) in 7 cases. Lesions characteristics were divided by TASC classification: TASC B in 7 cases; TASC C in 1 case (in-stent occlusion); TASC D in 3 cases. Mean ABI was 0. 5± 0.4. Patency was evaluated with color duplex sonography or CTA besides clinical examination during follow-up. Results Nine totally occlusive lesions were recanalizated successfully via intraluminal approach. 18 lesions achieved technical success (residual stenosis ＜50％ ) leaving 15％ ±7％ mean residual stenosis in mean (8 ±3)min, predilation was needed in one lesion ( in-stent occlusion) prior to atherectomy. Clinical symptoms improved or disappeared with mean ABI 1.07 ±0. 12 and Rutherford grades: 0 (n =9) and 1 (n =2). Patency rate was 100％ with mean 0. 93 ± 0. 14 ABI and Rutherford grades remain unchanged after follow-up of mean ( 9 ± 4 ) monthes.Conclusions SilverHawk directional atherectomy is safe and effective for the treatment of lower extremity ischemia.     

DebakeyⅢ型夹层动脉瘤远侧破口的腔内封堵

目的 初步总结使用腔内技术处理夹层动脉瘤远侧破口的经验.方法 总结15例DebakeyⅢ型夹层动脉瘤近端破口腔内修复术后腹主动脉以远破口的二期介入处理经验.所有病例远侧破口持续存在,出现腰腹部症状或局部腹主动脉外径增加.本组病例中内脏动脉处破口7个(1个腹腔动脉内破口,6个肾动脉处破口),肾下腹主动脉破口4个,髂动脉破口7个;其中3例为内脏动脉破口合并髂动脉破口.肾下腹主动脉破口均采用一体式覆膜支架封堵;1例近右肾动脉破口使用先心封堵伞;其余内脏动脉和髂动脉破口均采用小覆膜支架封堵.结果 所有病例均顺利完成操作,腹主动脉和髂动脉破口封堵良好,无内漏.使用封堵伞的病例,夹层破口封堵良好,但由假腔供血的右肾动脉同时闭塞;肾动脉破口使用覆膜支架封堵病例中,1例显著内漏,2例微量内漏,其余病例封堵良好,无内漏.病例随访2 ～10个月,平均(5.0±2.0)个月,内漏病例CTA示假腔内部分血栓形成,但破口附近假腔仍有血流,其余病例夹层内均血栓形成.结论 针对适当患者,个体化方案封堵夹层动脉瘤的远侧破口是可行和安全的.     

斑块旋切联合药物涂层球囊在下肢动脉硬化闭塞症中应用的现状及研究进展

下肢动脉硬化闭塞症（ASO）是中、老年人的常见病和多发病,且发病率呈逐年升高趋势。腔内治疗以微创、安全、有效、恢复快等优势,已成为ASO治疗的首选。近年,腔内减容（leave nothing behind）理念的提出以及腔内器具的快速更新,使得ASO的治疗有了全新的发展方向。以药物涂层球囊（DCB）的应用为代表的腔内血管成形术和新兴的腔内减容术是近年来ASO腔内治疗发展的热点。斑块旋切术（DA）作为ASO腔内减容治疗的重要技术,联合DCB治疗,能够在扩大管腔容积基础上,应用抗细胞增殖药物持续抑制内膜增生,从而最大程度提高中远期管腔通畅率。两者联合应用可能是目前治疗下肢ASO的最优策略,也将是未来10年最具发展潜力的主要措施之一。笔者基于DA技术和DCB的特点对两者联合治疗下肢ASO,如股腘动脉硬化闭塞、膝下动脉硬化病变、下肢动脉跨关节病变及支架内再狭窄等的应用现状和研究进展进行综述。     

Rotarex机械性减容联合药涂球囊治疗动脉型胸廓出口综合征的疗效分析

背景与目的 胸廓出口减压术,锁骨下动脉重建术被认为是治疗动脉型胸廓出口综合征（TOS）的标准术式,需要根据动脉受压的位置选择不同的手术入路,手术疗效确切,通常情况下术后患肢的长期功能预后满意。然而上述手术难度大,术者学习曲线长,手术创伤大,出血及神经损伤等并发症多,患者术后恢复慢。近年来,腔内技术的进步和血管耗材的创新使得相当一部分血管狭窄性病变可以通过介入手术的方式进行有效治疗,腔内治疗具有创伤小、并发症少、患者恢复快、可反复操作的优点。既往应用血管腔内技术治疗动脉型TOS的报道极少,因此,本研究探讨Rotarex机械性减容联合药涂球囊治疗动脉型TOS的初期临床疗效,以期为动脉型TOS提供新的可靠的治疗途径。方法 回顾性分析北京积水潭医院自2019年1月—2021年12月期间采用Rotarex机械性减容联合药涂球囊治疗的6例动脉型TOS患者的临床资料,统计手术成功率、手术时间、住院时间、术中出血量、手术并发症以及术后3个月的动脉通畅率、靶血管再干预率,比较术前与术后颈-臂症状评分、McGill疼痛评分,桡动脉搏动情况。结果 6例患者,手术成功率为100%,平均手术时间为（52.3±18.7）min,平均住院时间为（5.7±1.6）d,术中平均出血量（31.5±20.7）mL,无手术相关并发症,术后3个月的动脉通畅率为100%,术后3个月的靶血管再干预率为16.67%,患者术后的颈-臂症状评分均较术前明显降低（59.3±17.3 vs. 83.1±11.2,P<0.05）,但术后McGill疼痛评分与术前差异无统计学意义（45.3±12.5 vs. 51.9±9.2,P>0.05）,术后患者的桡动脉搏动较术前明显改善（P<0.05）。结论 Rotarex机械性减容联合药涂球囊是治疗动脉型TOS的一种微创、安全、有效的方法,具有良好的近期疗效,但是需要严格控制腔内介入手术的适应证,仔细筛选应用该种手术方式治疗动脉型TOS的患者,同时需要严密随访,中远期疗效仍有待于进一步地探究。     

TEVER 术中主动脉弓部分支动脉的重建

目的：探讨胸主动脉腔内修复术中主动脉弓部分支动脉的重建方法。方法：回顾性分析北京大学人民医院2001年12月—2014年3月间45例行胸主动脉腔内修复术患者的临床资料。结果：分别通过杂交技术、烟囱技术、分支支架技术共重建分支动脉64支,其中包括无名动脉6支,右颈总动脉1支,左颈总动脉21支,左锁骨下动脉36支。技术成功率100%,术后7例患者发生内漏,30 d内死亡4例。39例患者获随访2~89个月,期间1例于手术后45 d可疑死于脑梗塞,2例死于与胸主动脉疾病无关的原因;1例患者内漏仍存在,所有桥血管、烟囱支架等保持通畅。结论：通过杂交手术、烟囱技术及分支支架技术重建弓部分支动脉后行TEVER手术是安全可行的,其短期效果令人满意,其远期效果仍有待继续观察。     

血管腔内治疗慢性下肢缺血时的溶栓治疗

目的 探讨导管溶栓在慢性下肢缺血腔内成形治疗时的可行性、疗效及安全性.方法 回顾性分析2009年2月～2011年2月在广州市中医院接受治疗的11例慢性下肢缺血(TASC Ⅱ D级)患者的临床资料.采用尿激酶(UK)溶栓,然后再行血管腔内治疗,对治疗后临床疗效及动脉通畅率进行统计分析.结果 9例患者(81.8％)血管成形技术获得成功,无并发症发生;2例(18.2％)未溶栓成功.8例患者获得随访,随访率为88.9％,平均随访时间14.5个月.术后1年一期通畅率、辅助一期通畅率和二期通畅率分别为80％、88％及92％,2年为67％、84％及88％.结论 对慢性下肢缺血TASC Ⅱ D级病变进行血管腔内成形时的溶栓是可行、安全且有效的.     

Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease

Background

Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease.

“烟囱”技术在Ⅲ型夹层动脉瘤和腹主动脉瘤腔内修复术中的应用

目的 总结“烟囱”技术在主动脉瘤腔内修复术中的应用体会和一期效果.方法 在30例主动脉瘤腔内修复术中使用“烟囱”技术增加近端覆膜支架锚定区,其中25例DebakeyⅢ型夹层动脉瘤使用“烟囱”支架保留左锁骨下动脉(23例)或左颈总动脉(3例),肾下腹主动脉瘤使用“烟囱”支架保留肾动脉(5例).结果 所有病例均顺利完成操作,放置“烟囱”支架的分支动脉术中造影均通畅.其中2例夹层动脉瘤(8％)和1例腹主动脉瘤残留(20％)少量Ⅰ型内漏,1例夹层动脉瘤左锁骨下动脉“烟囱”病例术后5d猝死,考虑为远侧破口所致夹层动脉瘤破裂.其余22例夹层动脉瘤和4例肾下腹主动脉瘤均无内漏.随访28例(90.3％),随访1～19个月,平均(6±5)个月.随访期超声或CTA示“烟囱”血管血流均通畅.1例腹主动脉瘤仍有内漏,2例夹层内漏病例随访中(尚未行CTA),其他病例瘤腔血栓形成.结论 “烟囱”技术能够有效的延长覆膜支架在主动脉瘤腔内修复术中的近端锚定区并保持重要分支动脉通畅.     

TurboHawk斑块切除系统联合药物涂层球囊在治疗股腘动脉硬化闭塞性疾病中的应用

目的:评价应用Turbo Hawk斑块切除系统联合药物涂层球囊(DCB)治疗股腘动脉硬化闭塞性疾病的安全性和有效性。方法:2016年4月—2017年10月,对17例股腘动脉硬化闭塞性疾病患者应用Turbo Hawk斑块切除系统联合DCB治疗。17例患者平均年龄(66.9±10.5)岁;其中男14例,女3例;股腘动脉狭窄病变13例,闭塞性病变4例;术前Rutherford分级2~5级;术前踝肱指数(ABI)为0.49±0.18。结果:17例患者的血管病变全部经腔内开通成功,其中1例股动脉穿孔患者行补救性覆膜支架植入术,另1例远端栓塞患者经股动脉切开球囊导管取栓后血流恢复通畅,技术成功率88.2%。术后ABI为0.99±0.27,明显高于术前(P=0.03)。术后3、6个月一期通畅率分别为94.1%,88.2%,二期通畅率100%。结论:Turbo Hawk斑块切除系统联合药物涂层球囊治疗股腘动脉硬化闭塞性疾病安全有效,早期效果满意。     

胸主动脉腔内修复术后截瘫发生的危险因素及处理

目的:探讨胸主动脉腔内修复术(TEVAR)后截瘫发生的危险因素及处理。方法:回顾性分析2011年5月—2015年5月593例行TEVAR手术的Stanford B型主动脉夹层患者资料,分析术后截瘫发生的危险因素并总结处理方法。结果:593例患者中,9例(1.5%)发生TEVAR术后截瘫。单变量分析结果显示,糖尿病、高血压、吸烟、围术期低血压和左锁骨下动脉封堵可能与TEVAR术后截瘫有关(均P0.05);多变量Logistic回归分析结果显示,围术期低血压是TEVAR术后截瘫的独立危险因素(P0.05)。所有截瘫患者经脑脊液引流、激素冲击、适当升压、抗凝、扩血管、营养神经、降颅压联合治疗后,神经系统功能均完全恢复。结论:围术期低血压是TEVAR后截瘫发生的重要危险因素。截瘫发生后早期采取相应保守治疗手段提高脊髓灌注可以有效改善预后。     

Angiosome指导下膝下动脉成形术治疗合并糖尿病的Fontaine1V级下肢动脉缺血

目的探讨Angiosome指导下膝下动脉成形术的临床价值。方法2011年1月～2012年2月20例合并糖尿病的FontaineIV级缺血（ABI：0．10～0．22,平均0．15）,按照Angiosome概念评价足部破损区域的靶血管并开通,其中胫前动脉7例,胫后动脉10例,胫前后动脉3例。患肢股浅动脉顺行穿刺,应用V18导丝及Reekross18球囊导管开通闭塞的靶血管,AmphirionDeep球囊行成形术。术后即时测定患肢踝肱指数（anklebrachialindex,ABI）,术后1、3、6个月采用血管多普勒和CTA／NCMRA以及局部切口愈合情况评价血管开通、通畅性和创面修复情况,同时记录有无截肢事件发生。结果20例均成功开通靶血管,无相关并发症发生。术后即时AB10．86±0．06,较术前0．154-0．03显著提高（t=-45．603,P=0．000）。术后1、3、6个月时靶血管的通畅率分别为100％（20／20）、95％（19／20）、75％（15／20）。术后6个月保肢率为100％,85％（17／20）的患肢6个月时完全愈合。结论Angiosome指导下膝下动脉成形术治疗合并糖尿病的FontaineIV级缺血安全可行,有助于保肢及促进创面愈合的治疗。     

Next generation catheters for excimer laser coronary angioplasty

. In response to the need for maximising debulking in complex lesions, three new excimer laser coronary angioplasty catheter designs have been introduced. The eccentric laser catheter features a fibreoptic bundle disposed opposite the guide-wire lumen at the catheter tip and a torque mechanism that allows the user to rotate the fibre bundle toward the lesion mass. Residual lumens 50% larger than the catheter tip diameter have been obtained when multiple passes were made, with each pass performed using a different tip rotation. A recent case series utilising this catheter in restenosed stents resulted in larger lumens and lower 6-month restenosis rates. The optimal spaced (OS) laser catheter features a fibre bundle placed concentrically around the guide-wire lumen. The 61 μm diameter core fibres are spaced at a nominal centre-to-centre distance of 90 μm, resulting in a 40% increase in ablative area as compared to previous concentric catheter designs. In vitro testing and clinical evaluation demonstrated OS catheters routinely achieve an ablated area ≥90% of the catheter tip size. The 0.9 mm catheter features a high-density fibre pack composed of 65 fibres. Peripheral dead space has been minimised to maximise penetration of calcified plaque. When combined with laser parameters of up to 80 mJ/mm², and 80 Hz pulse repetition rate, the catheter demonstrated improved hard tissue and calcified tissue penetration in vitro. Clinical evaluation in Canada revealed a 94% lesion recanalisation rate in high-grade stenoses with angiographic evidence of calcification, chronic total occlusions, and lesions which have failed balloon angioplasty.     

Endovascular reconstruction of an interrupted inferior vena cava

INTRODUCTION

Inferior vena cava (IVC) interruption was established as a procedure to treat refractory venous thromboembolism (VTE) complicated by pulmonary embolism. Ilio-caval thrombosis and lower limb chronic venous insufficiency (CVI) are well known long-term complications of IVC interruption, where subsequent treatments may carry significant morbidity and mortality.

PRESENTATION OF CASE

We present here a case of chronic venous insufficiency resulting from IVC interruption with a vascular clip placed forty years previously. A novel approach utilising endovascular stents was used to reconstruct the iliocaval confluence and interrupted distal IVC without the need for laparotomy to remove the plicating clip. This procedure was associated with minimal morbidity and resulted with a quick resolution of the patient''s CVI symptoms.

DISCUSSION

Endovascular angioplasty and stenting is an alternative to open reconstruction of the interrupted inferior vena cava. We have demonstrated successful opening of a plication vascular clip using only endovascular utilities. Advantages include a shorter hospital stay, and reduced morbidity and mortality when compared to a re-do laparotomy.

CONCLUSION

Endovascular stents may be used safely and effectively to reconstruct the surgically interrupted inferior vena cava in the treatment of chronic venous insufficiency.     

腹主动脉瘤腔内修复术中瘤腔内压力监测的意义

目的 探讨腹主动脉瘤腔内修复术(endovascular aneurysm repair,EVAR)中瘤腔内压力监测的意义.方法 选择2006年4月至2007年3月12例肾下腹主动脉瘤腔内修复术病例,瘤体最大直径(5.83±0.95)cm.术中应用测压导管监测治疗前、后瘤腔内压力的变化,观察内漏类型、部位及随访结果与压力的关系.结果 12例支架型血管(stent-graft,SG)释放前瘤腔内压力约等于体循环压.EVAR后11例瘤腔内收缩压下降＞40%,其中7例下降≥50%;1例无明显改变.12例脉压差下降＞30%,其中6例下降＞75%.术后随访无内漏发生,无动脉瘤相关死亡.5例收缩压下降＞50%的病例瘤径出现不同程度的缩小(1.6～3.1 mm),压力未下降的l例瘤径增长3.2 mm,余6例瘤径无明显变化.结论 腹主动脉瘤腔内修复术中瘤腔内压力监测可了解手术前后压力的变化,从而判断腔内治疗效果.