69例急性下肢缺血的诊治分析

目的探讨急性下肢缺血的治疗方法及预后。方法回顾性分析我科2007年1月～2012年1月治疗69例急性下肢缺血患者的临床资料,其中急性动脉栓塞14例,动脉硬化闭塞基础上继发急性血栓形成50例,血栓闭塞性脉管炎3例,不明原因2例。根据病情采用:动脉切开Fogarty导管取栓8例,人工血管旁路17例;球囊扩张成形/支架置入15例;置管溶栓后进一步行腔内治疗12例;低位静脉动脉化2例;单纯药物治疗9例;I期截肢6例。结果 12例(17.4%)治疗成功,50例(72.5%)治疗好转,1例(1.4%)治疗无效。57例(82.6%)患者获得随访,随访时间3～62(平均26.4)个月,42例症状不同程度改善,7例Ⅱ期截肢,5例死于心、肺疾病。结论急性下肢缺血早期诊断与及时采用合适的治疗方法是治疗成功的关键。     

外周血干细胞移植治疗慢性下肢动脉缺血性疾病

目的 观察自体外周血干细胞移植治疗慢性下肢缺血性疾病的疗效.方法 应用自体外周血干细胞移植治疗46例慢性下肢缺血性疾病的患者.结果 42例小腿疼痛缓解,小腿冷、凉感觉消失;35例足部疼痛改善;29例足部冷、凉感消失;4例术后4周因为小腿中段以下出现坏死导致截肢.42例保肢病例,干细胞移植术后3个月,间歇性跛行距离由(87.45±41.22)m增加到(348.52±147.24)m,下肢皮温由(28.52±0.51)℃增加到(33.56±0.62)℃,踝肱指数(ABI)由(0.48±0.06)增加到(0.75±0.07),移植前后3项指标的差异均具有统计学意义(P＜0.05),移植后优于移植前.术后6个月和12个月下肢动脉影像学检查显示,37例均有不同程度的新生侧支血管形成.结论 自体外周血干细胞移植治疗下肢缺血性疾病是一种有效的方法,尤其对远端动脉流出道差的患者是一种较好的治疗手段.     

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目的 探讨腹主动脉瘤（AAA）手术合并急性下肢动脉缺血的病因、预防和治疗。方法 对1979－2001年AAA术后急性下肢动脉缺血6例临床资料进行回顾性分析。结果 6例均经手术治疗。5例行股动脉切开、Fogarty管取栓术，3例行再次开腹探查，取栓或旁路术，肢体保存3例，因合并多器官系统功能衰竭（MOSF）死亡3例。结论 避免动脉硬化斑块脱落和防止血栓形成是预防急性下肢动脉缺血的关键，可提高AAA手术存活率。     

急性下肢动脉缺血的临床研究

目的 探讨急性下肢动脉缺血(ALLI)的治疗策略和预后.方法 回顾性分析2003年1月至2009年12月收治的ALLI患者的临床资料.结果 ALLI 130例,包括急性动脉栓塞82例和急性动脉血栓形成48例.单纯全身溶栓和抗凝治疗12例,Fogarty导管取栓81例,行取栓及动脉旁路术15例,9例行导管性溶栓,骨筋膜室切开减压27例.一期截肢13例;死亡9例,死亡率为6.9％,二期截肢8例;总体截肢率为19.3％(21/109).吸烟史、合并糖尿病和起病时间超过24小时是影响保肢的独立危险因素.结论 尽早开始治疗ALLI和选择适当的治疗方法有助于提高疗效.     

血管生长素治疗家兔肢体缺血的实验研究

目的观察动脉内注射重组人血管生长素（rhANG）对家兔缺血肢体血管再生的影响。方法将28只家兔随机均分为空白对照组、小剂量组、中剂量组、大剂量组。手术结扎、切断家兔股动脉各分支,插入硅塑导管至髂内、髂外动脉处。于术后第11天经动脉内导管注射不同剂量的rhANG。分别作肢体血压测定、动脉造影、放射性核素血流测定及计算肢体肌肉毛细血管密度。结果中剂量组、大剂量组与对照组、小剂量组各项指标于术后20、30、40d时差异有非常显著性（P<0.01）,尤以大剂量组变化最为明显。结论家兔动脉内注射rhANG治疗肢体缺血,在用药（20～40μg）后10～40d可观察到明显的促血管新生作用,此作用随rhANG的剂量增大而明显。     

急性肢体缺血的治疗

目的 探讨急性肢体缺血的治疗方法 .方法 回顾性分析28例急性肢体缺血的临床资料.4例急性动脉栓塞者行急症取栓术,1例假性动脉瘤患者行假性动脉瘤切除及人工血管植入术,23例动脉闭塞症者采用取栓、血管旁路术、血管腔内治疗、截肢、单纯药物等治疗.结果 5例急性动脉栓塞及假性动脉瘤患者治疗成功,23例动脉闭塞症患者中,5例(21.7%)治疗成功,12例(52.2%)好转,6例(26.1%)无效,4例截肢(占动脉闭塞疾病的17.4%).无1例死亡.6～45个月随访中,另有5例截肢,死亡4例.结论 急性肢体缺血患者需根据病情选择合理的治疗策略,包括取栓及血管重建等,以达到挽救肢体和生命的目的 .     

急性下肢缺血130例的临床特点分析和治疗体会

目的探讨急性下肢缺血（ALLI）的临床特点及治疗方法。方法回顾性分析2003年1月至2009年12月收治的ALLI患者的临床资料,根据病因将其分为急性动脉栓塞组（AE组）和急性血栓形成组（AT组）,比较两组起病特点和治疗方法的异同,分析影响保肢的因素。结果共收治130例ALLI,其中AE组82例,发病率略高,合并冠心病、风湿性心脏病、房颤者多,起病情况急,症状重,就诊时间多较短;AT组48例,冬季发病率较高,男性较多,平均年龄大,多有吸烟史,就诊时间相对较迟,并且多数有肢体慢性缺血病史。AE组脉搏消失、运动障碍症状出现率较AT组为高（P值分别为0．001和0．031）,其他症状发生率两组之间差别无统计学意义。死亡9例,死亡率6．9％。一期截肢13例,二期截肢8例,总体保肢率为80．70％（88／109）,AT组的总体截肢率、一期截肢率和二期截肢率均高于AE组（JP值分别为1．0×10-4,4．2×10-3,0．051）。吸烟史、合并糖尿病和起病时间超过24h是影响保肢的独立危险因素。结论ALLI应当尽早治疗,动脉切开导管取栓是治疗急性动脉栓塞的有效方法,而治疗急性血栓形成应尽可能地完善术前评估,选择合适的综合治疗方案,必要时联合置管溶栓和（或）旁路治疗。     

外科治疗非创伤急性下肢缺血154例

目的 探讨非创伤急性下肢缺血的外科治疗方法及影响预后的因素,对比急性动脉栓塞和急性动脉血栓形成的发病率和预后.方法 回顾性分析1999年7月至2007年12月手术治疗的154例急性下肢缺血病例,所有病例均行股动脉或胭动脉切开、Fogarty导管取栓术.单纯取栓128例,Fogarty导管取栓+内膜剥脱术8例,Fogarty导管取栓+人工血管或自体大隐静脉转流术13例,Fogarty导管取栓+一期截肢术5例.按照病因将病例分为急性动脉栓塞组(99例)和急性动脉血栓形成组(55例),对比两组发病率、截肢率、病死率及截肢高危因素.结果 急性动脉栓塞组男性发病率(39.4%)低于女性(60.6%)(P<0.05);急性动脉血栓形成组男性发病率(72.7%)高于女性(27.3%)(P<0.05).所有患者的截肢率为9.7%,院内病死率为11.7%.急性动脉栓塞组截肢率(5.1%)低于急性动脉血栓形成组(18.2%)(P<0.05),急性动脉栓塞组院内病死率(11.1%)与急性动脉血栓形成组(12.7%)相当(P>0.05).两组病例截肢的共同高危因素是肢体缺血时间,急性动脉血栓形成组截肢风险还与吸烟和糖尿病有关.结论 急性动脉栓塞男性发病率高于女性,急性动脉血栓形成女性发病率高于男性,急性动脉栓塞截肢率低于急性动脉血栓形成,而急性动脉血栓形成比急性动脉栓塞具有更高截肢风险.     

肢体缺血预处理减轻肝缺血/再灌注损伤的研究进展

背景 肝缺血/再灌注损伤(hepatic ischemia/reperfusion injury,HI/RI)是肝外科手术及肝移植中常见的病理生理现象,是术后肝功能衰竭和移植物无功能的主要原因.研究表明肢体缺血预处理(limb ischemia preconditioning,LIPC)可减轻HI/RI,具体机制仍不清楚.目的 通过综述LIPC减轻HI/R1的可能机制,为临床减轻HI/RI提供新的思路.内容 介绍HI/RI机制及LIPC减轻HI/RI的可能作用机制.趋向 LIPC作为减轻HI/RI的措施具有重大的临床应用价值.     

A novel femoral arterial cannula to prevent limb ischemia during cardiopulmonary support: preliminary report of experimental and clinical experiences

Distal limb ischemia may occur as a serious complication related to the use of femoral cannulation during veno-arterial cardiopulmonary support (CPS). We developed a simple cannula for femoral arterial cannulation with two holes in the side wall, which could provide the distal limb blood flow without additional cannulation or surgical procedure. This cannula can be inserted into the femoral artery by routine Seldinger technique. The distal blood flow from the side holes can be confirmed by Doppler detector without specialized techniques. In porcine experimental model, the distance between the position where the blood flow was first detected and those where the blood leakage took place was at least more than 10 mm. When this cannula and its side holes were adequately positioned, the mean distal limb flow ranged from 75 to 90 mL/min under CPS at a flow of 1.5 L/min. We employed this cannula for six patients in clinical settings. Three patients showed a good distal limb blood flow at the introduction position without its adjustment. The other three patients showed distal limb ischemia at the introduction position, but the limb ischemia was soon recovered after a slight adjustment of its position. There was no blood leakage from the percutaneous entry into the artery in all cases. We currently use this cannula as the first choice for patients undergoing a prolonged CPS.     

大鼠慢性肢体缺血模型的建立及其与急性肢体缺血模型的比较

目的建立大鼠慢性后肢缺血模型并与其急性后肢缺血模型比较,分析两者术后血流灌注和基因表达的差异。方法 40只SD大鼠随机均分为2组,分别建立大鼠慢性(结扎、离断右侧髂股动脉分支,股动脉内置入抗凝硅胶管并固定)和急性后肢缺血模型(结扎、离断右侧髂股动脉分支后直接结扎并切除股动脉)。用激光多普勒血流检测仪记录术前至术后连续4周肢体血流灌注情况。用实时荧光定量PCR法检测术后24 h患肢股内收肌缺氧诱导因子1α(HIF-1α)和血管内皮生长因子(VEGF)基因的表达。结果术后24 h,急性缺血组患肢股内收肌HIF-1α和VEGF表达水平均明显高于慢性缺血组(均P<0.05)。急性缺血组血流灌注在术后即刻降至对侧肢体的24%,但恢复较迅速,至术后28 d达到并稳定在82%;慢性缺血组于术后7 d达到血流灌注谷值(48%),随后缓慢恢复,至术后28 d至最高值(67%)。两组血流灌注水平在各观察时间点均有统计学差异(均P<0.05)。结论大鼠慢性和急性后肢缺血模型的病变特点及基因表达存在差异,慢性后肢缺血模型更符合临床严重肢体缺血的病理过程。     

A new model of brainstem ischemia by embolization technique in cats

An experimental model of brainstem ischemia was developed by embolization technique with cylindrical silicone rubber emboli in cats. The embolus reached the basilar artery in 55 cats (58.5%) and stopped in the upper basilar artery (UB) in 32, the middle basilar artery (MB) in 22 and the lower basilar artery (LB) in one animal. When the basilar artery distal to the embolus was not visualized (type 1) by postoperative vertebral angiogram. Evans blue extravasation was observed in the brainstem caudal to the embolus. When only a filling defect of the basilar artery at the site of the embolus was noted (type 2), dye extravazation was observed in the brainstem around the site of the embolus. In UB type 1, the regional cerebral blood flow of pons and medulla oblongata decreased immediately after embolization, and six hours after embolization it was 11.4±5.7 (pons) and 11.7±4.6 ml/100 g/min (medulla oblongata). In UB type 1 and MB type 1 animals, coma, apnea, tetraplegia, and disturbance of swallowing were noted. These animals died within 50 hours after embolization. Animals of UB type 2 and MB type 2 showed neurological deficits, but survived for three days. This paper discusses this method of producing experimental brainstem ischemia, the sites of ischemic lesions, and clinicopathological findings.     

急性下肢缺血动脉再通后并发骨筋膜室综合征的诊治

目的：探讨急性下肢缺血动脉再通后并发骨筋膜室综合征的临床表现、早期诊治及预后。方法：回顾性分析2005年1月至2009年1月因急性下肢缺血在我科行动脉再通治疗后并发急性下肢骨筋膜室综合征病人的临床资料,包括发病原因、时间、治疗方式、治疗效果、骨筋膜室综合征的处理方法及预后。结果：126例病人因急性下肢缺血行动脉再通治疗,发病至再通时间平均为26h（3h至6d）,其中24例（共27条肢体）并发骨筋膜室综合征而行筋膜切开（包括3例行双侧肢体预防性切开）。21例动脉再通术后延迟切开时间平均为10（5—48）h,其中2例术中行血液透析,1例行术后血液透析。本组3例截肢,2例死亡（包括1例截肢）。结论：骨筋膜室综合征是急性下肢缺血动脉再通后的严重并发症,动脉再通后持续疼痛或疼痛加重伴局部张力升高者应高度怀疑为骨筋膜室综合征,其治疗方法是充分切开4个筋膜腔减压,同时动态监测病人电解质和肾功能指标,维持肾功能和内环境的稳定,必要时应早期进行透析。     

下肢慢性缺血合并急性血栓形成的外科治疗

目的 探讨治疗下肢慢性缺血合并急性血栓形成的最佳外科治疗手段.方法 回顾性分析2000年1月～2010年10月我科收治的26例下肢慢性缺血合并急性血栓形成患者的临床资料,比较单纯采用股动脉切开导管取栓术组(10例)与股-腘动脉切开取栓联合动脉重建手术组(16例)的疗效.结果随访时间1～114个月,单纯股动脉切开术组中的...     

Prognostic risk factors for recurrent acute lower limb ischemia in patients treated with intra-arterial thrombolysis

ObjectiveThe objective of this study was to assess factors predisposing patients to recurrent acute lower limb ischemia (RALLI).MethodsAcute lower limb ischemia patients treated with catheter-directed thrombolysis (CDT) at Tampere University Hospital and Turku University Hospital between March 2002 and December 2015 were included. The patients' baseline demographics, comorbidities, and other characteristics were assessed retrospectively. Significant factors revealed by univariable analysis were tested in a multivariable model for associations with RALLI. A patency analysis was performed, and the risks of reocclusion were identified. The limb salvage rates after reocclusion were evaluated.ResultsAltogether, 303 consecutive patients with a mean age of 71 years (standard deviation, 11.8 years) were included. Of them, 159 (52.5%) were men. A total of 164 (54.1%) native arterial and 139 (45.9%) bypass graft occlusions were initially treated with CDT. On completion of CDT, 204 additional endovascular or conventional surgical procedures on 203 patients were performed to obtain adequate distal perfusion. During a median follow-up of 40 months (interquartile range, 69 months), 40 (24.4%) cases of RALLI occurred in native arteries and 90 (64.7%) in bypass graft patients (P < .001). In native arteries, the absence of appropriate anticoagulant and antiplatelet medication was independently associated with the development of acute reocclusions (hazard ratio, 6.51) in the Cox multivariable regression analysis. The patency rates were 86.6%, 72.2%, and 68.0% at 1 year, 5 years, and 9 years, respectively. In bypass grafts, worsened tibial runoff (crural index III: hazard ratio, 2.40) was independently associated with RALLI. The respective patency rates were 60.5%, 34.0%, and 29.2% for synthetic conduits and 30.8%, 20.5%, and 13.7% for autologous vein grafts at 1 year, 5 years, and 9 years. Altogether, 38 (29.2%) major amputations were performed on patients with reocclusions. Patients with synthetic conduits demonstrated superior limb salvage rates after reocclusion in comparison to native arteries or vein grafts (P = .025).ConclusionsAppropriate post-thrombolytic antiplatelet or anticoagulant treatment after native arterial events is of great importance, but additional data are needed to improve treatment algorithms. Adequate outflow in bypass graft patients is crucial. Patients with prosthetic bypass grafts have superior limb salvage rates after reocclusion.     

急性下肢缺血介入治疗疗效的影响因素分析

目的探讨影响急性下肢缺血（ALI）介入治疗疗效的因素。方法回顾性分析我科收治的95例ALI患者资料,对可能影响治疗效果的因素进行分析。结果治疗总有效率为84.21%（80/95）。统计学检验结果显示合并高血压、合并外周动脉硬化性疾病、病变部位为多部位病变、Rutherford分级高、溶栓时间长的患者治疗效果较差。结论患者是否合并高血压、外周动脉硬化性疾病及病变部位、Rutherford分级及溶栓时间可影响介入治疗ALI的疗效。对于ALI患者应该尽早诊断及治疗,以提高治疗效果。     

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

Objective

Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia.

肢体缺血/再灌注损伤诱发大鼠小肠组织自噬的机制研究

目的 观察大鼠肢体缺血/再灌注损伤（limb ischemia/reperfusion injury,LI/RI）对小肠组织自噬的影响. 方法 采用大鼠LI/RI模型,将雄性SD大鼠48只按随机数字表法随机分为两组（每组24只）：假手术组（S组）和缺血/再灌注（ischemia/reperfusion,I/R）组,两组分别再分为再灌注0（T0）、2（T2）、4（T4）、8 h（T8）4个亚组,每亚组6只.I/R组阻断血流3h后再灌注,S组不阻断血流,分别于上述4个时点测定各组血清中乳酸脱氢酶（lactate dehydrogenase,LDH）活性,荧光显微镜下观察小肠细胞自噬小体,聚合酶链式反应（polymerase chain reaction,PCR）检测自噬相关基因Beclin1、Atg5的mRNA表达,蛋白免疫印迹法（Western blot）检测自噬标志蛋白LC3蛋白的表达水平. 结果 I/R组T2、T4、T8时点血清LDH分别为[（4 623±397）、（5046±413）、（4 762±431） U/L]（P〈0.05）,与S组相同时点比较,分别升高约78％、87％、81％;I/R组荧光显微镜下单位面积自噬小体与S组比较明显增加;I/R组T2、T4、T8时点Beclin1表达增加,与S组比较,分别增加约42％、69％、33％（P〈0.05）;I/R组T2、T4、T8时点Atg5表达增加,与S组比较,分别增加约80％、121％、73％（P＜0.01）;I/R组T2、T4、T8时点LC3表达增加,与S组比较,LC3Ⅱ与LC3I的比值分别增加约169％、186％、176％（P＜0.01）. 结论 LI/RI可致大鼠小肠组织自噬水平增加.     

Traumatic lower-limb ischemia: an unusual acute presentation of femoral bony exostosis

The current observation reports a traumatic lower-limb ischemia due to an unusual mechanism, associating a bony exostosis and an open fracture of the femoral lower end. The exostosis was removed critically, allowing the artery to resume its modal anatomical location with no thrombosis or dissection. Femoral bony exostosis is rare. The usual presentation is subacute or chronic, leading to the emergence of pseudoaneurysms, and subsequently thrombosis.