血透内瘘闭塞的介入治疗

目的讨论使已闭塞的血透内瘘恢复功能的介入治疗方法。方法4例患者采用PTD行经皮机械血栓切除术、尿激酶血栓溶解及时严重狭窄的静脉流出道、动静脉吻合口行PTA治疗共进行了5次介入治疗。结果4例患者的血透内瘘术后即刻恢复了功能,造影示内瘘血流通畅,吻合口有震颤、杂音明显,静脉明显搏动。结论采用多种介入方法治疗闭塞的血透内瘘是一种安全、简单、有效的方法,尤其适合门诊病人的治疗。     

血液透析动静脉内瘘的静脉血管造影

通过对30例血透动静脉內痿进行静脉血管造影,作者认为静脉血管造影不仅可显示造瘘静脉,还可显示造瘘动脉和吻合口。动静脉内瘘的并发症多发生于静脉。因此,静脉血管造影是发现动静脉内瘘并发症有效而安全的方法。由于其操作方便,患者痛苦小,可广泛应用。静脉血管造影最常见的副作用是手部烧灼感。     

吲哚菁绿荧光血管造影技术对神经外科手术效果的影响

目的:研究在神经外科血管性疾病的手术中应用吲哚菁绿(ICG)荧光血管造影技术对手术效果的影响。方法:不同的神经外科血管性疾病患者47例,男性21例,女性26例;年龄16～73岁,平均57岁。在手术中进行ICG荧光造影,以进一步指导及评估手术效果。其中,颅内动脉瘤患者37例(后交通动脉瘤12例,前交通动脉瘤14例,大脑中动脉动脉瘤11例);颞浅动脉-大脑中动脉吻合术7例;脊髓动静脉瘘3例。上述患者均在术后行DSA血管造影或CTA以明确手术效果。结果:37例动脉瘤术中经ICG血管造影,发现动脉瘤颈夹闭后载瘤动脉狭窄3例,动脉瘤颈残留4例,远端分支狭窄2例,均根据术中吲哚菁绿血管造影情况重新调整瘤夹位置后,瘤颈夹闭满意,术后DSA血管造影及CTA显示载瘤动脉通畅,远端分支无狭窄,术后早期CT检查显示无脑梗死。7例颞浅动脉-大脑中动脉吻合术中行ICG造影见1例吻合口狭窄,予以拆除吻合线重新缝合,再次ICG造影显示吻合血管通畅。3例脊髓动静脉瘘切除病变前均可发现畸形血管轮廓、供血动脉、引流静脉情况,引导精准的切除动静脉瘘,术后血管造影显示3例畸形血管团均被彻底切除。结论:吲哚菁绿荧光血管造影可以准确判断动脉夹闭后瘤颈是否有残留、穿通动脉是否闭塞;可以及时发现血管吻合是否通畅;可以明确脊髓动静脉瘘的轮廓及其供血动脉、引流静脉;能显著提高上述血管性疾病的手术效果。     

静脉支架成形治疗矢状窦复杂性硬脑膜动静脉瘘

目的 探讨通过静脉支架植入改善硬脑膜动静脉瘘引流,治疗伴引流静脉狭窄的硬脑膜动静脉瘘的可行性及疗效。方法 1例上矢状窦,左侧横窦及颈静脉球区的复杂性硬脑膜动静脉瘘患者,伴右侧横窦闭塞,左侧颈静脉严重狭窄达80％,矢状窦扩张,将支架植入狭窄静脉,改善静脉引流。结果 成功植入静脉支架,残余狭窄约30％,症状明显改善,头痛逐渐消失,行走不稳消失,视力较前明显改善。6个月后复查脑血管造影显示颈静脉支架位置形态好,无支架内狭窄,上矢状窦、横窦及乙状窦瘘口较前无明显变化。结论 静脉支架植入改善硬脑膜动静脉瘘引流,治疗伴引流静脉狭窄的硬脑膜动静脉瘘是可行的,其近期疗效满意,长期疗效有待进一步随访观察。     

动脉穿刺自体动静脉内瘘造影评价血管透析通路

目的 应用静脉留置针直接动脉端顺行穿刺的方法行自体动静脉内瘘血管造影,评估血透患者的血管通路狭窄情况,为临床手术重建内瘘功能或经皮腔内血管成形术(PTA)提供正确的术前影像指导.方法 采用西门子Artis U中型C臂机对46例临床自体动静脉内瘘流量不佳的维持性血透患者进行检查,穿刺针选用BD Intima Ⅱ 20G或22G 密闭式静脉留置针,在内瘘动脉端顺穿成功后,经高压注射器注入非离子型对比剂安射力,速率1～1.5ml/s,对比剂总量约2～5ml,造影图像采集为4帧/s.结果 46例患者均顺利完成检查,无任何并发症发生.所有患者均获得满意的内瘘造影图像,包括动脉流入道、吻合口和静脉流出道等影像,血管狭窄程度、长度、部位均得到清晰显示.其中内瘘吻合口狭窄2例;桡动脉流入道狭窄伴头静脉流出道狭窄5例;头静脉流出道狭窄37例,内瘘吻合口狭窄伴静脉流出道狭窄1例,桡动脉流入道闭塞伴内瘘侧枝循环形成1例.结论 采用静脉留置针在内瘘动脉端顺穿的方法行内瘘血管造影检查,具有操作简便、微创、患者易接受、可重复性好、对比剂用量少、图像清晰、动态显示等的优点,尤其是对患者的残余肾功能保护十分有利,能准确评估患者的透析血管通路情况,为临床治疗提供指导.     

多排螺旋CT血管造影评估血液透析患者自体动静脉内瘘功能不全

目的 探讨16排螺旋CT血管造影(CTA)对血液透析患者自体动静脉内瘘功能不全的价值.方法 21例自体动静脉内瘘功能不全的患者进行血管造影检查后,分别采用最大密度投影(MIP)和容积再现(VR) 技术对扫描的图像进行二、三维重建后处理,观察自体动静脉内瘘血管的成像情况.结果 21例患者病变血管成像清晰,显示单纯吻合口狭窄4例;流入动脉狭窄4例,其中多处狭窄3例;流出静脉狭窄7例,其中多处狭窄5例,伴有明显的静脉侧支循环4例;流入动脉及流出静脉同时狭窄2例;流入动脉、流出静脉及吻合口均狭窄2例;仅有动脉粥样斑块但无明显狭窄2例.本组合并附壁血栓6例,静脉瘤样扩张5例.结论 CTA评估血液透析患者自体动静脉内瘘功能不全,具有微创、能精准地显示内瘘血管的全貌和病变等优点.     

硬脊膜动静脉瘘的MRI和DSA影像学特点及栓塞治疗

目的 探讨硬脊膜动静脉瘘的MRI和DSA影像学特点及血管内栓塞治疗方法。方法 12例硬脊膜动静脉瘘患者均行MRI和脊髓血管造影检查,4例行栓塞治疗。分析其MRI和血管造影表现。结果 12例硬脊膜动静脉瘘中,MRI屉示脊髓内弥漫性长T2信号影11例,脊髓斑片状强化2例,脊髓背侧异常血管影6例。脊髓血管造影均能显示其瘘口和引流静脉,并反映其病变范围、供血状况及特征。4例行栓塞治疗患者其临床症状均有改善。结论 脊髓血管造影是诊断硬脊膜动静脉瘘的主要确诊方法。MRI对确定诊断具有重要作用。血管内栓塞是一种有效的治疗方法。     

前臂自体动静脉内瘘数字减影静脉造影方法分析

目的探讨前臂自体动静脉内瘘数字减影静脉造影(DSV)方法。方法2017年8月至2019年3月,对62例震颤减弱或无震颤低位自体动静脉内瘘通路进行DSV检查。检查中采用不阻断血流静脉顺行造影、阻断血流后动静脉容量灌注造影、保留对比剂旋转观察及释放止血带压力时血流恢复造影等多种方法。结果62例患者成功完成DSV检查,术中和术后均无明显并发症发生。其中动静脉瘘口完全闭塞5例(8%),前臂回流静脉主干血管闭塞12例(19%),主干不同程度狭窄45例(73%);伴有明显静脉瘤样扩张8例(13%),桡动脉狭窄12例(19%)。结论前臂自体动静脉内瘘DSV是一种安全、操作简单、结果可靠的检查方法。     

血液透析之自体动静脉内瘘的CT血管造影初步研究

目的:利用16层CT研究血液透析之自体动静脉内瘘的血管造影.材料和方法:慢性肾衰进行血液透析患者14例,2例肘部内瘘,其余均腕部标准内瘘.采用16层CT机,1mm×16方式,从非患肢前臂静脉进针,非离子型碘造影剂90ml,注射速度3ml/s,延时25～30s开始扫描,数据薄层重建采用低通滤过(FC01),层厚1mm,重建间隔0.8mm,分别完成容积显示、最大强度投影、多层面重建或曲面重建的CT血管造影(CTA).结果:所有病例患肢血管在CTA上均得到良好显示,包括4例掌动脉弓良好显示.流入动脉均未见异常,前臂或肘部的引流静脉闭塞、中断6处,侧支循环明显;吻合口及其后的流出道狭窄19处,包括吻合口狭窄4处、吻合口后近处狭窄6处、其余各处狭窄8处,狭窄可为局限或细长.1例见头臂静脉支架内栓子形成.结论:CTA可以充分显示自体动静脉内瘘及其相关血管,有助于临床相关问题的解释和指导治疗.     

经微导管局部灌注无水乙醇治疗肝癌高流量性动静脉瘘

目的：探讨经微导管血管内局部灌注无水乙醇栓塞治疗肝癌动静脉瘘的可行性及临床疗效。方法：对29例肝癌患者动静脉瘘血管分别应用微导管行超选择性插管局部灌注无水乙醇，造影观察动静脉瘘闭塞情况及对非靶血管的影响。结果：29例肝癌患者共发现41支动静脉瘘血管，单支血管局部灌注无水乙醇1-6次，2-3ml/次，总量2-12ml。造影示瘘管全部闭塞，非靶血管保持通畅，随后经导管动脉化疗栓塞（TACE）碘油沉积满意，临床症状明显好转或消失。结论：应用微导管局部灌注无水乙醇可安全有效地治疗肝癌动静脉瘘，为肝癌TACE治疗创造有利条件。     

Balloon angioplasty of venous structures

Percutaneous transluminal angioplasty was attempted in 20 patients with stenoses of venous structures. It concerned one stenosis in a native subclavian vein, 12 stenoses in venous bypass grafts and 7 stenoses in hemodialysis-access fistulas. Primary results were excellent for the procedures in the native vein and the venous bypass grafts with success in all patients (13/13). In the arteriovenous fistulas for hemodialysis, dilatation of the venous stenoses was only possible in 5 out of 7 patients. The subclavian vein stenosis did not recur within a follow-up period of 3 years. Of the stenoses in the venous bypass grafts, two lesions reoccluded within one week and 6 lesions recurred within one year. Two of these lesions were successfully redilated so that 6 lesions remain patent with a follow-up of more than one year. Of the 5 successful dilatations in hemodialysis-access fistulas, two lesions recurred within 2 months. Only 3 veins are still accessible for hemodialysis. It is concluded that attempts at balloon dilatation of stenoses in venous bypass grafts or hemodialysis-access fistulas are meaningful in order to prolong the life of these surgical procedures. Recurrence of stenoses is however likely to occur within one or two years.     

Hemodialysis grafts: color Doppler flow imaging correlated with digital subtraction angiography and functional status

Twenty-two patients with hemodialysis grafts were prospectively evaluated with color Doppler flow imaging and digital subtraction angiography (DSA). Eighteen patients had normal functional parameters during hemodialysis, and four had increased venous pressure during hemodialysis. Color Doppler flow imaging allowed identification of nine macroaneurysms related to wall degeneration, two cases of spontaneous fistula formation between the graft and peripheral veins, and 20 stenoses. Use of color Doppler flow imaging led to overestimation of the degree of stenosis at the venous anastomosis when compared with use of angiography. Three cases of subclavian venous stenosis were identified only at angiography. Color Doppler flow imaging appears accurate in the detection of stenoses and seems sufficient for follow-up of normally functioning grafts. However, because of its low sensitivity for identification of proximal stenoses and the necessity of obtaining an angiogram to plan surgical or percutaneous correction, DSA remains the technique of choice.     

The importance of preoperative evaluation of the subclavian vein in dialysis access planning.

Adequate venous outflow is critical to the proper function of a vascular-access graft (arteriovenous fistula) used for chronic hemodialysis. Stenosis of the subclavian vein can significantly compromise this venous outflow. The development of such subclavian vein stenoses has been associated with the prior placement of temporary subclavian vein dialysis catheters. We evaluated the importance of preoperative detection of these stenoses before placement of a permanent vascular-access graft in the upper extremity. Upper extremity venography was performed before placement of a permanent vascular-access graft in 43 patients. A total of 62 extremities were evaluated. A 40% prevalence of moderate or severe subclavian vein stenosis was found in patients with prior or existing temporary dialysis catheters in the subclavian vein. No stenoses were found in patients without a history of dialysis catheters in the subclavian vein. This difference in the prevalence of subclavian vein stenosis is statistically significant (p less than .001). In no case was the stenosis suspected clinically. Before placement of a permanent vascular-access graft, the subclavian vein should be evaluated in all patients with a history of a temporary dialysis catheter in the subclavian vein. The use of sites other than the subclavian vein for temporary dialysis is strongly encouraged.     

Intravenous digital subtraction angiography in patients with femoral arteriovenous fistulas and ilio-iliac crossover graft

Fourteen patients with femoral arteriovenous (AV) fistulas and ilio-iliac crossover bypass grafts after postthrombotic occlusion of an iliac vein were studied by intravenous digital subtraction angiography (IV DSA). Digital radiography's utility may be evaluated in the demonstration of the vascular status of AV fistulas and venous return through the reopened iliac vein or ilio-iliac graft. Digital subtraction imaging is a suitable modality to plan operations, such as closure of temporary AV fistula. In follow-up studies of these cases, patency of the crossover bypass can be assessed by noninvasive DSA of the ascending veins.     

Traumatic fistula between internal iliac artery and external iliac vein

Traumatic iliac arteriovenous fistulas (AVFs) are extremely rare, with only two cases reported in literature involving the internal iliac artery and the external iliac vein. We report the case of a 23-year-old man who sustained a gunshot injury to the left lower quadrant of his abdomen and subsequently developed unilateral leg edema of "elephantiasic proportions." Intra-arterial digital subtraction angiography six years later was essential for diagnosis and comprehension of the pathomechanism. The angiographic examination showed an internal iliac false aneurysm, as well as a high-flow arteriovenous communication between the left internal iliac artery and external iliac vein complicated by thrombotic occlusion of the left common iliac vein. The initial vascular injury and the surgical management of simple ligation were thought to be responsible for the iliac AVF and the subsequent thrombosis of the common iliac vein. On the one hand, the thrombotic occlusion of proximal vein led to a sharp increase of mean pressure in the proximal and distal arteries and in the distal vein, resulting in chronic venous insufficiency with incompetent varicose veins. On the other hand, the restriction of venous outflow produced extreme peripheral edema and large superficial veins serving as collaterals to bypass the fistula. Vascular surgery could repair the lesion by closing and bypassing the AVF.     

头颈部双源CT血管成像诊断硬脑膜动静脉瘘的价值探讨

目的探讨头颈部双源cT血管成像（CTA）诊断硬脑膜动静脉瘘（DAVF）的价值。方法收集2009年6月至2012年6月8例DAVF患者的头颈部CTA资料,以8例性别及年龄相似的正常头颈部CTA为对照组,对比分析DAVF患者与正常头颈部CTA的征象差异,分析征象包括畸形血管的供血动脉数量,患侧硬膜窦边缘是否规整,有无异常穿颅血管通道,大脑皮层静脉是否扩张以及双侧颈内静脉密度是否对称等。结果多支（≥3条）供血动脉诊断DAVF的特异性、敏感性分别为88％、100％。患侧静脉窦边缘不规则的敏感性较低（50％）,特异性很高（100％）。出现异常穿颅血管通道的敏感性较低（38％）,特异性较高（88％）。DAVF组的双侧颈内静脉密度不对称性差异存在统计学意义（P=0．017）。结论头颈部双源CTA对诊断DAVF具有较高的价值,出现多支供血动脉、患侧静脉窦边缘不规则及双侧颈内静脉密度不对称高度提示DAVF。     

Percutaneous transluminal angioplasty of stenotic lesions in dialysis vascular accesses

Forty-five stenoses behind arteriovenous fistulas in 35' haemodialysed patients were treated with percutaneous transluminal angioplasty (PTA). Immediate stenoses dilatation results in relation to the AVF type were haemodynamically significant in 40 cases (88%), with poorer results on bovine heterograft stenoses. Dilatation results in relation to the site of the lesion showed haemodynamically efficient angioplasty on stenoses next to the anastomosis (67.5%) but a poor result on distal lesions (4 cases). We observed 4 cases of thrombosis but 2 recovered after treatment, one after local fibrinolytic perfusion one after surgical thrombectomy. Follow-up over a period of one to 18 months (mean 8 months) including angiography and appreciation of the dialysis quality were performed in 30 patients who had a successful dilatation. PTA appears to be a technically feasible and clinically effective method of treating stenoses lying on the venous limb fistula in patients on chronic haemodialysis.     

Directional atherectomy treatment for hemodialysis access: early results.

The Simpson atherectomy device was used to treat 12 intragraft stenoses, six complete subclavian vein occlusions, and 14 venous outflow stenoses in 24 patients undergoing hemodialysis. Patients were followed up clinically and by means of venography at approximately 1, 3, 6, 9, and 12 months after treatment. Twenty-eight atherectomy specimens were examined histologically. Twenty-six (81%) of 32 lesions were treated with initial technical success. Including technical failures, seven (58%) of 12 intragraft stenoses are angiographically patent at a mean of 5.0 months and five (50%) of 10 are clinically patent at 6 months. Three (50%) of six subclavian veins are angiographically patent at a mean of 5.6 months, and four (67%) of six are clinically patent at 6 months. Three (21%) of 14 venous outflow stenoses are angiographically patent at a mean of 5.0 months and five (38%) of 13 are clinically patent at 6 months. Histologic examination showed neointimal fibromuscular hyperplasia in 26 of 28 lesions. When 30% or less angiographic residual stenosis is used as the criterion for initial technical success, directional atherectomy appears to be effective therapy for intragraft stenoses and, with balloon angioplasty, for some catheter insertion-related subclavian occlusions. Directional atherectomy appears to have a recurrence rate for venous outflow stenoses similar to that for balloon angioplasty when the same criterion is used.     

Stenoses of vascular anastomoses after hepatic transplantation: treatment with balloon angioplasty.

Vascular complications after liver transplantation include occlusion or stenosis at the sites of anastomosis in the hepatic artery, portal vein, and vena cava. From our experience with more than 600 liver transplants, vascular stenoses have been identified in 10 patients and treated by balloon angioplasty in nine. Three patients with hepatic artery stenosis and deteriorating graft function were treated by balloon angioplasty with a coaxial technique. A specially designed catheter facilitated a successful femoral artery approach. Portal vein stenoses in three patients resulted in portal hypertension. These were treated by balloon dilatation via transhepatic catheterization of the portal vein. Stenoses of the suprahepatic caval anastomosis were dilated in three patients with severe lower limb edema. Technical success was achieved in all three cases of hepatic artery stenosis with improvement in graft function. Recurrent stenoses in two patients were successfully treated with repeated dilatations. Portal hypertension resolved in two of three patients after portal venoplasty. Dilatation of a caval stenosis resulted in the resolution of leg edema in all three cases. Repeated dilatation was required in one case. No reduction in the portal venous pressure gradient occurred after venoplasty in one case, and an ultimately fatal caval thrombosis developed in one patient with caval stenosis before venoplasty could be performed. Our experience suggests that balloon angioplasty of arterial and venous stenoses complicating hepatic transplantation carries little risk and is a useful procedure for the treatment of these problems.     

支架植入治疗血液透析动静脉瘘中心静脉阻塞的价值分析

目的 探讨经皮血管支架植入术(PTS)治疗自体动静脉内瘘(AVF)透析患者中心静脉阻塞(CVO)可行性及临床应用价值.方法 回顾性分析10例AVF伴CVO患者,临床均表现为手肿胀综合征.术前或术中均接受DSA检查明确阻塞部位,根据不同病情采用合适手术入路,伴有血栓形成患者先行导管接触溶栓(CDT),严重狭窄或闭塞患者先以小直径球囊预扩张遂行PTS,其余患者直接行PTS.结果 DSA显示5例有颈内静脉置管史患者为头臂静脉闭塞或/和锁骨下静脉、颈内静脉、上腔静脉闭塞或狭窄,5例无颈内静脉置管史患者均表现为内瘘侧锁骨下静脉内侧段局限性严重狭窄.10例PTS技术成功率为100％,植入支架19枚,1例(锁骨下静脉狭窄)术后7个月支架内再狭窄再行PTS术.一期通畅率在术后6个月为8/8,术后1年为3/4.结论 AVF透析患者CVO多为闭塞性或严重狭窄病变,PTS治疗成功率高、近中期效果满意、并发症轻微,安全有效、可行,可作为首选治疗方法.