复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

糖尿病下肢缺血膝下动脉重建临床效果的初步评价

目的 评价糖尿病下肢缺血患者膝下动脉旁路移植术的中远期通畅率.方法 回顾性分析2001年11月至2006年12月因糖尿病下肢缺血行膝下动脉旁路移植的患者51例共56条肢体.其中男性35例,女性16例,平均年龄68岁,平均缺血时间26个月,平均糖尿病史11年.静息痛26例,足部溃疡坏疽25例.所有患者均行至小腿(胫前、胫后或腓)动脉的旁路移植手术.应用Kaplan-meier生存分析法评价中远期通畅情况,并按照手术方式和流出道血管的不同,进一步采用Log-rank检验比较其对通畅率的影响.结果 平均随访23个月,失访率15%.随访患者总体1年和5年的一期通畅率为68%和54%,二期通畅率为70%和60%,保肢率为69%和65%,存活率为82%和60%.股-腘动脉人工血管-小腿动脉自体静脉旁路移植、股/腘-小腿动脉人工血管旁路移植和股/腘-小腿动脉自体静脉旁路移植的1年(3年)的通畅率分别为70%(50%)、33%(33%)和70%(70%);以胫后、胫前和腓动脉作为流出道的1年(4年)通畅率分别为65%(60%)、80%(53%)和77%(66%);经Log-rank检验,以上各组间差异均无统计学意义(P>0.05).结论 糖尿病下肢缺血旁路移植手术的血管桥应首选自体静脉无论采用胫前、胫后还是腓动脉作为流出道,其中远期通畅率均是可以接受的.     

血栓闭塞性脉管炎合并动脉硬化闭塞导致下肢缺血的手术治疗

目的 探讨下肢血栓闭塞性脉管炎(thmmboangiitis obliterans,TAO)合并动脉硬化闭塞症(arteriosclerosis obliterans,ASO)手术治疗效果.方法 回顾性分析2007年治疗的TAO合并ASO 6例患者的资料.2例行腹主动脉切开取栓+内膜剥脱+腹主动脉-股深动脉人工血管旁路移植-胭动脉人工血管-小腿动脉自体大隐静脉旁路移植术,1例行腹主动脉切开取栓+内膜剥脱+腹主动脉-右股深动脉人工血管旁路移植-膝下胭动脉人工血管旁路移植术;1例行左髂总动脉-左股深动脉人工血管旁路移植一胫前动脉自体大隐静脉原位移植术,1例行左侧人工血管切开取栓+左股深动脉成形-膝下腘动脉人工血管旁路移植术,1例行右股总动脉-左股总动脉人工血管旁路移植-胫后动脉自体大隐静脉旁路移植术.结果 5例患者术后恢复顺利,1例于术后当天出现股动脉-腘动脉人工血管和远段的大隐静脉桥血栓形成,立即再次手术行人工血管和大隐静脉切开取栓术,并同时行胫后动静脉吻合.6例患者均痊愈出院,无死亡病例.5例患者的下肢远端静息痛完全缓解,1例部分缓解.足部溃疡的2例创面明显缩小,无感染发生.所有患者得到随访,平均随访为6.5个月,3例足部溃疡愈合.1例术后3个月出现左股部切口感染,最终行膝上截肢处理,残端一期愈合.其他5例患者的移植血管通畅,症状缓解.结论 对TAO合并ASO患者如果手术治疗方式恰当,可以取得比较好的疗效.     

小腿动脉为流出道的股-小腿动脉或股-腘-小腿动脉旁路术随访分析

.9%.保肢患者中重症下肢缺血占13.0%,随访时踝肱指数足背动脉0.66±0.26,胫后动脉0.64±0.25,与术前和术后相比差异均有统计学意义.自体静脉和复合血管、股-小腿动脉直接旁路和股-腘-小腿动脉序贯旁路在保肢率和旁路血管通畅率上差异无统计学意义.结论 以小腿动脉为流出道的旁路术对于腔内治疗失败或长段、多节段动脉闭塞濒临截肢者是有效的治疗方法 .加强术后随访和早期干预有助于提高二期通畅率和保肢率.     

股腘动脉闭塞症的手术治疗

目的 探讨股腘动脉旁路移植术治疗下肢动脉硬化闭塞症(C、D级病变)的近中期疗效.方法 2005年1月至2009年2月,170例患者(191条肢体)行股动脉以远血管重建术.其中男性108例,女性62例;年龄45～85岁,平均67岁.症状包括间歇性跛行78例,静息痛62例,下肢缺血性溃疡19例,远端组织坏死11例.所有患者术前均行动脉造影检查,根据TASC Ⅱ分级:C级病变127条肢体,D级病变64条肢体.手术方法包括大隐静脉原位旁路移植术15条肢体,大隐静脉转位20条肢体,人工血管旁路移植术128条肢体,大隐静脉与人工血管组合旁路移植术28条肢体.结果 围手术期无死亡病例.术后随访6～36个月,平均(24±6)个月;76例失访,随访率57%(109/191).一期通畅率84.4%(92/109),其中人工血管旁路移植通畅率88.2%(75/85),大隐静脉(原位、转位、组合)旁路移植通畅率70.8%(17/24).二期通畅率89.9%(98/109).结论 人工血管旁路移植术是治疗严重股腘动脉闭塞症(TASC C和D级病变)的主要方法,手术疗效满意.     

自体大隐静脉倒置旁路转流术治疗下肢血栓闭塞性脉管炎

目的:探讨自体大隐静脉倒置旁路转流术治疗下肢血栓闭塞性脉管炎的疗效.方法:回顾性分析2007年1月-2012年5月采用自体大隐静脉倒置旁路转流术治疗下肢血栓闭塞性脉管炎21例患者临床资料,其中行股浅动脉-胫后动脉旁路转流术9例,股浅动脉-腓动脉旁路转流术5例,股浅动脉-腘动脉远端旁路转流术4例,腘动脉-胫后动脉旁路转流术3例.结果:1例拟行股浅动脉-胫后动脉旁路转流术患者术中证实远端流出道差而终止手术,20例完成手术,成功率为95.2％.患者术后肢体远端血供均改善、静息疼消失、间隙性跛行距离延长、溃疡愈合;平均踝肱指数(ABI)由术前0.46±0.12上升到术后1.05±0.07 (P＜0.001).18例获得随访5～59(30.6±7.5)个月,治疗效果稳定.结论:自体大隐静脉倒置旁路转流术是存在远端流出道的血栓闭塞性脉管炎患者有效的治疗方法.     

注射毒品所致假性股动脉瘤18例的外科治疗

目的 探讨注射毒品所致假性股动脉瘤的外科疗法。方法 对18例注射毒品所致辞假性动脉瘤患者的临床资料进行回顾分析。13例直接采用ePTFE人工血管行旁路髂外动脉和股浅动脉端侧吻合术；3例采用自体大隐静脉间置移植术，其中１例吻合口破裂出血改用ePTFE人工血管行旁路髂外动脉和股浅端侧吻合术；2例股动脉结扎术。结果 全部病例保肢成功。血管移植术后复查彩色多普勒超声显示移植血管通畅。结论 在患者不能提供合适的自体大隐静脉移植时，人工血管移植仍是治疗假性股动脉瘤的有效方法。术中彻底清创及避免污染是预防术后人工血管并发感染的最主要措施     

联合动静脉瘘对流出道不良患者动脉旁路术通畅率的影响

目的通过对流出道不良患者行动脉旁路术联合动静脉瘘通畅率的分析,强调对流出道不良患者积极手术抢救患肢的重要性,并探讨合理的手术方式。方法回顾性分析行动脉旁路术(ePTFE)联合动静脉瘘手术治疗的26例下肢流出道严重不良患者的临床资料。结果26例(28条肢体)患者中,有14例行浅组(膝部大隐静脉)动静脉瘘,有12例联合行深组(腘、胫腓干、胫后静脉)动静脉瘘。24例获随访,平均随访8个月,近期通畅率两组均为78·6%,远期通畅率深组为78·6%,浅组为57·1%。结论动脉旁路术联合动静脉瘘可提高流出道不良的下肢缺血患者术后通畅率。     

经人工血管腔内治疗转流后血管通路狭窄

目的 探讨经人工血管径路的血管腔内治疗的安全性与疗效.方法 17例人工血管转流术后患者,16例吻合口狭窄伴有人工血管血栓形成(10例同时有流人道或流出道狭窄),1例仅有流入道狭窄.局麻下,16例(有吻合口狭窄和人工血管血栓形成)在人工血管取栓后行血管腔内治疗;1例直接经皮穿刺人工血管行血管腔内治疗.观察转流血管的通畅情况.结果 13例远端吻合口,1例近端吻合口各置入支架1枚,2例远端吻合口放置支架失败(10例同时行髂动脉、腘动脉、胫后或胫前动脉支架置入或球囊扩张术),1例只行股总动脉支架置入.随访时间为1～35个月,平均为(12±4)个月;2例下肢缺血加重,其中1例出现足部及小腿的坏疽,1周后行膝上截肢术,另1例又行转流术;1例3个月后又出现下肢缺血症状,1例6个月后死于心肌梗死,其他病例血管仍保持通畅.结论 经人工血管径路的血管腔内治疗,创伤小,近期疗效尚可,为处理人工血管转流术后吻合口狭窄、流人道和流出道病变添加了一种方法.     

旁路移植人工血管闭塞原因分析及再手术的术式选择

目的 分析旁路移植人工血管闭塞的原因，探讨再手术术式的选择。方法 回顾性分析自1993年1月至2002年5月治疗的旁路移植人工血管闭塞患者47例。均给予再手术治疗，其中单纯人工血管切开取栓9例；人工血管取栓 吻合口成形16例；人工血管或自体大隐静脉再移植22例。结果 单纯人工血管切开取栓术及人工血管取栓 吻合口成形术的2年再闭塞率分别为67％、56％，明显高于人工血管或自体大隐静脉再移植手术术式的9％。结论 人工血管或自体大隐静脉再移植手术的效果明显优于单纯人工血管切开取栓术及人工血管取栓 吻合口成形术。     

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.     

Infrainguinal bypass grafting using lyophilized saphenous vein allografts for limb salvage

Critical ischemia in patients with extensive femoropopliteal occlusive disease often ends in amputation in the absence of a suitable autologous vein for reconstruction. Cryopreserved vascular allografts have been used as an alternative conduit with poor results. Antigenicity and rejection are assumed to account for graft failure. Lyophilized vessels have demonstrated patency and structural integrity in the vascular system in our previous experimental studies. We report four patients that underwent femorodistal bypass grafting with lyophilized saphenous veins who lacked usable autologous vein for arterial reconstruction. Early graft thrombosis occurred in three patients who required major amputations. Duplex scans for graft surveillance did not reveal previous significant abnormalities. These cases demonstrate that the clinical use of lyophilized venous allografts for infrainguinal arterial reconstructions failed to yield satisfactory patency and limb salvage. Lyophilized veins therefore are not useful alternative conduits in patients with critical ischemia and no suitable autologous vein grafts.     

Staged infrainguinal revascularization: initial prosthetic above-knee bypass followed by a distal vein bypass for recurrent ischemia. A valid concept for extending limb salvage?

Optimal infrainguinal revascularization should provide limb salvage for the longest duration of time. It is not known whether limb salvage is longer with an initial below-knee popliteal or tibial in situ saphenous vein graft or with staged bypasses; that is, an initial above-knee popliteal prosthetic bypass if feasible, followed by a more distal vein graft should the above-knee prosthetic graft fail. A retrospective review of 197 lower extremity vascular reconstructions performed since 1976 utilizing polytetrafluoroethylene (PTFE), umbilical vein, or in situ saphenous vein was completed. The data were analyzed for differences in limb salvage and prevention of limb threatening ischemia among three subgroups: above-knee prosthetic bypass, below-knee or tibial in situ saphenous vein bypass, and staged reconstructions (above-knee prosthetic bypass with subsequent in situ bypass). The groups were similar with respect to severity of limb threatening ischemia as indicated by mean preoperative ankle-brachial indices. Cumulative secondary limb salvage at 36 months was 73 percent for prosthetic grafts in the above-knee position, 78 percent for in situ saphenous vein grafts in the below-knee or tibial position, and 87 percent for staged reconstruction with an initial prosthetic graft to the above-knee position followed by a distal in situ vein bypass when the prosthetic graft fails.     

大隐静脉原位转流术重建下肢血液循环

目的:评价大隐静脉原位转流术治疗下肢动脉硬化闭塞症的疗效.方法:运用自制瓣膜切除器开展大隐静脉原位转流术治疗下肢动脉硬化闭塞症38例共40例肢体.患者术前踝肱指数(ABI)为0-0.58(平均0.29),均经动脉造影证实.术后移植物均可扪及搏动,有28条肢体足背或胫后动脉搏动恢复,17例同时行输入输出道动脉重建术,溃疡清创术6例,4例于术后3天内出现移植物搏动消失,行第2次重建术,结果:ABI平均值同术前0.29上升至0.84,严惩缺血肢体挽救率为100%,经寿命表统计分析,1-5年的血管累积通畅率分别为92%,87%,82%,72%和65%,结论:大隐静脉原位转流术是治疗下肢动脉硬化闭塞症的理想方法之一,同时行输入功输出道动脉重建术,对保证移植血管的通畅有着重要的意义.     

Composite sequential grafts in severe ischemia: a comparative study

From October 1978 to June 1983, 64 sequential bypass grafts were performed in 59 patients with limb-threatening ischemia. These patients were classified into three study groups as follows: reversed saphenous vein graft alone (12), composite sequential (proximal polytetrafluoroethylene [PTFE] and distal vein) graft (30), and PTFE graft in entirety (22). Graft patency was confirmed in all cases by serial Doppler ankle pressure measurements or by angiography. Cumulative life-table patency rates were then compared over a period of 27 months. The patency rates for composite sequential grafts using a distal short segment of vein were statistically indistinguishable from those for bypasses performed entirely with saphenous vein. These yielded a patency rate of 80% at 1 and 2 years. In contrast, the 1- and 2-year patency rates of the PTFE sequential grafts were 52% and 47%, respectively (p less than 0.05). Composite sequential bypasses using an otherwise inadequate segment of saphenous vein are a sound alternative revascularization procedure, with a patency rate comparable to that of reversed saphenous vein bypasses.     

Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.     

Infrapopliteal bypass grafts for severe ischaemia of the lower limb

A retrospective survey of 27 infrapopliteal bypass grafts performed for rest pain revealed a cumulative limb salvage rate of 65.3% with an overall operative mortality of 8%. When pre-operative angiography demonstrates a patent infrapopliteal artery, reversed saphenous vein bypass grafting offers a realistic alternative to primary amputation when femoropopliteal occlusion threatens limb viability.     

Popliteal-crural bypass through the posterior approach with lesser saphenous vein for limb salvage

PURPOSE: A review of popliteal-crural bypasses via the posterior approach was done to evaluate the results of this technique. METHODS: During a period of 36 months, 21 patients with limb-threatening ischemia underwent 21 popliteal-crural bypasses via the posterior approach in the prone position with reversed lesser saphenous vein. All patients had limb-threatening ischemia, with rest pain in five patients, ulceration in nine patients, and gangrene in seven patients. Diabetes mellitus was present in 17 patients. RESULTS: The inflow site was the supragenicular popliteal artery in 12 patients and the infragenicular popliteal artery in nine patients. The outflow sites were the tibioperoneal trunk in five patients, the posterior tibial artery in six patients, the peroneal artery in eight patients, and the anterior tibial artery in two patients. Of the seven patients with gangrene, three patients underwent transmetatarsal amputation and four underwent toe amputation. The limb salvage rate for the entire group was 100% at 24 months. No early graft failures were seen, and the 12-month and 24-month primary graft patency rates were 89% and 77%, respectively, with life-table analysis. The primary assisted patency rate was 95% at 12 and 24 months. Patency was determined with duplex scan graft surveillance. CONCLUSION: The posterior approach to popliteal-distal bypass is an acceptable alternative to traditional bypass procedure with excellent early patency and limb salvage results. The approach has the advantage of better utilization of lesser saphenous vein and easier operative exposure in patients with short segment infrapopliteal occlusive disease.     

Reinforced long saphenous vein bypass graft for infrainguinal reconstruction procedures: case series and literature review

Poor rehabilitation rates and the high-cost of managing postamputation patients justify an aggressive revascularization policy in critical lower limb ischemia. Endovascular therapy is our first choice for limb salvage in these patients. However there are patients for whom endovascular therapy is not feasible. When bypass is necessary, autologous vein is a superior conduit to synthetic material. However, varicosities usually contraindicate autologous vein bypass because of the risk of aneurysm formation, rupture and increased intimal hyperplasia compared with nonvaricose venous grafts. We report the use of varicosed long saphenous vein (LSV) with external Dacron support in infrainguinal bypass procedures for limb salvage, where endovascular therapy was not feasible. The external Dacron tube was not brought close to the distal anastomotic area itself. With a mean follow-up of 18 months, duplex ultrasonography and computed tomography angiography showed no evidence of stenosis of the reinforced vein segments or aneurysmal degeneration of the residual vein. External reinforcement with Dacron prosthesis allows the use of autogenous greater saphenous veins with varicose dilatation without compromising graft patency and limb salvage.