介入治疗锁骨下动脉窃血综合征

目的探讨锁骨下动脉狭窄或闭塞引起的锁骨下动脉窃血综合征（SSS）的介入治疗效果。方法回顾性分析15例锁骨下动脉狭窄（10例）或闭塞（5例）的患者资料。采用经股动脉顺行穿刺或经肱动脉逆行穿刺方式开通,行球囊扩张及支架植入术。术后观察患者体征及并发症。结果技术成功率为100%（15/15）,术后患者症状、体征消失,双上肢收缩压差由术前的（47.00±19.30）mmHg下降至（5.33±2.32）mmHg,差异有统计学意义（P〈0.05）。术后造影示椎动脉血流转为正向血流。随访1～4年,未发现再狭窄。结论介入治疗锁骨下动脉狭窄或闭塞性病变引起的SSS安全、有效。     

锁骨下动脉闭塞的血管腔内治疗

目的：探讨经皮血管内成形术(PTA)和血管内支架置放术治疗锁骨下动脉起始段闭塞的疗效。方法：应用经皮血管内成形术(PTA)和血管内支架安置术治疗5例锁骨下动脉起始段闭塞的病人。结果：5例手术均获成功。术后患肢动脉搏动恢复正常，多普勒测压双上肢血压压差由术前平均54mmHg降至术后9．6mmHg．术后随访1～3月；彩超提示支架无脱落及移位，病变部位血流通畅，椎动脉恢复为正常人颅血流。结论：PTA和血管内支架安置术是治疗锁骨下动脉起始段闭塞的一种微创、安全可行和疗效满意的方法。     

经皮血管内治疗症状性基底动脉粥样硬化性狭窄的探讨

目的 探讨经皮腔内血管成形支架置入术治疗症状性基底动脉粥样硬化性狭窄的可行性、安全性及有效性.方法 回顾性分析2003年8月至2009年12月,经皮腔内血管成形支架置入术治疗的40例基底动脉粥样硬化性狭窄患者的临床资料及术后随访结果 .其中男性33例,女性7例;年龄30～75岁,平均58岁.患者均为经药物治疗无效、反复短暂性脑缺血发作或有明显脑缺血症状.结果 40例经皮腔内血管成形支架置入术均获成功,术后平均狭窄率由术前的82%±14%降为14%±11%,术后继续给予抗血小板聚集治疗.38例患者临床脑缺血症状和体征明显改善,2例术后发生脑干缺血症状加重,经治疗后临床症状好转但遗留神经功能障碍.无出血性并发症发生.随访2个月～7年,经颅多普勒复查26例,显示基底动脉血流速度增快2例.行全脑数字减影血管造影复查6例,1例支架内发生再狭窄,因有临床症状而行二次血管成形支架置入术;1例基底动脉支架内闭塞但侧支循环良好,临床上无后循环缺血症状.结论 经皮腔内血管成形支架置入术治疗基底动脉粥样硬化性狭窄是可行、安全、有效的;大样本的长期疗效有待于进一步观察.     

微创治疗锁骨下动脉窃血综合征

目的 探讨经皮血管内成形术(PTA)及内支架置放术治疗锁骨下动脉窃血综合征(SSS)的疗效。方法 应用PTA及内支架置放术治疗因锁骨下动脉狭窄致SSS患者78例,单纯行PTA22例,行PTA加支架置放术56例。结果 78例患者手术全部获得成功。随访66例,随访时间1～71个月,平均27个月,随访率84．6％。随访病例经彩超及多普勒血流图检查,均未发生病变部位再狭窄,血流通畅良好,椎动脉均为正常血流,放置支架无脱落及移位。结论 PTA及内支架置放术治疗因锁骨下动脉起始段狭窄引起的SSS是一种创伤小、疗效满意、安全可行的微创治疗方法。     

微创治疗锁骨下动脉窃血综合征的探讨

目的:探讨经皮腔内血管成形术(PTA)及内支架置放术治疗锁骨下动脉窃血综合征(SSS)的疗效。方法:应用PTA及内支架置放术治疗锁骨下动脉狭窄所致SSS病人78例,其中单纯行PTA者22例,PTA加支架置放术56例。结果:78例病人全部获得成功。随访66例,随访时间1～71个月(平均27个月),随访率84.6%。随访病例经彩超及多普勒血流图检查,均未发生病变部位再狭窄,血流通畅良好,椎动脉均呈正常血流,放置支架无脱落及移位。结论:PTA及内支架置放术治疗锁骨下动脉起始段狭窄所引起的SSS是一种创伤小、疗效满意、安全可行的微创治疗方法,但操作应耐心、仔细和规范化。     

儿童肝移植术后门静脉狭窄的诊断与治疗

目的分析儿童肝移植术后门静脉狭窄(PVS)的可能危险因素,并探讨不同治疗方式的临床疗效。 方法回顾性分析2013年6月至2017年12月首都医科大学附属北京友谊医院肝移植中心396例儿童肝移植受者临床资料(年龄≤14周岁)。随访至2018年6月,有26例发生PVS(6.6%)。对于超声怀疑PVS的儿童受者,本中心多选用门静脉血管造影确诊。术后采用超声监测门静脉直径及流速,观察血管通畅情况。采用随访观察并口服药物抗凝治疗、球囊扩张、门静脉支架置入或Meso-Rex分流术治疗PVS。监测肝功能变化,评估有无门静脉相关的移植物损伤,并观察有无门静脉高压相关的症状或体征。 结果26例儿童受者术后发生PVS中位时间为9.5个月(1.3～50.0个月),其中3个月以内发生者占26.9%(7/26),3个月以后占73.1%(19/26)。行介入球囊扩张和支架置入或Meso-Rex分流术共47例次,均未因PVS死亡。2例儿童受者动态随访,期间口服抗凝药物;23例行门静脉球囊扩张术,1例因门静脉冗长行1次门静脉球囊扩张＋支架置入术,10例经1次门静脉球囊扩张术后无效后行二次球囊扩张,7例经二次门静脉球囊扩张术后无效行门静脉支架置入术,2例经门静脉支架置入术后再次狭窄,行Meso-Rex手术。1例口服药物抗凝治疗的儿童受者,随访期间超声提示门静脉流速偏快,其余随访至今未见PVS复发。 结论超声是监测儿童肝移植术后门静脉情况、早期发现PVS的有效办法。发生PVS时,轻症儿童受者可动态随访,期间口服抗凝药物;中重度儿童受者首选门静脉球囊扩张、门静脉支架置入术。Meso-Rex分流术是对门脉支架置入术后PVS复发或发生门静脉闭塞的一种可选择的手术方式。     

锁骨下动脉窃血综合征的腔内治疗

目的:探讨锁骨下动脉窃血综合征的腔内治疗效果。方法:回顾性分析10年间86例行血管腔内治疗的锁骨下动脉窃血综合征患者临床资料,其中锁骨下动脉闭塞11例,狭窄75例,狭窄程度均>70%。结果:86例患者均成功释放支架,无并发症发生。支架置入术后即刻造影显示:锁骨下动脉狭窄或闭塞段血流通畅,椎动脉血流正向。术后患侧肱动脉即刻恢复搏动,与健侧压差<10 mmHg(1 mmHg=0.133 kPa)。72例患者获随访,平均随访24个月。2例死于恶性肿瘤,4例死于心肌梗死。其余随访患者椎-基底动脉缺血及上肢缺血症状均明显改善或消失。复查超声提示:支架无脱落及移位,血流通畅。结论:锁骨下动脉窃血综合征的腔内治疗微创、安全、成功率高,近期效果肯定,可作为首选治疗方法。     

准分子激光消蚀联合药物涂层球囊治疗左锁骨下动脉支架内再闭塞一例

目前, 针对锁骨下动脉支架内再狭窄/闭塞的治疗主要有球囊扩张成形术、支架植入术、药物涂层球囊扩张成形术以及旁路移植术等。减容术联合药物涂层球囊在下肢动脉硬化闭塞症的治疗中得到广泛应用并取得了良好的疗效, 但是针对锁骨下动脉支架内再狭窄/闭塞的减容术治疗报道很少。本文将汇报1例准分子激光消蚀联合药物涂层球囊治疗左锁骨下动脉支架内再闭塞, 术后效果良好。     

症状性大脑中动脉狭窄的血管内干预治疗

目的 探讨经皮腔内血管成形术及血管成形支架置入术治疗症状性大脑中动脉狭窄的可行性、安全性及有效性.方法 回顾性分析39例患者经药物治疗无效、反复短暂性脑缺血发作(TIA)或有明显脑缺血症状的大脑中动脉狭窄,经皮腔内血管成形或支架置入术的治疗及术后随访结果.结果 39例大脑中动脉狭窄(左侧23例,右侧13例,双侧3例,合并颈动脉狭窄5例)患者经皮腔内血管成形术9例、血管成形支架置入术30例(术后残余狭窄程度均<10%)均获成功,术后给予抗血小板聚集治疗,临床脑缺血症状和体征明显改善.2例患者术中见对比剂外泄,但无明显临床症状,且恢复良好;1例在术后1 h出现意识变化、对侧肢体活动障碍,CT提示支架侧底节区脑出血,经手术治疗后患者遗留语言障碍及右侧肢体不全偏瘫.其余患者无并发症发生.临床随访5～60个月,仅1例在支架置入7个月后右上肢无力症状复发,但较前轻微.经颅多普勒复查26例,显示原病变侧大脑中动脉血流速度增快2例;行数字减影血管造影复查14例,2例支架内发生再狭窄,均行药物治疗观察.结论 经皮腔内血管成形术及血管成形支架置入术治疗大脑中动脉狭窄是可行、安全、有效的;大样本的长期疗效有待于进一步观察.     

27例多发性大动脉炎血管介入治疗

目的探讨血管介入治疗多发性大动脉炎(Takayasu arteritis,TA)所致血管狭窄或闭塞性病变的临床疗效。方法 2003年6月～2011年6月对27例TA经股动脉穿刺选择性血管造影,确定病变部位,明确诊断,并对因大动脉炎引起的锁骨下动脉、颈动脉、肾动脉、腹主动脉病变进行了选择性球囊扩张或支架植入手术。结果 27例施行血管腔内扩张成形术或支架植入术,其中颈总动脉扩张10例,支架2例;锁骨下动脉扩张6例;腹主动脉扩张4例;肾动脉扩张10例,支架4例;无名动脉扩张1例,支架1例;共置入支架7枚。2例颈动脉扩张时因并发症而终止治疗,其余病例病变血管均获得满意的治疗。27例随访5个月～7年,平均4年,其中<12个月6例,1～3年12例,3～5年6例,>5年3例:11例头晕、视觉异常等脑缺血症状改善;12例肾动脉狭窄所致高血压经球囊扩张及支架植入后血压控制正常;2例肾动脉狭窄在球囊扩张后14、18个月再次发生血压增高,造影显示扩张后肾动脉再次狭窄,再次行肾动脉球囊扩张成形术,扩张后高血压恢复正常。结论介入性血管内成形术治疗TA所致血管狭窄或闭塞性病变疗效满意。     

Two cases of percutaneous transluminal angioplasty (PTA) for the treatment of subclavian steal syndrome

Recently percutaneous transluminal angioplasty (PTA) has been used to treat atherosclerotic lesion of the brachiocephalic arteries. We treated two patients with subclavian steal syndrome successfully by PTA. The first patient was a 52-year-old man complaining of vertigo and ischemic symptoms of the left arm. Blood pressure was 110/90 mmHg in the left arm and 140/92 mmHg in the right. On the angiogram, about 80% stenosis was found in the proximal portion of the left subclavian artery, and retrograde filling of the left vertebral artery was observed. At first, a carotid-subclavian bypass surgery was performed, but unfortunately failed because of obstruction of the artificial arterial graft. Then we performed PTA using Grüntzig balloon dilatation catheter. The dilatation was carried out successfully. Immediately after PTA, to-and-fro and antegrade flow of the vertebral artery was observed, and one month later it became normal flow. Neurological symptoms gradually disappeared within two months. The second patient was a 57-year-old man suffering from vertigo on effort and TIA. Blood pressure was 130/78 mmHg in the left arm, and 152/82 mmHg in the right. Angiogram showed more than 95% stenosis of the left subclavian artery, and retrograde filling of the left vertebral artery. We also observed bilateral severe stenosis of the MCA. Carotid-subclavian bypass was dangerous because of the low perfusion of the ipsilateral MCA area. PTA was performed as the first choice, and the dilatation of the stenosis was sufficient. In two months natural antegrade filling of the left vertebral artery was obtained. We followed these patients for 12 months and no restenosis was observed neurologically and radiologically. We performed PTA with the Grüntzig balloon catheter using the Seldinger's method through the right femoral artery. Diameter of the balloon was 6 mm and its length was 4 cm. After setting the balloon to the stenotic lesion, we inflated the balloon with 5atm (75 psi) pressure for 30 minutes. Monitoring the blood pressure and arterial pressure wave at the tip of the catheter, we repeated inflation of the balloon 4 times. We used continuous venous infusion of low molecular dextran and heparin during PTA procedures. No complication occurred and neurological symptoms disappeared gradually. PTA is a safe and effective method, so it should be the first choice in the treatment of subclavian steal syndrome caused by severe stenosis of the subclavian artery.     

256层螺旋CTA在左锁骨下动脉窃血综合征患者术前评估的价值

目的应用256层CTA技术观测左锁骨下动脉解剖特点,评价CTA对锁骨下动脉窃血综合征(SSS)介入治疗术前评估的应用价值。方法回顾性分析60例经临床确诊的SSS患者(疾病组)及500例无SSS受检者(对照组)左锁骨下动脉CTA资料,测量受检者左锁骨下动脉自主动脉弓的起始角度;评价疾病组左锁骨下动脉斑块的特点、管腔狭窄及闭塞情况。结果所有受检者左锁骨下动脉自主动脉弓的起始角度为:71.98°±8.26°,疾病组左锁骨下动脉起始角度71.98°的比例明显高于对照组,差异有统计学意义(P0.05)。疾病组左锁骨下动脉管腔闭塞11例(18.33%),闭塞范围为9~24mm;中度狭窄7例(11.67%),重度狭窄42例(70.00%),狭窄长度8~31mm;偏心性斑块33例,环形斑块16例。以DSA为金标准,CTA诊断左锁骨下动脉狭窄、闭塞的敏感度为96.77%,特异度为100%,诊断符合率为96.97%。结论 256层CTA可准确测量左锁骨下动脉的各项解剖数值;对左SSS术前评估具有重要的应用价值。     

Das koronare Stealsyndrom

The internal mammary artery is being used more frequently for the revascularization of the coronary arteries in patients with angina pectoris. A stenosis of its donor vessel can result in a so-called coronary steal syndrome. The clinical and investigational aspects as well as the therapeutic options for this phenomenon are discussed. A 59-year-old man, active in sports, was suffering from renewed pain in the arm and angina pectoris when participating in sports after revascularization of the coronary arteries with the internal mammary artery. The reason for the recurrent complaints was a stenosis of the proximal left subclavian artery, which was successfully treated with PTA. The so-called coronary steal syndrome can be suspected clinically when the radial arterial pulse is decreased or absent and a significant fall in systolic blood pressure and a supraclavicular bruit are found. The diagnosis is confirmed by angiography. Percutaneous dilatation, mostly combined with primary stenting, is the therapy of choice in the treatment of a stenosis. The occluded subclavian artery is best treated surgically by transposition of the subclavian artery into the common carotid artery.     

Endovascular therapy in prevention and management of coronary-subclavian steal

BACKGROUND: The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal. METHODS: The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed. RESULTS: Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%. CONCLUSION: PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.     

急性左下肢深静脉血栓形成合并Cockett综合征的治疗

目的 探讨急性左下肢深静脉血栓形成(DVT)合并Cockett综合征(CS)的有效治疗方法.方法 回顾性分析2004年8月-2008年1月收治16例急性左下肢DVT合并CS的临床资料.16例均行下腔静脉滤器置人术及左下肢股静脉切开取栓术,其中13例患者同时行左髂总静脉PTA及支架置入术,另3例行PTA术,术后均予抗凝,祛聚,溶栓治疗.结果 全组无手术死亡及肺栓塞的发生,14例患者取得了满意的疗效.16例中2例术后第2天再发生左下肢急性血栓形成,予药物抗凝、溶栓、祛聚治疗,出院时肢体肿胀明显好转.随访14例,随访时间1～25个月(平均11个月),2例出现下肢DVT后综合征,余12例左下肢无肿胀,无静脉曲张及色素沉着.结论 急性左下肢DVT并CS行手术取栓加左髂总静脉PTA术及支架置入术可获得满意疗效.     

Percutaneous transluminal angioplasty in subclavian artery stenosis

The technique of percutaneous transluminal angioplasty (PTA) that was introduced initially by Dotter and Judkins in 1964 has been applied to various arterial stenoses and some occlusive lesions and has advanced dramatically with the development of the Grüntzig catheter in the treatment of peripheral vascular disease. However, the application to occlusive disease in brachiocephalic arteries is still considered to be disputable and has been made only in selective cases, especially in Japan. We report here a case with stenosis of the left subclavian artery successfully treated with PTA. The patient was 66 year-old man, who had been suffering from transient attacks of vertigo, ataxia, visual disturbance and the left arm claudication. Blood pressure was 150/92 mmHg in the right arm and 110 mmHg in systole in the left arm. Diagnostic arteriography identified the right carotid artery occlusion at its origin and significant stenosis in the proximal left subclavian artery. PTA under fluoroscopic control was performed by passing dilating catheter in antegrade fashion by Seldinger method through the left femoral artery. Anatomic correction was achieved without hemorrhagic or embolic complications. Systolic blood pressure gradient measured at the brachial artery level disappeared immediately after PTA and symptomatic relief was obtained completely. One month later, wide patency of the left subclavian artery and sufficient antegrade flow in the vertebral artery were confirmed angiographically. During follow-up period of 4 months, the patient was asymptomatic. We reviewed the literature reporting PTA for occlusive disease in brachiocephalic arteries and discussed its problems and possibilities, especially for the treatment of subclavian artery stenosis.