血管内治疗肠系膜缺血28年的经验

正摘要目的报道慢性肠系膜缺血(CMI)病人血管内治疗的结果。方法回顾性复习自1981年4月-2009年9月间在一家机构接受血管内治疗病人的资料。评价操作细节、治疗的肠系膜动脉、技术与临床的成功率、每例病人与每支血管的治疗结果。结果28年166例在治疗中使用了不同球囊与内支     

经皮腔内球囊扩张联合动脉内灌注药物治疗慢性下肢缺血

目的临床观察球囊扩张联合动脉内灌注药物治疗慢性下肢缺血的近期疗效。方法慢性下肢缺血患者21例,采用经股或腋动脉入路,先用球囊扩张闭塞段血管,然后经导管向动脉内灌注尿激酶、前列腺素E1、银杏叶注射液。胫腓动脉闭塞的部分患者保留血管鞘,经鞘灌注上述药物,每日1次,共5～7 d。术后观察患肢缺血症状、皮肤溃疡和趾端坏疽的改善情况。结果21例中20例成功实现经皮经腔球囊扩张和动脉内灌注药物治疗,技术成功率95.2%。无严重并发症。其中5例患者术后保留血管鞘,灌注药物5～7 d后复查造影,显示经球囊扩张后血管腔保持通畅。术后20例患者均出现诸如患肢皮温升高、间歇性跛行消失、静息痛减轻或消失等临床症状改善情况;随访2～7个月,4例皮肤溃疡愈合,2例坏死足趾脱落,创面愈合,已坏疽的足趾均变干燥,坏死范围停止扩大,未出现需截肢现象。结论经皮腔内球囊扩张联合动脉内灌注尿激酶、前列腺素E1、银杏叶注射液治疗慢性下肢缺血安全有效,能够改善肢体缺血症状,促进溃疡愈合,阻止病变发展;保留血管鞘连续灌注药物有助于保持扩张后的血管通畅。     

DEEP 球囊导管在膝下动脉腔内成形术治疗严重下肢缺血中的应用

目的应用DEEP球囊导管膝下动脉成形术治疗严重下肢缺血的疗效分析。方法回顾性分析2007年8月至2008年4月采用膝下动脉成形术治疗11例患者17条严重缺血患肢的结果。所有患者均有静息痛,其中6条患肢合并溃疡(2条)或坏疽(3条)或两者同时存在(1条)。12条患肢踝肱指数(ABI)为0.2～0.5,5条患肢为0.51～0.7,平均0.47。结果手术技术成功率为100%,13条患肢疼痛明显缓解,2条肢体减轻,2条患肢疼痛无缓解而行膝关节以上截肢;有溃疡的2条患肢,溃疡愈合。有足趾坏疽的3条患肢,1条干性坏疽无变化,1条坏疽足趾脱落,1条行半足截除术后,创面愈合,同时伴有溃疡和坏疽的1条患肢,溃疡愈合,坏疽足趾脱落。10条患肢ABI增加超过0.5,5条增加0.3～0.5,2条无改变,平均值为0.83。10例患者16条患肢得到随访,平均随访时间4.3个月(1～9个月)。15条患肢疼痛明显缓解,其中12条无复发,3条复发,3条中2条再次行下肢动脉PTA后疼痛缓解,1条未行PTA治疗而行截肢。ABI平均值为0.70。结论应用DEEP球囊导管行膝关节以下动脉成形术治疗严重下肢缺血具有较高的成功率,短期随访有较好疗效,中长期疗效有待进一步观察。     

经皮血管内球囊扩张及支架置入术治疗症状性大脑中动脉狭窄

目的：探讨症状性大脑中动脉狭窄的血管内治疗适应证、技术可行性及疗效。方法：回顾性分析自1997年3月至2001年10月收治的经血管内方法治疗的症状性大脑中动脉狭窄14例患者的技术成功率、并发症以及临床疗效，14例患者中9你是2001年以前的病例，单纯采用血管内球囊扩张术，而2001年5例患者全部采取血管内支架成形术。结果：采用球囊扩张的9例患者成功扩张5例，从术前平均狭窄67％扩张到术后的18％，2例由于球囊到位困难而放弃，2例患者出现与技术有关的严重并发症。该5例手术成功的患者，经过平均21个月随访，症状消失2例，所有患者随访期间病情平稳，无卒中发生。5例近期使用冠状动脉支架置入患者，4例成功，术后即刻造影显示狭窄程度从术前的平均85％下降到术后的平均10％，大脑中动脉血流明显增加。1例在支架到位后出现血管破裂。短期随访无卒中再发作（3-5个月）。结论：经皮球囊血管成形术以及支架置入术对于症状性大脑中动脉狭窄的治疗有效，技术可行。支架血管内成形术虽然刚刚起步，更有发展潜力，需要进一步的实践和临床随访。     

长球囊治疗重症下肢动脉缺血性病变的近期疗效观察

目的观察长球囊治疗重症下肢动脉缺血性病变的可行性和近期效果。方法对2007年1至6月收治的21例重症下肢缺血患者,根据病变范围,选择合适长度的球囊对狭窄或闭塞性病变进行球囊扩张成形,相临近多处短段病变也尽可能采用长球囊一次成形;观察术中及术后患者的并发症发生率、技术成功率和临床疗效;通过随访,判断治疗的初始通畅率、再次通畅率、救肢率和生存率。结果21例患者早期技术性的并发症2例(9.5%),均为穿刺点假性动脉瘤。狭窄性病变的技术成功率100%;股、腘动脉闭塞性病变再通的总的成功率为88.9%,其中采用内膜下成形(5例)技术成功4例;胫前动脉、胫后动脉和腓动脉闭塞性病变的技术成功率分别为55.6%、28.6%和25.0%。未出现影响血流的夹层。临床成功率为90.5%。术后平均住院时间6 d。术后6个月的初始通畅率为95.2%;再次通畅率和救肢率均为100%。结论对于重症下肢动脉缺血性病变患者,长球囊PTA后无影响血流的夹层瘤出现,初始技术和临床成功率都很高,是安全、有效的治疗重症下肢动脉缺血性病变的方法。     

髋关节区动脉支架植入治疗下肢动脉重症缺血的临床效果评价

目的观察与评价髋关节区支架植入治疗下肢动脉重症缺血的安全性、有效性及对股深动脉血流的影响。 方法66例动脉硬化闭塞所致下肢重症缺血患者（共70条动脉,均累及股总动脉和/或股动脉近心段）。平均年龄74.6岁。男46例,女20例。左下肢动脉40条,右下肢动脉30条。开通闭塞动脉后,行球囊扩张及支架植入。 结果术中股动脉急性闭塞3例（局部溶栓后获得通畅）,余下肢动脉即刻血流均获得通畅,下肢缺血症状均明显改善。术后15例患肢出现血流过度灌注,无严重并发症发生。随访54例（失访12例）,随访时间2～30个月,平均（16.2±2.6）个月。25例因再狭窄或闭塞发生患肢缺血,其中16例接受再次介入治疗（PTA及导管溶栓后获二次通畅）。跨髋关节支架均无断裂,股深动脉均仍保持通畅。6例发生心、脑血管意外,其中2例死亡。 结论跨髋关节动脉支架植入可安全、有效地改善下肢动脉重症缺血,且不影响股深动脉血流。     

主髂动脉长段闭塞腔内治疗的技巧和疗效

主髂动脉闭塞是最常见的动脉闭塞性疾病.治疗方法主要包括以药物治疗为主的基础治疗,以经典的外科旁路术为代表的开放式外科手术治疗和新近发展的血管腔内治疗.随着临床医师和患者对于腔内治疗认知的不断加深,血管腔内治疗已成主髂动脉闭塞首选的治疗方法,本文对主髂动脉长段闭塞腔内治疗的技巧和疗效作一综述.     

大动脉炎颈动脉狭窄球囊扩张和内支架的治疗

目的：探讨应用球囊扩张和血管内支架治疗大支脉炎、颈动脉狭窄、材料和方法：３例大动脉炎性颈动脉狭窄的患者，狭窄段均超过８ｃｍ，１例单纯球囊扩张；２例球囊扩张后植入Ｗａｌｌｓｔｅｎｔ支架。结果：术后狭窄率均为０，达到了良好的治疗效果，单纯球囊扩张的动脉一年后动脉完全闭塞、西入血管内支架的２例，分别是在４．５个月和４个月检查，一例血管内支架的近端出现了再狭窄，另一例未出现再狭窄。结论：对于大动脉炎性长段     

上腔静脉综合征的血管内支架治疗

上腔静脉综合征，特别是恶性肿瘤所致且放疗、化疗无效或复发临床处理比较困难。八十年代中期开展的以血管内支架为主，结合球囊扩张、局部溶栓等治疗方法，临床应用表明是治疗上腔静脉综合征安全、有效的方法。本就上腔静脉综合征血管内支架治疗现状作一综述。     

放疗后腹腔动脉和肠系膜上动脉损伤:内支架放置术治疗

目的：本文用于评价血管成形术和内支架的放置在放疗后所致腹腔动脉和肠系膜上动脉损伤的治疗。方法：采用血管成形术和内支架放置的方法治疗2例腹腔运用肠系膜上动脉病变。结果：放疗性动脉性病变为临床治愈，结论：血管成形要和内支架的综合有效治疗放疗所致的动脉性病为，应考虑其为动脉损伤性病变的首选治疗。     

Acute mesenteric ischemia: recent advances in diagnosis and endovascular therapy

Acute mesenteric ischemia is a complex disorder associated with high morbidity and mortality. Recent advances in interventional radiology techniques have provided a variety of less invasive, endovascular approaches to the treatment of acute mesenteric ischemia. This article reviews the etiologies and imaging findings of acute mesenteric ischemia and describes evolving endovascular therapies.     

急性非闭塞性肠系膜血管缺血的诊断和介入治疗

目的探讨选择性肠系膜上动脉造影,经肠系膜上动脉持续灌注罂粟碱在诊断和治疗急性非闭塞性肠系膜血管缺血(NOMI)的价值。方法回顾分析从1999年8月到2005年3月经选择性肠系膜上动脉造影确诊,并行介入诊疗的18例NOMI。明确NOMI诊断后即行经导管肠系膜上动脉灌注罂粟碱治疗。结果本组18例NOMI中15例患者治愈;3例有效,介入治疗后腹痛减轻,但仍有局限性的腹膜刺激征,转外科行肠切除治愈;1例10d后死于严重肺部感染导致的呼吸衰竭。结论选择性肠系膜上动脉造影持续经导管肠系膜上动脉灌注罂粟碱是NOMI有效的诊断和治疗方法。     

急性肠系膜缺血的DSA诊断和经皮血管内治疗的临床价值探讨

目的:探讨急性肠系膜缺血的DSA诊断价值和经皮血管内治疗的临床应用价值。方法:12例临床疑诊患者,均经皮行右侧股动脉穿刺、插管,依次进行升主动脉、腹主动脉、腹腔干和肠系膜上、下动脉造影。其中8被诊断为急性肠系膜缺血,急性肠系膜上动脉栓塞4例;急性肠系膜上动脉血栓形成3例,非闭塞性肠系膜缺血1例。对4例肠系膜上动脉栓塞患者经导管注入溶栓剂(尿激霉)和血管扩张剂(罂粟碱)治疗,2例治疗后血管开通;另2例因症状缓解不明显行外科手术治疗;3例病程较长者造影后直接转外科进行手术治疗。结果:DSA诊断急性肠系膜上动脉栓塞4例。造影表现为肠系膜上动脉主干远端(中结肠动脉起始部)或分支的突然截断(截断征)或管腔内局限性充盈缺损(不完全栓塞)。急性肠系膜上动脉血栓3例,造影表现为肠系膜上动脉起始部的狭窄。1例造影表现为肠系膜上动脉分支弥漫性痉挛(腊肠征)诊断为非闭塞性肠系膜动脉缺血,手术证实为急性肠系膜静脉血栓形成。手术后1周因再次肠坏死而死亡。1例广泛血栓形成患者于造影后6h死亡。另2例肠系膜上动脉血栓患者手术后2周死亡。结论:DSA是诊断各型急性肠系膜缺血的有效手段,可以明确病变的部位和范围,为手术治疗提供定位信息。对急性肠系膜静脉血栓的诊断有一定的局限性。经导管溶栓术是治疗肠系膜动脉栓塞的有效手段。亦可作为外科手术前的辅助治疗手段,减少死亡率。     

Acute and chronic mesenteric ischemia: Multidetector CT and CT angiographic findings

Aim of the work

To assess the role of multidetector CT (MDCT) and CT angiography (CTA) in the diagnosis of acute and chronic mesenteric ischemia.

Patients and methods

This prospective study was performed on 57 consecutive patients clinically suspected of having mesenteric ischemia, they were examined with 16-row multidetector CT, MDCT and CTA were evaluated for evidence of bowel wall changes and abnormal mesenteric vascular changes.

Results

Twenty one patients of studied 57 patients had an abnormal CTA finding diagnostic of mesenteric ischemia and they constituted the material of this study, the most prevalent MDCT findings were bowel wall thickening, bowel distension and non-enhanced bowel wall. MDCT and CTA gave an accurate diagnosis of the cause of mesenteric ischemia as proved by the final diagnosis based on surgical exploration, conventional angiography, laboratory investigations and clinical follow up with 100% sensitivity and specificity.

Conclusion

MDCT and CTA are fast, safe, accurate and non-invasive imaging modalities of choice in patients with suspected mesenteric ischemia which are able to evaluate not only mesenteric vascular structures but also evaluate bowel wall changes and adjacent mesentery, thus detecting the primary cause of mesenteric ischemia that can lead to earlier diagnosis and intervention.     

Non-occlusive mesenteric ischemia: etiology, diagnosis, and interventional therapy

Non-occlusive mesenteric ischemia (NOMI) compromises all forms of mesenteric ischemia with patent mesenteric arteries. It generally affects patients over 50 years of age suffering from myocardial infarction, congestive heart failure, aortic insufficiency, renal or hepatic disease and patients following cardiac surgery. Non-occlusive disease accounts for 20-30% of all cases of acute mesenteric ischemia with a mortality rate of the order of 50%. Acute abdominal pain may be the only early presenting symptom of mesenteric ischemia. Non-invasive imaging modalities, such as CT, MRI, and ultrasound, are able to evaluate the aorta and the origins of splanchnic arteries. Despite the technical evolution of those methods, selective angiography of mesenteric arteries is still the gold standard in diagnosing peripheral splanchnic vessel disease. In early non-occlusive mesenteric ischemia, as opposed to occlusive disease, there is no surgical therapy. It is known that mesenteric vasospasm persists even after correction of the precipitating event. Vasospasm frequently responds to direct intra-arterial vasodilator therapy, which is the only treatment that has been shown to be effective.     

Post traumatic arterial occlusive mesenteric ischemia: a rare case report

Mesenteric ischemia is an uncommon condition with very high mortality rates characterized by inadequate blood supply, inflammatory injury, and subsequent necrosis of the bowel wall. Acute arterial mesenteric ischemia is usually caused by cardiac emboli, atherosclerotic vascular disease, aortic aneurysm, or dissection. We report a case of a 60-year-old male who presented to the accident and emergency department complaining of abdominal pain following blunt abdominal trauma. An urgent contrast enhanced computed tomography scan demonstrated superior mesenteric artery thrombosis with ischemic small bowel. Surgical intervention was carried out with resection of the necrotic bowel followed by anastomosis. Acute occlusive mesenteric ischemia needs to be considered in cases of blunt trauma presenting with abdominal pain. Proper early diagnosis and management is essential as it carries a high risk of morbidity and mortality.     

急性肠系膜缺血诊治的有关进展

本文简要介绍了急性肠系膜缺血（AMI）病理分裂、诊断和治疗的有关进展。     

Percutaneous recanalization and stent placement in chronic proximal superior mesenteric artery occlusion

Atherosclerotic stenosis involving the proximal portion of at least two visceral arteries usually causes symptoms of intestinal ischemia and can lead to massive bowel infarction and death. This report describes a case of chronic proximal occlusion of the superior mesenteric artery (SMA) in a 51-year-old man, successfully treated by local catheter-directed thrombolytic therapy, followed by balloon dilatation and stent placement of the residual atherosclerotic stenosis. At 3 months follow-up, the patient was free of symptoms. This case shows that local thrombolytic therapy, percutaneous transluminal angioplasty and stent placement can be useful in the treatment of chronic atherosclerotic occlusion of the proximal SMA. Received 5 November 1996; Revision received 5 February 1997; Accepted 27 March 1997     

Multidetector CT angiography in the evaluation of acute mesenteric ischemia

The aim of this study was to determine the accuracy of multidetector row CT angiography in the diagnosis of acute mesenteric ischemia. Ninety-three consecutive studies on 91 patients with clinically suspected acute mesenteric ischemia underwent abdominal CT angiography as the first, and usually the sole, diagnostic procedure. CT was performed with a multidetector 16-row CT system from the level of the diaphragm to the pelvis in two phases: early arterial and late portal phase. CT examinations were reviewed by the duty radiologist. Final diagnosis was established by a senior radiologist. CTA was diagnostic in 92 studies. Mesenteric ischemia was diagnosed in 18 patients, 14 of them were of the thromboembolic type and four from the nonocclusive type. Positive CTA findings were confirmed by surgery in 13 patients and by clinical follow-up in three cases. Other reasons for abdominal pain were diagnosed by CT in 38 patients out of the remaining 74. There were two false positive and two false negative CT results, resulting in an overall accuracy of 95.6%. Multidetector CT angiography is a fast and accurate investigation for the diagnosis of acute mesenteric ischemia and in most cases can be used as the sole diagnostic procedure.     

Limitations of angiography for mesenteric ischemia caused by midgut carcinoid tumors

Mesenteric ischemia associated with carcinoid tumors often presents with nonspecific abdominal pain and is usually due to mesenteric branch artery occlusion caused by elastic vascular sclerosis. Mesenteric ischemia was defined by the operative findings of cyanosis or infarction. Eleven patients with intraabdominal metastatic carcinoid tumor were evaluated by angiography. Angiographic narrowing and occlusion of multiple peripheral jejunal and ileal intramesenteric branch arteries was present in 3 patients with mesenteric ischemia, but also occurred in 5 of 8 patients without mesenteric ischemia. Other angiographic abnormalities included staining of the primary tumor (5) or metastases (6), tenting of small mesenteric vessels (5), and occlusion of draining mesenteric veins (2). We conclude that in patients with midgut carcinoid tumors, angiographic narrowing and occlusion of peripheral mesenteric arteries most likely represents elastic vascular sclerosis, is indicative of mesenteric invasions of tumor, but correlates poorly with the presence of ischemia in the subtended bowel. Alternatively, a normal selective arteriogram should exclude mesenteric ischemia as the cause of abnormal pain.