TASC-D型下肢动脉硬化闭塞症腔内治疗现状

2007年泛大西洋协作组织共识（TASCⅡ）会议指南将主髂动脉和股腘动脉病变分为4型,建议对TASC-A型病变行腔内介入治疗,对B、C型病变参考多种因素行个体化治疗,对D型病变选择外科手术治疗。近年随着影像学及材料学研究进展、介入操作者技能提升,临床上对相对复杂的TASC-D型主髂动脉、股腘动脉硬化闭塞症也越来越多地采用创伤相对小的介入治疗,并取得了较好的临床疗效。本文就TASC-D型下肢动脉硬化闭塞症腔内介入治疗现状作一综述。     

支架成形联合置管溶栓治疗TASC(Ⅱ)D型主髂动脉闭塞性疾病

目的探讨TASC(Ⅱ)D型主髂动脉闭塞性疾病血管内成形术辅助置管溶栓治疗的可行性、安全性及疗效,并对髂-股/股深动脉血管内成形术的可行性作一探索。方法 8例主髂动脉闭塞患者病变均为TASC(Ⅱ)D型,其中3例主动脉-髂总动脉-髂外动脉闭塞,主动脉闭塞长度为2~6 cm,1例腹主动脉远端重度狭窄伴右侧髂总动脉、髂外动脉闭塞,另外4例为双侧或单侧髂总动脉及髂外动脉闭塞。其中4例伴有股浅动脉长段闭塞。所有患者均采用PTA+内支架治疗,5例于血管内成形术后行辅助置管溶栓治疗。结果8例患者主髂动脉闭塞段病变均成功开通;4例伴股浅动脉长段闭塞患者仅行主/髂-股/股深动脉内支架成形术,而股浅动脉病变未予处理。技术均获成功,症状均获缓解,踝臂指数术前为0.58,术后为0.76。1例于术后出现左侧小脑小面积梗死,未发生严重后遗症。平均随访时间14个月,无再狭窄发生。结论慢性广泛主髂动脉闭塞病变,血管腔内成形术是一项安全有效的治疗措施,可获得较满意的临床疗效及近中期通畅率;支架植入后留置导管溶栓可以有效防止血栓形成的发生;髂-股深动脉血管内成形术可以达到改善患肢症状的治疗目的。     

介入治疗TASCC型及D型主髂动脉闭塞的护理体会

主髂动脉闭塞是血管外科常见的动脉硬化闭塞性疾病。主髂（股）动脉人工血管转流术是目前治疗广泛主髂动脉闭塞的首选术式,具有较高的远期通畅率。但对于年老体弱者特别是全身一般情况差伴有冠心病、肺气肿、脑血管动脉硬化等慢性疾病的患者,主髂（股）动脉人工血管转流术的手术并发症发生率及死亡率高,导致其应用受限。我们采用多种腔内技术治疗了44例慢性广泛主髂动脉闭塞的高危患者,取得了较满意的临床疗效,现将护理体会报告如下。     

接力穿刺技术治疗无对侧股动脉入路的下肢动脉硬化闭塞症的应用研究

目的：研究接力穿刺技术治疗无对侧股动脉入路的下肢动脉硬化闭塞症患者的有效性和安全性。 方法：选取2014年4月—2017年9月入住我院的22例无对侧股动脉入路的下肢动脉硬化闭塞症患者,22例中对侧股动脉植入覆膜支架5例,主髂动脉病变已行对吻支架6例,主髂动脉病变同时累及双侧股动脉3例,腹主动脉瘤腔内修复术后4例,对侧截肢术后4例,采用接力穿刺技术（先肱动脉入路完成患侧髂股动脉病变治疗,获得患侧股动脉安全穿刺区,然后接力顺行穿刺患侧股动脉完成股腘动脉、甚至膝下动脉病变的腔内治疗）进行一期血运重建,治疗其下肢动脉硬化闭塞症,总结手术成功率及并发症情况。 结果：手术成功率为100%,共植入103枚支架,平均4.7枚/人。所有缺血症状术后立即得到缓解,患肢踝肱指数（ABI）显著提高[（0.90±0.16）vs.（0.33±0.18）,t=18.80,P<0.01）。随访2~36月(平均19.5个月),围手术期及随访期间无严重手术相关并发症,术后1年的一期通畅率为81.8%（18/22）。 结论：应用接力穿刺技术治疗无对侧股动脉入路、肱动脉入路腔内器械过短无法完成血运重建的下肢动脉硬化闭塞症是安全、有效的,可以作为首选治疗方法。     

2018年第6期继续教育选择题

正1.有关下肢动脉硬化闭塞症(ASO)的治疗,下列哪些正确()A.应参照泛大西洋协作组织第2版指南(TASCⅡ)进行分级分型,以利制订适宜的治疗方案B.分级分型的主要依据包括狭窄或闭塞病变的数量、长度、部位及严重程度C.根据TASCⅡ指南,可将主-髂动脉和股-腘动脉病变分别分为A～D级D.根据TASCⅡ指南,A～C级病变首选血管腔内介入治疗E. D级病变存在手术禁忌时可选择腔内治疗2.下肢ASO患者存在下列哪些情况,应列为介入诊疗的禁     

主－髂－股动脉多发病变腔内治疗策略及临床意义

目的：探讨主－髂－股动脉多发病变腔内治疗的策略、技巧及临床意义。方法本组8例主－髂－股动脉多发病变患者,术前均行CTA或MRA血管成像,肾动脉水平以下腹主动脉完全闭塞2例,腹主动脉远段闭塞4例,腹主动脉远段狭窄1例、膜性闭塞1例;病变累及髂总动脉12条,髂外动脉8条,股动脉1条,腘动脉2条;选择不同的路径,贯通、溶栓、球囊扩张、支架植入。结果术后8例患者腹主动脉全部开通,12条髂总动脉除3条未处理外9条全部贯通,髂外动脉均贯通,股动脉、腘动脉未处理。随访1~12个月,5例患者下肢缺血症状消失,2例明显改善;1例1年后又形成血栓闭塞,插管溶栓后恢复正常。结论血管腔内治疗主－髂－股动脉多发病变,对改善下肢缺血症状疗效显著,操作简便,并发症少,是安全有效的方法。     

慢性主-髂动脉闭塞内膜下再通治疗的可行性及初步应用

目的 探讨经动脉内膜下途径治疗主.髂动脉闭塞的可行性与治疗方法.方法 对1例慢性主髂动脉闭塞患者经右肱动脉穿刺,使用超滑导丝自腹主动脉闭塞端穿入内膜下腔,分别向两侧髂动脉行内膜下再通.右侧导丝顺利重入髂外动脉真腔,左侧使用了双向内膜下再通技术.2支导丝经双侧股动脉穿刺点引出体外.经两侧股动脉用对吻技术行球囊扩张和支架置放(主动脉下端支架1枚,双侧髂动脉支架5枚).结果主-髂动脉闭塞经内膜下途径成功再通.治疗后主.髂动脉支架内腔形态良好,血流通畅.双下肢缺血症状完全消失,踝臂指数(ABI)由0.32上升至0.96.10个月随访未见再狭窄表现.结论 经动脉内膜下途径治疗主.髂动脉闭塞安全、可行,适用于慢性动脉硬化闭塞病变.     

三明治技术在腹主动脉瘤累及髂总动脉腔内治疗中保留髂内动脉的疗效分析

【摘要】 目的 分析三明治技术应用于腹主动脉瘤（AAA）累及髂总动脉腔内治疗保留髂内动脉的近期疗效。 方法 回顾性分析重庆医科大学附属第二医院2016年6月至2018年7月采用主动脉腔内修复术（EVAR）治疗的9例AAA累及髂总动脉患者（累及单侧髂总动脉3例，双侧6例），术中均接受髂内动脉三明治重建。术后观察和随访围手术期死亡率、腔内修复效果、内漏、支架一期通畅情况及手术相关并发症发生情况。 结果 9例患者EVAR术和髂内动脉三明治重建技术均获成功，围手术期无死亡。术中即刻造影显示9例支架均获通畅，瘤腔均成功修复。出现1例Ⅰ型内漏，2例Ⅲ型内漏，随访时自行消失；1例左上肢急性缺血，再次予急诊肱动脉修复术；3例左肱动脉切口处血肿形成，2例右股动脉穿刺点处血肿形成。术后1周、3个月、6个月复查CTA分别显示支架通畅9例、8例、8例，均无肠缺血、脊髓缺血或瘫痪症状。 结论 三明治技术在AAA累及髂总动脉腔内治疗中保留髂内动脉安全可行，术后臀肌跛行发生率低，近期随访支架通畅率可，值得临床推广，但远期效果尚需进一步随访及更大临床样本验证。     

下肢动脉硬化闭塞症介入治疗效果及影响术后复发因素分析

目的 探讨介入治疗下肢动脉硬化闭塞症(ASO)的效果及影响术后复发的相关因素.方法 回顾性分析2011年1月至2014年10月介入治疗的137例下肢ASO患者(184条患肢)临床资料,术后随访18个月,分期观察患者术后血管通畅性及影响复发的因素.结果 介入技术成功率在髂动脉、股腘动脉、膝下动脉病变分别为97.4％、92.5％、88.6％,在TASCⅡA型、B型、C型、D型病变分别为97.4％、96.1％、89.7％、87.0％.术后随访发现膝下动脉病变血管通畅率较髂动脉及股腘动脉病变降低(P＜0.05),TASCⅡC、D型病变再狭窄率高于A、B型病变(P＜0.05);多因素Cox回归模型分析提示糖尿病、吸烟、高血脂是影响术后复发的独立危险因素.结论 介入治疗下肢ASO安全、有效,术后再狭窄率与病变血管解剖位置及分型相关,有效控制血糖、戒烟、降脂有助于降低术后复发率.     

介入腔内治疗在下肢动脉硬化闭塞症的应用

目的探讨下肢动脉硬化闭塞症（LEASO）的介入腔内治疗。 方法收集37例LEASO患者,共进行40次手术,处理病变血管56支,其中狭窄病变39处（39/56,69.64%）,闭塞病变17处（17/56,30.36%）,其中髂动脉病变19处(19/56,33.93%),股动脉病变30处(30/56,53.57%),胫动脉病变7处(7/56,12.50%)。 结果支架植入6处,球囊成形（PTA）9处,PTA+支架植入38处,手术成功率为94.64%（53/56）,术后30天内无死亡病例。手术成功病例术后临床症状明显改善或消失,术前踝肱指数（ABI）为0.35±0.05,术后明显升高(0.73±0.14,P<0.01)。 结论介入腔内治疗LEASO成功率高,安全可靠,可显著改善临床症状。     

Clinical Features and Endovascular Management of Iliac Artery Fibromuscular Dysplasia

PurposeTo identify the spectrum of clinical presentation of iliac artery fibromuscular dysplasia (FMD) and to evaluate the outcomes of endovascular management of iliac artery FMD for claudication.Materials and MethodsAll patients in a single institution with a diagnosis of FMD between January 1980 and December 2010 were identified. Iliac artery FMD was present in 14 patients. Associated risk factors included hypertension (79%), hyperlipidemia (64%), smoking history (36%), coronary artery disease (21%), diabetes (0%), and obesity (36%).ResultsIn eight (57%) patients, iliac artery FMD was incidentally found on imaging. Lifestyle-limiting claudication involving one or both extremities was present in six (43%) patients. All six patients were reported to have mild peripheral arterial disease based on ankle-brachial index measurements (0.7–0.9). These six patients underwent 10 endovascular procedures for claudication, including angioplasty (n = 8) and self-expanding stent placement (n = 2). Mean symptom-free survival was 56.3 months.ConclusionsIliac artery FMD that is amenable to endovascular treatment may be found incidentally or may manifest with disabling claudication.     

Endovascular treatment of acute arterial complications after living-donor liver transplantation

AIM: The aim of this study was to evaluate the efficacy of endovascular treatment for acute arterial complications following living-donor liver transplantation (LDLT). MATERIALS AND METHODS: Of 79 LDLT patients, 17 (mean age 48+/-8 years, range 33-66 years) who had acute arterial complications and underwent endovascular treatment were evaluated. Transcatheter arterial embolization was performed to control peritoneal bleeding. Catheter-directed thrombolysis using urokinase was performed in hepatic artery thromboses. The locations of complications and materials used were evaluated. The technical and clinical success rates were calculated. RESULTS: Twenty-three acute arterial complications, including four hepatic artery thromboses and 19 cases of peritoneal haemorrhages were identified in 22 angiographic sessions in 17 patients. The mean duration between LDLT and first angiography was 3.2+/-3.5 days (range 1-13 days). Hepatic artery recanalization with catheter-directed thrombolysis using urokinase was achieved in two patients. Transcatheter arterial embolization for peritoneal bleeding was successfully performed in 16 cases. The most common bleeding focus was the right inferior phrenic artery. Additional surgical management was needed in five patients to control bleeding or hepatic artery recanalization. Technical and clinical success rates of transcatheter arterial embolization were 84.2 and 63.1%, respectively. Overall technical success was achieved in 18 of 23 arterial complications (78.2%), and clinical success was achieved in 14 of 23 arterial complications (60.8%). CONCLUSION: Endovascular treatment for the acute arterial complications of haemorrhage or thrombosis in LDLT patients is safe and effective. Therefore, it should be considered as the first line of treatment in selective cases.     

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

Carotid artery stenting (CAS) may be an alternative to surgical endoarterectomy not only in high-risk patients. We report results in the endovascular treatment of carotid artery disease with up to 8 years' follow-up. In this retrospective study, we analysed data from 853 consecutive patients (946 arteries) treated for carotid artery stenosis between April 1999 and March 2007; 491 (52%) arteries were symptomatic and 455(48%) were asymptomatic. Preprocedural evaluation of the patients was performed with echo Doppler, magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) and a neurological examination. A cerebral protection device was used in 879 (92.9%) procedures. Anti-platelet therapy was administered before and after the procedure. All patients were included in a follow-up of up to 8 years. Technical success was achieved in 943 (99.6%) lesions. At 30 days, there was a 0.21% (n = 2) death rate, a 0.42% major stroke rate, a 1.69% minor stroke/transient ischaemic attack (TIA) rate and a combined 2.32% TIA/stroke and death rate. During follow-up, echo Doppler evidenced restenosis in 39 (4.85%) cases; of these, only five, presenting restenosis >80%, were treated with an endovascular reintervention. At the long-term follow-up, two strokes (0.23%) were reported, which both occurred within the first 2 years. In our experience, carotid artery stenting seems to be a safe and effective treatment, providing satisfactory long-term clinical results.     

腘动脉穿刺逆行内膜下血管成形术治疗股浅动脉起始部长段硬化性闭塞疾病

目的：探讨经腘动脉逆行内膜下血管成形术（subintimal angiop lasty,SIA）治疗股浅动脉起始部长段闭塞疾病的临床效果和应用价值。方法：经腘动脉穿刺逆行SIA治疗股浅动脉起始部长段慢性硬化闭塞19例,采用PTA＋内支架（stent）置入。结果：全组治疗成功率100%（19/19）,无严重并发症发生;19例股浅动脉闭塞经腘动脉穿刺逆行SIA后,随访3~48个月,血流仍保持通畅为94.74%（18/19）,1例股浅动脉逆行SIA并支架置入12个月出现再阻塞,经局部溶栓,支架腔内血流均保持通畅。术前术后踝肱指数（ankle brachial index,ABI）平均0.25（0.12~0.43）和0.89（0.69~1.08）,两者比较差异有统计学意义（P〈0.05）。结论：经腘动脉逆行SIA是治疗股浅动脉起始部长段硬化闭塞,所致慢性严重肢体缺血的安全有效的方法。     

Role of color-Doppler sonography in the follow-up of renal artery stenting

PURPOSE: The aim of this study was to evaluate the utility of color-Doppler ultrasound (CDUS) in detecting haemodynamically significant in-stent restenosis in patients who underwent endoluminal renal artery revascularisation by stent deployment. MATERIALS AND METHOD: Between January 2000 and December 2006, 42 patients (nine women and 33 men, age range 45-87 years) treated by endovascular renal artery stenting were studied with CDUS. Renal artery haemodynamics were evaluated to identify haemodynamically significant restenosis. Patients with CDUS signs of restenosis underwent angiography for a possible further revascularisation procedure. RESULT: Of 42 patients examined by CDUS, 13 (31%) showed signs of haemodynamically significant in-stent renal artery restenosis. Of these 13, three did not undergo endoluminal renal artery revascularisation because renal ischaemia deterioration and irreversible renal circulation impairment. In the remaining ten patients (23.8%), who had no signs of severe nephropathy, angiography confirmed the CDUS findings of in-stent restenosis in all cases. Restenoses were successfully treated by a repeat endovascular revascularisation procedure. CONCLUSION: Our results confirm the fundamental role of CDUS in the follow-up of patients after renal artery stenting. It enables early restenosis detection and evaluation of renovascular disease associated with renal artery stenosis. CDUS provides essential information for the subsequent clinical management of these patients.     

Management of Splenic Artery Aneurysms and False Aneurysms with Endovascular Treatment in 12 Patients

Purpose: To assess the endovascular treatment of splenic artery aneurysms and false aneurysms. Methods: Twelve patients (mean age 59 years, range 47–75 years) with splenic artery aneurysm (n = 10) or false aneurysm (n = 2) were treated. The lesion was asymptomatic in 11 patients; hemobilia was observed in one patient. The lesion was juxta-ostial in one case, located on the intermediate segment of the splenic artery in four, near the splenic hilus in six, and affected the whole length of the artery in one patient. In 10 cases, the maximum lesion diameter was greater than 2 cm; in one case 30% growth of an aneurysm 18 mm in diameter had occurred in 6 months; in the last case, two distal aneurysms were associated (17 and 18 mm in diameter). In one case, stent-grafting was attempted; one detachable balloon occlusion was performed; the 10 other patients were treated with coils. Results: Endovascular treatment was possible in 11 patients (92%) (one failure: stenting attempt). In four cases among 11, the initial treatment was not successful (residual perfusion of aneurysm); surgical treatment was carried out in one case, and a second embolization in two. Thus in nine cases (75%) endovascular treatment was successful: complete and persistent exclusion of the aneurysm but with spleen perfusion persisting at the end of follow-up on CT scans (mean 13 months). An early and transient elevation of pancreatic enzymes was observed in four cases. Conclusion: Ultrasound and CT have made the diagnosis of splenic artery aneurysm or false aneurysm more frequent. Endovascular treatment, the morbidity of which is low, is effective and spares the spleen.     

Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils--a prospective randomized study

PURPOSE: To compare the use of electrolytically detachable coils versus surgical ligation for the management of acutely ruptured intracranial aneurysm. MATERIALS AND METHODS: A prospective randomized study included 109 patients with acute (< 72 hours) subarachnoid hemorrhage caused by a ruptured aneurysm (Hunt and Hess grade I-II [n = 67], grade III [n = 26], or grade IV-V [n = 16]). All patients were suitable candidates for both endovascular and surgical treatment and were randomly assigned to undergo coil embolization (n = 52) or surgical ligation (n = 57). RESULTS: Significantly better primary angiographic results were achieved after surgery in patients with anterior cerebral artery aneurysm (n = 55, P = .005) and after endovascular treatment in those with posterior circulation aneurysm (n = 11, P = .045). No significant differences were seen in middle cerebral artery (n = 19) or internal carotid artery (n = 24) aneurysms. Early rebleeding occurred in one patient after incomplete coil embolization. The technique-related mortality rate was 4% in the surgical group and 2% in the endovascular group. Clinical outcome (Glasgow Outcome Scale score) at 3 months was not significantly different between treatment groups in terms of intended treatment modality. No late rebleedings had occurred at the time of this writing. CONCLUSION: In selected patients with a recently ruptured intracranial aneurysm, favorable results were achieved by using endovascular treatment. Subsequent acute or late open surgery was sometimes required. The clinical outcome at 3 months was comparable in the endovascular and surgical treatment groups.     

Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results

PURPOSE: To evaluate retrospectively the outcome for patients with acute ischemic stroke in the territory of the middle cerebral artery (MCA) who had undergone stent implantation in the proximal segment of the internal carotid artery (ICA) in addition to intraarterial thrombolysis (IAT). MATERIALS AND METHODS: Stent implantation and retrospective analysis of clinical and radiologic data were approved by the institutional ethical committee. Endovascular treatment was performed after obtaining informed consent from patients or their closest relatives. Informed consent for retrospective review was not required. After pharmacologic and/or mechanical IAT, 25 consecutive patients (seven women, 18 men; mean age, 59 years +/- 14 [standard deviation]) underwent stent implantation in the proximal segment of the ICA (endovascular group). The clinical and radiologic characteristics (ie, interval from symptom onset to arrival at the emergency department, prevalence of vascular risk factors, causes of stroke, stroke severity, early signs of cerebral ischemia, duration of endovascular intervention, type of occlusion, and prevalence of leptomeningeal collateral vessels), recanalization rates, and clinical outcomes for patients in the endovascular group were compared with those for patients in the medical group (10 women, 21 men; mean age, 62 years +/- 12) who experienced ischemic stroke in the territory of the MCA as a result of ICA occlusion and who received antithrombotic treatment only. Differences between groups were assessed by using the chi2 test. A logistic regression analysis was performed to assess the effect of clinical and radiologic factors on recanalization rates and outcome. RESULTS: ICA recanalization was successful in 21 patients. Good recanalization of the MCA was achieved in 11 patients. In nine of these patients, recanalization of the MCA was achieved by using mechanical IAT only. In the remaining 12 patients, administration of intraarterial urokinase was performed in addition to mechanical thrombolysis. Two patients from the endovascular group experienced symptomatic intracerebral hemorrhage. At 3 months, 56% of the endovascular group and 26% of the medical group had a favorable outcome. Mortality was 20% in the endovascular and 16% in the medical group. CONCLUSION: IAT and stent implantation in the proximal segment of the ICA seem to improve the outcome for patients with ischemic stroke caused by occlusion of the cervical portion of the ICA.     

Endovascular treatment for an iliac artery-ureteral fistula with a covered stent

Iliac artery-ureteral fistula (IAUF) is a rare entity that has a potential risk of life-threatening hemorrhage. It is difficult to diagnose and treat appropriately. Conventional treatment for the disease consists of surgical ligation and vascular reconstruction or coil embolization. Surgical treatment is usually difficult for patients with several risk factors. In recent years, endovascular stent-graft treatment for iliac artery pseudoaneurysm has been reported. The present report describes two cases in which endovascular covered stent-graft treatment was successfully applied to treat IAUF, with good clinical outcomes.     

Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients

We have reviewed initial diagnostic features, treatment, and outcome in 29 patients with acute subarachnoid hemorrhage due to non-traumatic vertebrobasilar artery dissection diagnosed in our hospital between 1993 and 2003. The dissections occurred in the vertebral artery in 19 patients, the posterior inferior cerebellar artery (PICA) in two patients, the basilar artery in four patients, and in the vertebral artery extending into the PICA in four patients. A pseudoaneurysm was found in 20 patients. Clinical manifestations typically included sudden onset of moderate to severe headache, nuchal rigidity, and drowsiness. Fourteen patients were treated conservatively. Fifteen patients underwent endovascular treatment with either parent artery occlusion (13 patients) or aneurysmal coil occlusion with preservation of the parent artery (2 patients). Re-bleeding occurred within 12 days and before treatment in nine patients. Eight of these had a pseudoaneurysm. No patient bled after endovascular treatment. Poor grade and early re-bleeding were associated with less favorable outcome. Outcome at 6 months did not differ significantly between endovascular and conservative treatment. Altogether, good recovery was achieved for 16 patients, moderate disability was seen in one, severe disability in four, and eight patients (27%) died. The absence of bleeding subsequent to endovascular treatment in this study suggests that endovascular treatment may be a rational approach in these patients at high risk of re-bleeding, especially those with a pseudoaneurysm.