复合手术治疗复杂下肢动脉硬化闭塞症的疗效评估

目的 探讨复合手术治疗多节段复杂下肢动脉硬化闭塞症（arteriosclerosis obliterans,ASO）的临床疗效.方法 回顾性分析2009年1月-2012年12月采用复合手术治疗多节段复杂下肢ASO的47例患者（均为单肢症状）.其中男性37例,女性10例.股动脉内膜切除补片成形＋逆向长段髂动脉内膜剥脱＋ stent/PTA 7例,股动脉内膜切除补片成形＋ stent/PTA（顺行、逆行）17例,股动脉内膜切除补片成形＋顺行长段股浅动脉内膜切除＋stent/PTA8例,股动脉内膜切除补片成形＋髂动脉stent/PTA＋股深动脉成形术5例,髂动脉stent＋股-股动脉人工血管移植术2例,股动脉切开取栓＋内膜剥脱补片成形/stent/PTA 8例,合并膝下动脉病变,部分予以小球囊局段扩张.以上补片为涤纶,人工血管材料为PTFE.结果 手术成功率100％,无严重并发症,踝肱指数（ankle brachial index,ABI）由术前（0.30±0.19）提高至术后（0.63 ±0.20）,下肢症状均不同程度改善,术后平均随访1年,通畅率87.2％ （41/47）,4例坏疽足趾自行脱落,6例股浅动脉支架内再狭窄.结论 复合手术（股动脉内膜切除结合腔内技术）治疗FontaineⅡ-Ⅳ期多节段复杂下肢动脉硬化闭塞症简洁微创、安全有效、中远期疗效可,尤其适合老年危重患者.     

糖尿病下肢动脉硬化闭塞症的外科和介入治疗的临床疗效

经彩色多普勒超声与血管造影确诊的糖尿病合并下肢动脉硬化闭塞症的患者39例，16例行腹主动脉或髂动脉股动脉人工血管移植术；12例行股-腘动脉人工血管或自体大隐静脉移植术；9例行经皮血管腔内成形术＋内支架术，2例单纯行PTA。术后6个月的血管通畅率为89.7％。     

经皮腔内血管成形术联合血管内支架治疗老年下肢动脉硬化闭塞症患者的疗效

目的探讨经皮腔内血管成形术(PTA)联合血管内支架治疗老年下肢动脉硬化闭塞症(ASO)的临床疗效。方法收集28例老年患者、31条肢体,共53处病变部位行血管形成术联合支架植入术(PTAS)进行治疗,术后1个月对患者的跛行距离及踝肱指数进行监测,同时对术后病变部位的血管通畅率进行随访。结果行PTAS手术后,髂动脉的成功率为100%,股腘动脉的成功率为95.24%;术后1个月,患者的踝肱指数由术前的(0.35±0.11)增加至术后的(0.95±0.09),间歇性跛行距离由术前的(117.3±29.9)m增加至术后的(518.4±122.7)m,手术前、后比较差异显著(P0.05);术后2年髂动脉的血管通畅率为91.67%,股腘动脉的血管通畅率为80.95%。结论 PTA联合PTAS治疗下肢动脉ASO手术成功率高、创伤性小、安全有效,且能有效改善缺血区的血液供应,再狭窄可能性减小。     

三维动态增强磁共振血管成像与彩色多普勒超声检查在下肢血管病变中应用的价值

目的探讨三维动态增强磁共振血管成像(3DCE-MRA)及彩色多普勒超声(CDFI)检查在下肢血管病变中的应用价值。方法对20例CDFI诊断为下肢血管病变的患者进行下肢血管3DCE-MRA扫描,范围包括肾平面以下腹主动脉、双侧髂内动脉、髂外动脉及股总动脉、股深动脉、股浅动脉、腘动脉、胫前动脉、胫后动脉、腓动脉。其中19例诊断为下肢动脉硬化、斑块形成,1例诊断为外伤后下肢血管损伤。结果20例患者均成功行3DCE-MRA扫描,图像显示清晰,诊断明确。CDFI检出155段病变血管,3DCE-MRA扫描显示病变血管共205段。3DCE-MRA检出病变的阳性率高于CDFI(χ2=14.88,P0.05)。结论3DCE-MRA以其诊断病变阳性率高,无创性,无辐射,对比剂过敏反应少、肝肾毒性小,可以整体显示感兴趣区血管等优点,在下肢血管病变诊断中应用越来越广泛。     

血管腔内成形术联合外科手术治疗下肢多节段动脉硬化闭塞症

目的探讨下肢多节段动脉硬化闭塞症的治疗手段及临床疗效。方法采用髂动脉球囊扩张和支架植入结合股-腘动脉人工血管转流术治疗下肢多节段动脉硬化闭塞症18例（20条患肢）。结果手术均获得成功,未出现严重并发症。患侧下肢末梢泛红试验均较术前明显改善。平均随访15个月（1-26个月）,与术前相比患者症状明显改善,跛行距离加大（〉1000m）。结论髂动脉腔内介入血管成形术结合股-腘动脉转流术是治疗多节段多平面下肢动脉硬化闭塞症的有效方法,手术创伤小、操作方便,尤其适合高危重症患者。     

3D-CEMRA在下肢动脉硬化闭塞症中的诊断价值

目的 探讨三维动态增强磁共振血管造影（contrast enhancement magnetic resonance angiography，3D-CEMRA）在下肢动脉硬化闭塞症（ASO）中的诊断价值及临床意义。方法对23例临床疑下肢ASO的患者行3D-CEMRA，扫描应用cage-bolus与三段动态扫描相结合。结果 23例患者腹主动脉、髂总动脉、髂内外动脉、股胭动脉、胫前后及腓动脉的动脉硬化闭塞的部位、范围、管壁及侧支循环建立情况均得到了清晰的显示。结论 3D-CEMRA对下肢ASO的诊断有重要意义，可作为血管介入治疗和手术前病人筛选的主要方法。     

股深动脉重建改善下肢动脉硬化闭塞症患者下肢缺血的疗效

目的 探讨股深动脉重建改善下肢动脉缺血方面的疗效.方法 根据CTA及血管彩超选择高危重症多节段动脉硬化闭塞症病例,对30例FontaineⅢ、Ⅳ期下肢动脉硬化闭塞症患者实施股深动脉重建.其中解剖外途径股-股深动脉人工血管转流术7例,髂总、髂外动脉-股深动脉人工血管转流术9例,髂动脉球囊扩张+支架植入术结合股深动脉成形术4例,腋动脉-股深动脉转流2例,单纯股深动脉成形术8例.结果 26例患者症状明显改善,皮温明显升高,静息痛消失,ABI明显升高(术前平均为0.23,术后平均为0.57).3例症状减轻,1例无效截肢.术后随访3～23个月(平均13个月).18例行人工血管转流术的病例中1例发生闭塞,人工血管通畅率为94.4％.8例单纯股深动脉成形的病例中1例闭塞.总体保肢率为96.7％.结论 在股浅动脉广泛闭塞时,股深动脉重建治疗Ⅲ、Ⅳ期动脉硬化闭塞症具有重要意义.     

股-腘动脉人造血管旁路移植的手术护理配合

动脉硬化闭塞症是一种慢性退行性血管炎症性病变.病变一般呈全身性疾患,好发于某些大中型动脉,血管因内膜损伤,脂质浸润等原因而使变狭窄,以至完全闭塞,肢体末段组织产生缺血性坏死.股-胭动脉人造血管旁路移植手术是将病人的股动脉和膝下胭动脉之间用PTFE人造血管架设一座"桥梁",让血管可以绕过闭塞的股浅动脉灌注小腿以下的组织,从而改善足部缺血组织的血运状况.现将手术护理配合情况总结探讨如下:     

旁路移植术治疗下肢闭塞性动脉硬化22例疗效分析

闭塞性动脉硬化(ASO)的发病率呈逐年增高趋势(1),已居下肢缺血性疾病的首位,轻者肢体发凉麻木疼痛,重者肢体坏疽,甚至截肢,给社会和家庭带来沉重负担.下肢ASO病变分为:I型(主髂动脉闭塞型)占10%;Ⅱ型(主-髂-股动脉型)占25%～35%;Ⅲ型(多节段型,即主-髂-股-小腿动脉)占60%～70%(2).特别是Ⅲ型治疗困难,仅有20%～50%手术机率然而手术失败率高达30%(3).但从整体来讲,特别是I型和Ⅱ型人还是有相当高的手术机率(4),而旁路移植术是治疗ASO的重要方法(3～5).     

血管镜辅助下内膜切除术治疗长段股—腘动脉闭塞35例疗效观察

目的提高长段股—腘动脉闭塞性病变的治疗水平。方法对35例长段股—腘动脉闭塞性病变患者行血管镜辅助下半闭合式内膜切除术：依据术前影像学资料,在病变动脉远、近端纵形切开,切除动脉内膜。动脉腔内引入血管镜,检查残留斑块或内膜,用Fogarty取栓导管或内膜剥脱器进一步处理,缝合固定远端内膜断端。结果手术成功率100%,动脉内膜切除长度10～36（25±8）cm,手术时间85～250（160±70）min。其中5例同时行股深动脉扩大成形术,3例行髂动脉球囊扩张及支架植入术,1例行髂外动脉内膜切除术。术后出现切口并发症2例,足趾溃疡5例,均经换药后愈合。术后踝肱指数由术前0.45±0.13提高至0.95±0.18（P〈0.01）。术后2周经动脉置管造影证实股—腘动脉通畅率100%。随访1～24个月,累积通畅率85.7%,保肢率100%。结论血管镜辅助下半闭合式内膜切除术治疗长段股—腘动脉闭塞性病变安全有效,近期通畅率与旁路手术及腔内介入手术相近,远期通畅率有待进一步观察。     

动脉硬化闭塞症膝下动脉血管腔内治疗的近远期疗效观察

目的:观察动脉硬化闭塞症膝下动脉病变经皮血管腔内治疗的疗效。方法:选取我科2006年10月至2009年10月期间,动脉硬化闭塞症膝下动脉病变经皮血管腔内治疗的117例患者,回顾性分析腔内治疗开通血管的成功率及术后随访资料。结果:117例患者(132条患肢)初次腔内治疗成功率为90.15%(119/132)。术后平均随访18个月(4～36个月)。血管再狭窄发生率分别为:6个月8.5%(10/117),12个月19.0%(22/116),18个月25.9%(30/116)。21例临床症状复发,再次腔内治疗成功率85.7%(18/21)。患者手术后间歇性跛行、静息痛、缺血性溃疡等临床症状均明显改善。结论:动脉硬化闭塞症膝下动脉腔内治疗手术成功率较高,临床效果满意,远期有一定的复发率,但可再次治疗。     

膝下动脉闭塞腔内治疗与手术治疗效果的临床分析

目的:评价膝下动脉闭塞球囊扩张成形术和动脉旁路术的治疗效果。方法:回顾性分析2005年12月至2009年5月北京协和医院收治的膝下动脉闭塞重症下肢缺血病例,全部资料都是前瞻性收集并录入数据库,并将治疗结果进行回顾性分析。根据膝下动脉初次处理手段的不同分为2组:球囊扩张成形术(PTA)组、以膝下动脉为流出道行自体静脉旁路移植术(bypass surgery,BPS)组,比较2组手术及随访结果。结果:PTA组54例(61条肢体),男性37例,女性17例,平均年龄66岁;手术前后踝肱指数(ABI)由(0.43±0.27)增加至(0.86±0.21),随访期间一期通畅率63.8%,二期通畅率74.1%,救肢率88.3%。动脉旁路术组17例(17条肢体),男性12例,女性5例,平均年龄67岁,ABI由(0.21±0.19)增加至(0.73±0.38),手术通畅率60%,救肢率87.5%。2组治疗结果差异无统计学意义。结论:膝下动脉腔内成形术的临床治疗效果不次于膝下动脉旁路手术,可以作为膝下动脉闭塞首选的治疗方法。     

Transluminal catheter dilatation. Indications, technical aspects, results

After 18 years of PTA experience, the results of a prospective study concerning the follow-up patency rate is demonstrated. The best results were seen in patients with claudication (1011) and treatment of iliac or superficial femoral artery stenoses and occlusions in the superficial femoral artery smaller than 12 cm. The 5 years patency rate in patients with claudication was 85 to 89%, and 65 to 72% in 491 patients with rest pain or gangrene. The primary and late results in patients with superficial femoral artery occlusion of more than 12 cm in length were not as good. In patients with claudication (82) the primary success rate was only 68%, but the follow-up patency rate was nearly as good as in the others. Patients with gangrene and occlusions of more than 12 cm showed only in 52% good primary success and only a patency rate of 30% out of all patients after 5 years. In 42% of this group PTA was a limb-saving procedure. Special details of technique and indications are discussed.     

Percutaneous transluminal angioplasty in 226 iliac artery stenoses: role of the superficial femoral artery for clinical success.

We reviewed the results of 174 consecutive percutaneous transluminal angioplasties (PTA) for 226 iliac artery stenoses (mean length 1.6 cm, range 0.2-9.6 cm) in 150 patients with lower limb ischaemia. Vascular intervention was indicated by intermittent claudication in 123 and critical ischaemia in 51 (29%) limbs. There were 12 (7%) failed guide-wire recanalizations. Four (2%) serious complications from puncture site haemorrhages or peripheral embolizations were handed surgically and caused one major amputation. Five-year patency in 162 successful dilatations was 68% primarily and 81% secondary to vascular surgical reconstructions during an average 28 (range 1-60) months of observation. One hundred and thirteen (70%) limbs improved clinically. In 95 limbs treated exclusively by iliac PTA, clinical improvement was achieved in 38/47 (81%) limbs with patency and 24/48 (50%) limbs with occlusion of the superficial femoral artery (SFA) (p < 0.003), whereas vascular patency of iliac PTA was unaffected by status of the SFA. Five-year limb salvage rate was 50% in limbs with critical ischaemia. We conclude that PTA for iliac artery stenoses is a low-risk procedure offering acceptable clinical results provided the SFA is patent. As an adjunct to distal bypass surgery, iliac PTA improves inflow without the requirement for major aorto-iliac surgery and may extend indications for vascular intervention in patients with lower limb ischaemia.     

高脂血症患者的下肢动脉血流动力学改变的研究

目的：研究高脂血症对下肢动脉血流动力学的影响。方法：选择我院2005年7月至2007年3月间的111例患者．按其血脂水平分为四组：正常对照组（I组）．高甘油三酯血症组（Ⅱ组）．高胆固醇血症组（Ⅲ组）,混合性高脂血症组（Ⅳ组）。抽取空腹肱静脉血进行血脂测定,同时应用多功能周围血管检查仪分别获取双侧股动脉、股浅动脉、胭动脉、胫后动脉、足背动脉的收缩期最大血流速度（Vmax）,阻力指数（RI）,搏动指数（PI）,并将结果用SPSS10．0进行统计分析。结果：按多功能周围血管检查仪检测的下肢动脉血流动力学参数异常率的高度排列依次为：（1）Ⅱ、Ⅲ、Ⅳ组的股浅动脉的P1;（2）Ⅱ、Ⅳ组的股动脉PI;（3）Ⅳ组的足背动脉的PI;（4）Ⅱ、Ⅳ组的胫后动脉RI;（5）Ⅳ组足背动脉的Vmax显著高于正常对照组（P〈0．05）。结论：混合性高脂血症对下肢动脉的血流动力学影响最大,股浅动脉、股动脉、胫后动脉和足背动脉较易受高血脂的影响而发生动脉硬化。     

一站式复合再血管化与经皮冠状动脉介入术治疗冠状动脉多支病变中期造影随访研究

目的 通过冠状动脉造影比较＂一站式＂复合再血管化技术（Hybrid技术）与经皮冠状动脉介入术（PCI）治疗冠状动脉多支病变的靶血管及旁路通畅率.方法 2007年6月至2009年12月我院实施＂一站式＂复合再血管化104例,冠状动脉介入治疗7165例.研究病例分为两组,Hybrid组和PCI组.入选标准：①合并前降支（LAD）病变的冠状动脉多支病变患者;②随访期间无胸痛等不适主诉、无心血管不良事件、无住院治疗、症状药物控制良好的患者;③外科术者和介入术者均为经验丰富的医生.按照上述标准,电话随访同意接受造影复查的患者Hybrid组102例,PCI组157例.2010年10月至2011年12月,50例Hybrid患者完成造影复查;采用倾向性评分1∶1匹配的统计方法抽取PCI组患者50例,完成冠状动脉造影检查.研究终点是两组患者冠状动脉造影随访的靶血管通畅率及二次血运重建率.结果 Hybrid组和PCI组各50例,随访时间分别为（18.0±8.0）个月和（19.3±9.1）个月.两组患者基线特征差异无统计学意义.Hybrid组LIMA-LAD旁路通畅率显著高于PCI组LAD靶血管通畅率（98%比80%,P＝0.004）;Hybrid组的LIMA旁路二次血运重建率显著低于PCI组LAD靶血管二次血运重建率（2%比20%,P＝0.008）.结论 ＂一站式＂复合再血管化技术使冠状动脉多支病变能获得良好的中期靶血管通畅率,其LIMA-LAD旁路通畅率显著优于PCI技术前降支药物洗脱支架通畅率.     

Primary results of laser recanalization in the endovascular treatment of arterial stenosis and occlusion of the lower limbs. Apropos of 45 treated cases]

Forty-five lower limb arterial lesions were treated by Nd Yag laser angioplasty using 1.4 and 2 mm hybrid catheters in 31 patients. This population comprised 28 men and 3 women (average age 63.8 +/- 3 years) 20 were in Stage II, 5 in Stage III and 6 in Stage IV of Fontaine's classification. The arteriographic lesions were 22 occlusions with an average length of 12.3 cm and 23 stenoses averaging 87% luminal reduction a few millimeters long to a maximum of a string of stenoses. Seventeen of these lesions were very calcified. The stenoses were situated on the iliac artery (7 cases), superficial femoral artery (28 cases), popliteal artery (9 cases) and the tibio-peroneal artery (1 case). There were no fatalities or recourse to emergency surgery. All patients underwent complementary balloon dilatation. The immediate patency rate was 91% in stenotic and 72% in occlusive lesions. At one week, the patency rate for stenotic lesions was unchanged but it had fallen to 59% for occlusive lesions (arteriographic evaluation). Angioscopy was used 22 times: it was indissociable to laser angioplasty as it enabled diagnosis and controlled the result. The use of thermal laser with hybrid catheters (metallic window tip) in endovascular procedures is a safe and effective method of treating stenosis and occlusion of lower limb arteries.     

The diagnosis of peripheral arterial embolism]

Acute embolic occlusion of a peripheral artery requires rapid and precise diagnosis in order to provide the appropriate treatment without delay. The symptoms and findings of acute arterial occlusion are characterized by "the six Ps": pain of sudden onset in the hypoperfused extremity, paleness, pulselessness, paresthesias, paralysis and, in the extreme case, prostration with the symptoms of shock. With embolization in arterial segments with only minimal residual perfusion via collaterals (for example, the femoral bifurcation), a complete ischemic syndrome is usually incurred manifesting the six Ps as delineated. If preformed collateral systems provide some perfusion distal to an arterial occlusion (for example, in the common iliac artery), there is frequently an incomplete ischemic syndrome observed which is characterized by pain, paleness and pulselessness. Peripheral arterial embolism has a predilection for the femoral bifurcation, the superficial femoral artery and the popliteal artery. In principle, however, embolization can occur in every arterial segment. The diagnosis of the acute ischemic syndrome can generally be established on the basis of the history and physical examination. Diagnostic aid can be provided by electronic segmental oscillography to demonstrate diminished or absent oscillations and with the Doppler sonographically-determined systolic arterial pressure at the ankle which, in the case of severe ischemia, is less than 50 mmHg. Arteriography provides the most accurate morphological information. Abrupt occlusion of the vessel and no collateral perfusion especially in the absence of arteriosclerotic changes are strongly indicative of embolism but not conclusive. If the clinical diagnosis is unequivocal, arteriography need not be performed prior to embolectomy with a Fogarty catheter.(ABSTRACT TRUNCATED AT 250 WORDS)