准分子激光斑块消蚀术治疗下肢动脉慢性闭塞△

目的分析准分子激光斑块消蚀术(excimer laser atherectomy,ELA)治疗下肢股浅动脉以及膝下动脉慢性闭塞病变的安全性和可行性。方法我们率先在华南地区采用ELA治疗下肢动脉慢性闭塞所致严重肢体缺血(critical limb ischemia,CLI)2例,1例为股浅动脉原发闭塞性病变,采用ELA联合紫杉醇涂层球囊处理;1例为胫后动脉原发闭塞病变,采用ELA联合普通球囊扩张处理。结果 2例患者手术顺利,术后前向血流通畅,下肢缺血明显改善,无需补救性植入支架,无手术并发症。术后1个月跛行距离延长,足部溃疡愈合,复查超声显示股浅动脉及胫后动脉血流通畅。结论 ELA治疗下肢股浅及膝下动脉慢性闭塞病变安全可行。     

定向斑块旋切治疗下肢股浅动脉硬化闭塞症

目的探讨定向斑块旋切治疗下肢股浅动脉硬化闭塞症的临床效果。方法选择下肢股浅动脉硬化闭塞症患者42例,随机分为观察组和对照组,各21例。观察组采用TurboHawk定向斑块旋切系统治疗,对照组采用球囊扩张及支架植入术治疗。收集数据,观察比较两组的治疗效果。结果观察组术后临床症状、踝臂指数改善情况与对照组差异无显著性(P>0.05)。观察组术后并发症发生率低于对照组,差异有统计学意义(P<0.05)。术后随访,观察组术后再狭窄率与对照组差异无显著性(P>0.05)。结论定向斑块旋切在治疗下肢股浅动脉硬化闭塞症中可以获得与球囊扩张、支架植入相似的通畅率,是一种安全、实用、有效的方法。     

准分子激光斑块消蚀术与球囊扩张交替处理重度钙化冠状动脉狭窄病变1例

69岁女性患者因胸痛7 h入院。既往有高血压和胆囊结石病史。半年前因急性下后壁心肌梗死,于右冠状动脉植入支架2枚,前降支因钙化严重拟择期处理。此次入院诊断为不稳定性心绞痛,在体外肺膜氧合系统辅助下行复杂高危经皮冠状动脉介入治疗。由于前降支钙化严重,导丝进入较困难,球囊难以通过,故使用准分子激光斑块消蚀术进行预处理。反复在血液稀释对比剂下行斑块消融,激光与球囊扩张交替进行,直至扩开病变,成功于前降支及对角支植入4枚支架。术后病情好转出院。6个月随访血管通畅。     

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。     

准分子激光冠状动脉内斑块消蚀术在大隐静脉桥血管病变介入治疗中的应用分析

目的：观察准分子激光冠状动脉内斑块消蚀术（ELCA）在冠状动脉旁路移植术后大隐静脉桥血管（SVG）病变经皮冠状动脉介入治疗（PCI）中应用的安全性和有效性。方法：总结2020年5月至2021年5月在云南省阜外心血管病医院冠心病中心应用ELCA治疗的5例大隐静脉桥血管病变PCI患者,导引钢丝通过SVG病变,应用血管内超声评价SVG病变特征,ELCA治疗后进行药物洗脱支架置入或药物洗脱球囊处理。观察手术成功率及并发症,并随访复发性心绞痛、心肌梗死、靶血管重建及心原性死亡等主要不良心脏事件（MACE）发生情况。结果：5例患者ELCA辅助SVG病变PCI全部成功,术中无1例发生血管夹层、穿孔、慢血流及无复流,随访期间无1例发生复发性心绞痛、心肌梗死、靶血管重建及心原性死亡。结论：应用ELCA辅助SVG病变行PCI安全有效,可显著减少相关并发症,改善预后。     

下肢动脉硬化闭塞症治疗现状及展望

血管重建、恢复远端肢体灌注是下肢动脉硬化闭塞症治疗的关键点。血管重建的方法包括开放重建和腔内重建。腔内治疗作为高新技术的代表,已逐渐成为下肢动脉硬化闭塞症治疗的主力军,甚至复杂主髂动脉、股腘动脉、膝下动脉硬化闭塞症也越来越多地采用创伤相对小的腔内治疗,并取得了较好的临床疗效。本文就下肢动脉硬化闭塞症治疗的现状和展望进行阐述。     

顺序介入治疗肢体动脉硬化闭塞症20例临床分析

为评价三种介入治疗技术对肢体动脉硬化闭塞症的临床疗效,采用局部溶栓、经皮球囊成形术和内支架植入术顺序应用治疗肢体动脉硬化闭塞症２０例（２８段病变）,治疗成功率９６．４％（２７／２８）,远期随访再狭窄率低。认为三种介入治疗技术顺序应用能明显提高疗效,减少再狭窄率,减轻经济负担,避免严重并发症。     

下肢动脉硬化闭塞症膝下病变潜在机制的加权基因共表达网络和免疫浸润分析

目的]探讨下肢动脉硬化闭塞症膝下病变的潜在机制和免疫相关性。 [方法]从高通量基因表达数据库下载GSE100927数据集,利用R语言软件Limma数据包和加权基因共表达网络分析筛选与下肢动脉硬化闭塞症膝下病变相关的基因并进行信号通路富集分析;构建蛋白-蛋白相互作用网络并筛选下肢动脉硬化闭塞症膝下病变相关的核心基因,分析核心基因在下肢动脉硬化闭塞症膝下病变样本与对照样本间的差异,利用受试者工作特征曲线下面积评价核心基因的诊断效能。采用反卷积算法(CIBERSORT)评估各样本中免疫细胞分布并计算不同免疫细胞在下肢动脉硬化闭塞症膝下病变样本与对照样本间的差异。 [结果]筛选获得下肢动脉硬化闭塞症膝下病变差异表达上调基因153个,差异表达下调基因63个,加权基因共表达网络分析结果表明下肢动脉硬化闭塞症膝下病变基因差异表达以上调为主,涉及胆固醇代谢、血小板活化等信号通路;蛋白酪氨酸磷酸酶受体C型(PTPRC)、Spi-1原癌基因(SPI1)、集落刺激因子1受体(CSF1R)和Fcγ受体Ⅲa(FCGR3A)可能是下肢动脉硬化闭塞症膝下病变的核心基因,且诊断效能较好。下肢动脉硬化闭塞症膝下病变与单核细胞的浸润程度呈正相关(r＝0.419,P＝0.037),与M2型巨噬细胞的浸润程度呈负相关(r＝－0.491,P＝0.013)。 [结论]下肢动脉硬化闭塞症膝下病变涉及胆固醇代谢、血小板活化等多种信号通路;与单核细胞、巨噬细胞介导的免疫反应密切相关;PTPRC、SPI1、CSF1R和FCGR3A可能是下肢动脉硬化闭塞症膝下病变的核心基因。     

糖尿病下肢动脉硬化闭塞症临床分析

糖尿病(DM)动脉硬化闭塞症(ASO)的发病率是非糖尿病的11倍,且周围动脉硬化发展快,程度重,一旦发生,其截肢率是非糖尿病人的40倍[1]。我们通过回顾性分析60例ASO的临床特征,探讨糖尿病与非糖尿病ASO之间的差异及糖尿病动脉硬化闭塞症的治疗方案。临床资料1.一般资料:收集1996年1月～2006年6月我院ASO患者60例(72条肢体),其中DM组32例(40条肢体),非糖尿病组28例(32条肢体)。两组临床资料见表1。2.诊断:本组患者ASO的诊断:(1)有肢体缺血性表现;(2)踝/肱动脉压力指数(ABI)小于0.9;(3)血管造影有明显狭窄;(4)彩超发现有动脉狭窄。72条肢…     

经皮腔内血管成形术治疗膝下动脉硬化闭塞症临床研究

目的探讨经皮腔内血管成形术（PTA）对膝下动脉硬化闭塞症的治疗效果。方法回顾性分析我院从2006年10月~2008年5月采用PTA治疗膝下动脉硬化闭塞症的18例患者（22条肢体）病史资料和术后随访资料。结果20条肢体获得影像学成功,技术成功率90.9%;治疗后第1周踝/肱指数较术前增加（P〈0.05）;术后6、12个月肢体通畅率分别为81.8%和63.6%,术后12个月肢体保全率和存活率分别为90.9%、95.5%。结论PTA是安全有效的治疗膝下动脉硬化闭塞症的方法。     

药物球囊治疗股腘动脉硬化闭塞症的临床研究

目的评估药物涂层球囊(DCB)治疗股腘动脉硬化闭塞的有效性及安全性。方法回顾性分析2016年6月至2017年5月哈尔滨医科大学附属第一医院血管外科及群力分院血管外科行球囊治疗的股腘动脉病变患者162例(Rutherford2~4级)。其中采用DCB治疗的患者102例(DCB组),采用普通球囊即经皮腔内血管成形术(PTA)治疗的患者60例(PTA组)。患者在术后30 d、6个月和12个月后于我院复诊并对其进行随访。收集2组患者一般资料,观察患者疗效终点和安全终点。采用SPSS 19.0软件对数据进行分析。根据数据类型,组间比较采用独立样本t检验、χ~2检验(Pearson χ~2或四表格校正公式)或Wilcoxon符号秩和检验。结果 2组患者一般资料差异无统计学意义(P0.05),但男性、有吸烟史患者比例均50%。2组患者病变特点及手术相关指标差异均无统计学意义(P0.05)。随访12个月后,与PTA组患者比较,DCB组一期通畅率[76.5%(78/102)vs 56.7%(34/60),P=0.008]和踝肱指数[(0.89±0.14)vs(0.82±0.20),P=0.027]显著升高,靶病变血运重建(TLR)比例显著降低[5.9%(6/102)vs 27.1%(16/60),P0.001],差异有统计学意义,但2组患者在提高步行受损问卷(WIQ)[22.3(8.0,39.4)vs 21.4(5.4,37.7)分,P=0.403]、手术成功比例[100%(102/102)vs 100%(60/60),P=1.000]方面差异无统计学意义。DCB组1例男性患者因严重慢性阻塞性肺疾病伴严重肺感染于随访6个月后死亡,PTA组1例糖尿病患者于随访6个月后因足外伤后感染严重行膝下截肢术;但2组患者安全终点事件及主要不良事件发生率差异均无统计学意义(P0.05)。结论 DCB治疗初发性股腘动脉硬化闭塞效果明显优于PTA,安全性不劣于PTA。     

准分子激光治疗股腘动脉支架内再狭窄的临床研究

目的探讨准分子激光联合药物涂层球囊(DCB)治疗股腘动脉支架内再狭窄(ISR)的可行性及安全性。方法回顾性分析股腘动脉ISR患者的临床资料,其中36例准分子激光斑块消蚀术(ELA)+普通球囊血管成形术(POBA)+DCB治疗者为观察组;57例POBA+DCB治疗者为对照组。观察两组手术成功率、并发症发生率、术后即刻最小管腔直径(MLD)、术后3天踝肱指数(ABI)等。术后随访:1、3、6、12月彩超和ABI,12月靶病变血流重建(TLR)、ISR、截肢率、MLD、晚期管腔丢失(LLL)等指标。结果术前两组患者性别、年龄、TASCⅡ分级以及合并症等基线资料比较,差异无统计学意义。术后1、3、6、12月ABI,12月TLR、ISR、截肢率、MLD、LLL等指标,观察组优于对照组(P均0.05)。结论 ELA+POBA+DCB治疗股腘动脉ISR安全有效,近中期效果优于POBA+DCB。     

单中心准分子激光冠状动脉消融术治疗复杂冠状动脉病变的安全性和有效性分析

目的 探讨准分子激光冠状动脉消融术(ELCA)在复杂冠状动脉病变中的安全性和有效性。方法 纳入2018年12月—2021年1月江苏大学附属医院心内科行ELCA辅助介入治疗的复杂冠状动脉病变病例5例共6处病变,观察ELCA成功率、PCI成功率和临床成功率,以及PCI并发症、术后住院期间和6个月随访期主要不良心脏事件(MACE)。结果 6处病变均为支架内再狭窄,其中完全闭塞病变3处,严重钙化病变1处,三支病变比例40.0%。ELCA成功率、PCI成功率和临床成功率均为100%,PCI并发症为0。光学相干断层扫描见ELCA处理后局部内膜撕裂(7.00±3.46)处,PCI后相较ELCA处理后无论最小管腔直径(MLD)[(2.56±0.27) mm比(1.47±0.37) mm,P=0.006]还是最小管腔面积(MLA)[(6.48±1.16) mm²比(2.14±0.62) mm²,P=0.005]均明显增加。住院期间MACE发生率为0,6个月内发生MACE 3例,其中2例心绞痛,1例心肌梗死,均行靶血管血运重建。结论 ELCA辅助治疗复杂冠状动脉...     

Differences in restenosis propensity of devices for transluminal coronary intervention: A quantitative angiographic comparison of balloon angioplasty, directional atherectomy, stent implantation and excimer laser angioplasty

With the increasing clinical application of new devices forpercutaneous coronary revascularization, maximization of theacute angiographic result has become widely recognized as akey factor in maintained clinical and angiographic success.What is unclear, however, is whether the specific mode of actionof different devices might exert an additional independent effecton late luminal renarrowing. The purpose of this study was toinvestigate such a difference in the degree of provocation ofluminal renarrowing (or ‘restenosis propensity’)by different devices, among 3660 patients, who had 4342 lesionssuccessfully treated by balloon angioplasty (n=3797), directionalcoronary atherectomy (n= 200), Palmaz-Schatz stent implantation(n= 229) or excimer laser coronary angioplasty (n= 116) andwho also underwent quantitative angiographic analysis pre- andpost-intervention and at 6-month follow-up. To allow valid comparisonsbetween the groups, because of significant differences in coronaryvessel size (balloon angioplasty=2.62±0.55 mm, directionalcoronary atherectomy= 3.28±0.62 mm, excimer laser coronaryangioplasty= 2.51±0.47 mm, Palmaz-Schatz=3.01±0.44mm;P<0.0001), the comparative measurements of interest selectedwere the ‘relative loss’ in luminal diameter (RLoss=losslvessel size) to denote the restenosis process, and the‘relative lumen at follow-up’ (RLfup=minimal luminaldiameter at follow uplvessel size) to represent the angiographicoutcome. For consistency, lesion severity pre-intervention was representedby the ‘relative lumen pre’ (RLpre=minimal luminaldiameter prelvessel size) and the luminal increase at interventionwas measured as ‘relative gain’ (relative gain=gainl vessel size). Differences in restenosis propensity betweendevices was evaluated by univariate and multivariate analysis.Multivariate models were constructed to determine relative lossand relative lumen at follow-up, taking account of relativelumen pre-intervention, lesion location, relative gain, vesselsize and the device used. In addition, model-estimated relativeloss and relative lumen at follow-up at given relative lumenpre-intervention relative gain and vessel size, were comparedamong the four groups. Significant differences were detectedamong the groups both with respect to these estimates, as wellas in the degree of influence of progressively increasing relativegain, on the extent of renarrowing (relative loss) and angiographicoutcome (relative lumen at follow-up), particularly at higherlevels of luminal increase (relative gain). Specifically, lesionstreated by balloon angioplasty or Palmaz-Schatz stent implantation(the predominantly ‘dilating’ interventions) wereassociated with more favourable angiographic profiles than directionalatherectomy or excimer laser (the mainly ‘debulking’interventions). Significant effects of lesion severity and location,as well as the well known influence of luminal increase on bothluminal renarrowing and late angiographic outcome were alsonoted. These findings indicate that propensity to restenosis afterapparently successful intervention is influenced not only bythe degree of luminal enlargement achieved at intervention,but by the device used to achieve it. In view of the clinicalimplications of such findings, further evaluation in largerrandomized patient populations is warranted.     

准分子激光冠脉消融术在急性ST段抬高型心肌梗死直接经皮冠脉介入治疗中的应用

目的评价准分子激光冠脉消融术(ELCA)在富含血栓的急性ST段抬高型心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)中应用的有效性和安全性。方法 2016年11月至2018年2月锦州医科大学北部战区总医院连续纳入25例富含血栓的STEMI患者,分成单纯球囊扩张成形术和(或)支架术(对照组n=13)和辅助的ELCA治疗组(ELCA组n=12),采用冠脉造影或冠状动脉定量测量(QCA)评估TIMI血流、TIMI血栓分级、校正的TIMI帧数(CTFC)、最小血管腔直径(MLD)和直径狭窄程度(DS),主要观察终点为手术即刻成功率和临床成功率。结果与对照组相比,ELCA组左心室射血分数更低[(49.0±11)%比(61.2±7.9)%,P=0.006],其他一般资料包括生活习性、既往史和冠脉造影指标,差异均无统计学意义(P>0.05)。PCI相关指标中,除球囊预扩张指标(P=0.022)外,其余差异均无统计学意义(P>0.05)。ELCA组手术即刻成功率为100%,术中未观察到无复流、夹层、冠脉穿孔等并发症,对照组发生慢血流2例,无复流1例,手术即刻成功率76.9%。采用CTFC评价系统评估术前和术后即刻冠脉灌注血流情况,ELCA组由(67.81±16.5)帧减少至(34.63±14.7)帧,对照组(55.77±12.10)帧减少至(39.54±12.54)帧,二者差异有统计学意义(P<0.05),两组MLD和DS差异无统计学意义(P>0.05)。住院期间及6个月随访期间,ELCA组无MACE事件发生,对照组发生MACE事件2例(因心衰再次住院)。结论 ELCA应用于富含血栓的STEMI直接PCI可提高心外膜血流,改善心肌灌注,减少慢血流或无复流风险,具有较高的即刻成功率和临床成功率,可作为急性心肌梗死直接PCI的辅助治疗手段。     

Clinical events following excimer laser angioplasty or balloon angioplasty for complex coronary lesions: subanalysis of a randomised trial

Objectives—To compare clinical outcome in patients with complex coronary lesions treated with either excimer laser coronary angioplasty (ELCA) or balloon angioplasty.
Patients and design—308 patients with stable angina and a coronary lesion of more than 10 mm in length were randomised to ELCA (151 patients, 158 lesions) or balloon angioplasty (157 patients, 167 lesions). The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomised segment during six months of follow up. Subanalysis was performed to identify a subgroup of patients with a beneficial clinical outcome following ELCA or balloon angioplasty.
Setting—Two university hospitals and one general hospital.
Results—There were no deaths. Myocardial infarction, coronary bypass surgery, and repeated angioplasty occurred in 4.6, 10.6, and 21.2%, respectively, of patients treated with ELCA compared with 5.7, 10.8, and 18.5%, respectively, of those treated with balloon angioplasty. ELCA did not yield a favourable clinical outcome in subgroups of patients with long (more than 20 mm) coronary lesions, calcified lesions, small diseased vessels (2.5 mm reference diameter), or total coronary occlusions. There was a worse clinical outcome in patients with tandem lesions treated with ELCA compared with balloon angioplasty (9/18 v 3/26 lesions; p = 0.01); while a trend towards an unfavourable clinical outcome was found in patients with vessels with a reference diameter of more than 2.5 mm (23/66 v 13/63 lesions, p = 0.07) and left circumflex coronary lesions (12/41 v 6/42 lesions, p = 0.08).
Conclusions—The findings indicate a worse clinical outcome in patients with lesions of more than 10 mm treated with ELCA compared with balloon angioplasty who have tandem coronary lesions and in those with vessels with a reference diameter of more than 2.5 mm and left circumflex coronary lesions.

Keywords: excimer laser angioplasty; laser assisted balloon angioplasty; balloon angioplasty; randomised trial; interventional cardiology     

Malignant restenosis after primary successful excimer laser coronary angioplasty

In a series of 20 coronary excimer laser angioplasties, two patients presented with a peculiar type of malignant restenosis 6 and 8 weeks after a successful laser angioplasty procedure. One patient had a successful recanalization of an occluded left anterior descending (LAD) coronary artery and the second patient had a successful angioplasty of a subtotal proximal stenosis of the left anterior descending coronary artery. After the procedure, no ischemia could be demonstrated by exercise ECG and thallium scintigraphy. Both patients were free of angina until the sudden development of nocturnal angina several hours before reangiography, which showed subtotal restenosis in both cases. One patient had a mammaria graft on the LAD and the second patient underwent a successful balloon angioplasty. This uncommon sudden and malignant development of restenosis seems to be related to the excimer laser angioplasty procedure and warrants some caution with the indiscriminative use of this new angioplasty procedure.     

Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.     

Intravascular ultrasound imaging after excimer laser angioplasty

To help elucidate the mechanism of excimer laser coronary angioplasty (ELCA), intra-vascular ultrasound (IVUS) imaging was performed in 19 of 29 patients who were treated with ELCA. The results were compared with a non-randomized control group of 18 patients who had IVUS studies both before and after PTCA alone. After ELCA alone, lumen diameter (1.9 × 1.7 mm) and lumen cross-sectional area (CSA) (2.9 mm²) by IVUS were not significantly different from baseline values in the patients before PTCA alone (2.1 × 1.8 mm, 3.2 mm²). After balloon dilatation in the laser treated group, lumen diameter (2.5 × 2.1 mm) and lumen CSA (4.9 mm²) were significantly greater than those post ELCA alone. However, there was no difference in lumen CSA or atheroma CSA in the group treated with excimer laser plus balloon dilatation vs. these measurements in the group treated with PTCA alone. ELCA does not ablate a large amount of atheroma (9% reduction) but creates a pathway to permit easier passage of a PTCA balloon. These quantitative and morphologic results may help explain why the restenosis rate with ELCA is similar to PTCA alone. © 1994 Wiley-Liss,Inc..