静脉动脉化治疗广泛性下肢动脉闭塞症

目的:探讨静脉动脉化手术对广泛性下肢动脉闭塞症的疗效.方法:对有慢性缺血表现的20条下肢行Doppler超声与DSA或MRA检查,确诊为广泛性下肢动脉闭塞症.然后用分期或一期静脉动脉化手术对所有患肢进行治疗.结果:术后近期3条截肢.17条患肢随访6～51个月,其中2条患肢深静脉血栓形成,15条患肢疗效理想,症状消失.术后Doppler超声与MRA复查可见动脉血向缺血肢体灌注.结论:静脉动脉化治疗广泛性下肢动脉闭塞症疗效良好,为治疗该病开辟了一条新途径.     

分期动静脉转流治疗肢体动脉闭塞症176例

目的探讨分期动静脉转流术治疗血栓闭塞性脉管炎(TAO)和动脉硬化闭塞症的远期效果。方法回顾性分析176例分期动静脉转流术的临床资料。结果147例获随访,随访率83 5%,中位随访时间9 8年。6例上肢和84例下肢低位深组转流患者中, 86例(95 5% )术后1周疼痛消失,肢体保留率100%。57例下肢高位深组转流者中, 43例(75 4% )疼痛术后2 ~3周消失,术后5例截肢,截肢率8 8% (5 /57),肢体保留率91 2%。结论分期动静脉转流治疗TAO和广泛性动脉硬化闭塞症临床效果满意,但应严格掌握手术适应证。     

一期静脉动脉化血运重建治疗四肢广泛性动脉闭塞性缺血

目的　探讨静脉动脉化血运重建对四肢广泛性动脉闭塞性缺血的疗效。　方法　 1 999年 5月～ 2 0 0 1年 8月 ,对有慢性缺血表现的 1 8条下肢和 6条上肢行彩色多普勒超声和数字减影血管造影检查 ,确诊为广泛性肢体动脉闭塞症。根据闭塞平面采用原位高位浅组静脉或低位深组静脉一期静脉动脉化重建血运手术对患肢进行治疗。　结果　术后住院期间除 1条下肢截肢外 ,1 7条下肢和 6条上肢获 3～ 2 6个月随访 ,其中 1条下肢出院 3个月后患肢趾缺血坏死再入院行低位截肢 ,其余 1 6条下肢和 6条上肢疗效满意 ,症状消失。术后彩色多普勒超声复查可见动脉血向缺血肢体灌注。　结论　根据闭塞平面采用高位浅组或低位深组一期静脉动脉化重建血运 ,治疗四肢广泛性动脉闭塞简便易行 ,效果良好     

静脉动脉化治疗广泛下肢动脉闭塞症

目的：探讨静脉动脉化手术对广泛性下肢动脉闭塞症的疗效。方法：对有慢性缺血表现的２０条下肢行Ｄｏｐｐｌｅｒ超声与ＤＳＡ或ＭＲＡ检查，确诊为广泛性下肢动脉闭塞症。然后用分解一期静脉动脉化手术对所有患肢进行治疗。结果：术后近期３条截肢。１７条患肢阴访６￣５１个月，其中２条患肢深静脉血栓形成，１５条患肢疗儿理想，症状消失。术后Ｄｏｐｐｌｅｒ超声与ＭＲＡ复查可见动脉血向缺血肢体灌注。结论：静脉动脉化治疗广泛     

胫后静脉一期动脉化治疗周围动脉广泛性闭塞性疾病

目的探讨应用胫后静脉一期动脉化治疗周围动脉广泛性闭塞性疾病的疗效。方法应用胫后静脉一期动脉化治疗周围动脉广泛性闭塞性疾病46例(56条患肢)。结果术后患者疼痛症状消失、皮温升高。经3个月～7年的随访,除2条患肢行截肢、2条患肢再行带蒂网膜移植术外,其余肢体治疗效果良好,总有效率为92.9%(52/56)。结论胫后静脉一期动脉化具有手术一期完成、适应证广、对静脉回流影响小、缺血症状解除快等优点。     

股深动脉扩大成形术治疗严重下肢缺血

目的评价股深动脉扩大成形术治疗严重下肢缺血的临床疗效。方法回顾性分析1990～ 2 0 0 2年应用股深动脉扩大成形术治疗下肢动脉广泛性闭塞所致严重下肢缺血 (Fontaine′s分类Ⅲ Ⅳ期 ) 2 3例 (2 5条下肢 )的临床资料 ,对术前和术后经踝 /肱血压指数 ,经皮氧分压 ,经皮氧饱和度 ,平板车运动负荷试验 ,近红外线分光仪和彩色多普勒超声检查进行综合评价临床疗效。结果术后随访 7个月至 7年 ,经各项检查综合评价 ,症状消失 ,疗效优良 13例 (14条下肢 ) ;溃疡愈合 ,但残留中、轻度下肢缺血症状 6例 (7条 ) ;膝下截肢 3例 (3条 )和半足截肢 1例 (1条 )。结论股深动脉扩大成形术方法简便 ,创伤小 ,安全和疗效可靠 ,为无条件施行常规动脉重建术的缺血性肢体的救肢治疗 ,开辟了一条良好途经。     

一期胫后静脉动脉化治疗下肢动脉闭塞症

目的探讨应用一期胫后静脉动脉化治疗下肢动脉闭塞症的疗效，总结其手术体会。方法应用胫后静脉一期动脉化治疗周围动脉广泛性闭塞性疾病57例(69个肢体)。结果术后患者疼痛症状消失、皮温升高。经观察3个月—15年，除4例(4个肢体)又分别行截肢及带蒂网膜移植术外，其余肢体治疗效果良好。结论该方法具有手术一期完成、适应证广、对静脉回流影响小、缺血症状解除快等优点。     

静脉动脉化治疗严重下肢缺血的远期疗效分析

目的：探索静脉动脉化治疗严重下肢缺血的新术式。方法：在对大隐静脉、胫后静脉瓣膜进行解剖学和生物力学研究的基础上，设计静脉瓣膜切除或破坏、原位一期静脉动脉化两种新术式，治疗动脉广泛闭塞所致严重下肢缺血患者７１例（７４条肢体）。结果：随访１～８年（其中随访５年以上３２例），静息痛消失率９６．５％，间隙性跛行消失率９３．７％，截肢率降至２．７％，获得满意效果。结论：两种新术式通过静脉通道，逆行灌注动脉血，确能改善或重建严重缺血下肢的血循环，具有满意的远期疗效。     

胫后静脉一期动脉化治疗下肢动脉广泛闭塞

应用在下肢闭塞以上正常动脉与腓静脉入口远侧胫后静脉之间搭桥及破坏胫后静脉远侧瓣膜的方法．一期完成胫后静脉动脉化，用于治疗下肢动脉广泛性闭塞病变15例（17肢），术后观察1～10年，除2例（2肢）又分别行截肢及带蒂网膜移植外。其余15肢效果良好。本法具有手术可一期完成、适应证广、对静脉回流影响小和缺血症状解除快等优点。     

DSA监视下急性下肢缺血的介入联合手术治疗

目的 探讨急性下肢缺血手术与介入联合的治疗方法。方法 分析2001年1月至2006年1月收治的72例（76条肢体）急性下肢缺血患者在DSA监测下行下肢动脉重建的临床资料。72例患者手术方式包括：（1）Fogarty导管取栓术45例；（2）Fogarty导管取栓＋股总动脉分叉处内膜剥脱＋补片成形5例；（3）Fogarty导管取栓＋球囊扩张支架植入2例；（4）Fogarty导管取栓术＋球囊扩张4例；（5）Fogarty导管取栓＋人工血管架桥术6例，其中股-股转流3例、腋-双股转流1例、股-胭转流1例、腹主动脉-双股动脉转流1例。（6）Fogarty导管取栓＋截肢（二期）6例；（7）Fogarty导管取栓＋腹主动脉夹层开窗术。结果 72例中，56例（59条肢体）救肢成功；7例（7条肢体）术前趾端坏死截除后愈合；6例（6条肢体）截肢；3例（4条肢体）围手术期发生多脏器功能衰竭死亡。结论 DSA监测下手术与介入联合治疗急性下肢缺血有助于提高重建下肢动脉供血成功率。手术的效果取决于肢体缺血的时间和程度以及对并发症的有效处理。     

A new surgical approach to extensive arterial occlusion of lower extremity—Femoro-popliteal open endarterectomy with arteriovenous shunt

A revascularized surgery for extensive arterial occlusive lesions of the lower extremities, namely open endarterectomy of the occluded femoro-popliteal artery with arteriovenous shunt, was devised. The procedure is specially indicated to the extensive arterial occlusion of the lower extremity for which the conventional reconstructive vascular surgery is not applicable. The patency of the reconstructed femoro-popliteal arteries are ensured by virture of an arteriovenous shunt and newly developed collaterals from the reopened genicular network is expected to provide effective blood flow to peripheral parts. From 1967 to 1975, this procedure was applied to 59 extremities in 53 patients, all of whom had extensive arterial occlusion from the femoral artery to the periphery with impending ulcer and severe rest pain. Fourtyfive out of 59 extremities had remarkable improvement of the ischemic symptoms and signs at the time of discharge. Long-term effectiveness was shown in 34 out of 59 extremities or 58 per cent.     

手术联合介入治疗急性下肢缺血42例

目的 探讨手术联合介入治疗急性下肢缺血的临床疗效.方法 回顾性分析2007年7月至2010年1月收治的42例急性下肢缺血患者的临床资料.所有患者术前均存在下肢急性缺血的症状,表现为疼痛、麻木、无脉、皮肤苍白、感觉异常等,均行彩超、MRI、CT诊断明确.在导管室行Fogarty导管取栓,术毕均行动脉造影检查,对血管狭窄程度＞50％者行介入治疗(包括接触性导管溶栓术、球囊扩张成形术及支架植入术).结果 42例急性下肢缺血患者无一例死亡.其中救肢成功40例,2例行截肢术,截肢平面均为膝下,截肢率4.76％.33例术后扪及足背及胫后动脉搏动,缺血症状明显改善.7例术后仍存在不同程度的缺血症状,表现为下肢疼痛、麻木等.结论 在导管室行手术取栓联合介入治疗急性下肢缺血是一种安全、有效的治疗方法,并能提高救肢率及远期通畅率.手术效果取决于肢体缺血时间和程度,以及对并发症的及时处理.     

The blue toe syndrome: hemodynamics and therapeutic correlates of outcome

We reviewed the limb and digit hemodynamics of 67 extremities of 48 patients evaluated for blue toe syndrome in our vascular laboratory during 7 years. These patients represented 1.4% of the arterial examinations during this period. Abnormal ankle/arm pressure indices (less than 0.9), signifying proximal arterial obstruction, were present in 31 limbs (47%). Toe/ankle indices were abnormal (less than 0.6) in 57 extremities (85%), indicating pedal or digital artery obstruction. Arteriograms were obtained in 40 of 64 extremities (63%) available for follow-up, which revealed atherosclerotic disease in 90% (aortoiliac 20%, femoropopliteotibial 30%, and combined 40%), aneurysm in 7.5%, and no disease in only one extremity (2.5%). Of 64 extremities followed for 1 to 84 months (mean, 26 months), only 28 (44%) manifested an uncomplicated outcome. Tissue loss was noted in 24 (38%), recurrent digital ischemia occurred in nine (14%), and 14 limbs (22%) required amputation of toe(s) (seven), forefeet (three) or legs (four). Nine patients (20%) died in the follow-up period. Outcomes did not correlate with limb or digit hemodynamics or with therapy (surgical in 31, medical in 11, or none in 22) except that tissue necrosis was more common in patients undergoing operation. The blue toe syndrome deserves recognition as an important sign of potential limb-threatening arterial disease, but the optimal therapy remains to be established.     

Surgical management of severe acute lower extremity ischemia.

Seventy-four patients (70 men [95%], 4 women [5%], mean age, 63 years) with severe, acute lower limb ischemia (acute clinical deterioration and absent pedal Doppler signals) caused by either arterial thrombosis (n = 68) or embolism (n = 6) underwent urgent surgical management consisting of operative revascularization with or without amputation in 67 patients (91%) and primary amputation alone in 7 patients (9%). Sixty-one patients (82%) had severely threatened limb viability, and 13 (18%) had major irreversible ischemic limb changes at presentation. Eighty-six percent of patients were initially anticoagulated with heparin. Seventy percent underwent preoperative angiography. Surgical revascularization included 42 inflow and 20 outflow arterial reconstructions and 9 thrombectomy or embolectomy procedures. Mean follow-up was 17 months (range, 0 to 64). Life-table primary patency at 36 months for arterial reconstructions was 81% for inflow and 78% for outflow procedures. Cumulative limb salvage was 70% at 1 month and 68% at 36 months. Patient survival was 85% at 1 month and 51% at 36 months. No death was directly attributable to complications related to limb reperfusion, and no patient required dialysis for myoglobinuria. We conclude that management of severe, acute lower limb ischemia with early amputation of nonviable limbs and heparinization, angiography, and prompt operative revascularization for threatened but viable extremities minimizes morbidity and mortality rates, while maximizing limb salvage. These results may be useful for comparison with comparable groups of patients treated with thrombolytic or endovascular modalities.     

Increased limb salvage. Distal tibial/peroneal artery thrombectomy/embolectomy in acute lower extremity ischemia

Fifty-five acutely ischemic lower extremities, in 35 patients, which remained ischemic after standard thrombectomy/embolectomy techniques were further treated with distal tibial/peroneal thrombectomy/embolectomy by ankle level arteriotomy to increase limb salvage. A total of 84 infrapopliteal arteries were explored and thromboembolectomy performed in 79. The precipitating ischemic event was arterial embolus in 38 per cent, arterial thrombus in 60 per cent, and trauma in 2 per cent of the cases. There were 16 female and 19 male patients. Additional bypass grafting was used in 18 per cent of extremities. The limb salvage rate was 91 per cent in this select "tibial/peroneal" group. This technique salvaged 50 limbs that otherwise would have required major amputation. The addition of this technique changed the potential limb salvage rate from 76 per cent of the entire 199 lower extremities treated during this period to an actual limb salvage rate of 97 per cent. Operative mortality was 16 per cent in this selected group with an overall mortality of 6 per cent for all patients with acutely ischemic lower limbs. A mean patient follow-up of 32 months (range 12 to 72 months) identified only three late amputations, demonstrating that distal tibial/peroneal thrombectomy/embolectomy is a durable procedure. It is a technically easy means of promoting limb salvage in the acutely ischemic limb which either 1) remains ischemic after standard transinguinal iliofemoral thromboembolectomy, or 2) is secondary to infrapopliteal artery occlusion. It allows successful thromboembolectomy of acutely occluded infrapopliteal arteries without distal popliteal arteriotomy. These techniques should be within the armamentarium of all surgeons dealing with acute lower extremity ischemia.     

The assessment of the efficacy of surgical treatment in critical ischemia of the lower extremities by the forming of arteriovenous anastomoses]

The authors show the significance of radionuclide angiography in evaluating the efficacy of surgical treatment of lower limb critical ischemia by formation of an arteriovenous anastomosis on the side of the affection. An operation for formation of an arteriovenous anastomosis on the lower third of the leg or the foot was found to be most effective. Increased perfusion of the ischemic limb on the level of balanced mixing of the blood flow was revealed in most patients, which the authors believe to be caused by venous stasis in the lower limb due to reduced difference in pressure in the arterial and venous bed. The highest percentage of favorable late--term results of the operation was revealed among this contingent of patients.     

Extensive revascularization in patients with "nonreconstructible" vascular disease

Elderly patients with severely ischemic lower extremities should undergo thorough noninvasive and angiographic evaluation. Although the visualization of a small nongraftable vessels in the lower extremity is a contraindication to an extensive limb salvage procedure, the inability to visualize angiographically any distal vessels in the lower extremity is not a contraindication. Patients with a severely ischemic but viable lower extremity and angiographic nonvisualization of any distal vessels of the lower extremity should be considered potential candidates for surgical exploration and possible salvage by simultaneous inflow and outflow procedures.     

腔内介入治疗膝下动脉缺血性疾病

目的 回顾性分析血管腔内介入治疗膝下动脉缺血性疾病的疗效,初步总结其技术要点、主要并发症防治与应用价值.方法 对2004年11月至2007年7月期间收治的60例(65条肢体)膝下动脉缺血性疾病的患者行膝下病变段动脉球囊扩张(percutaneous transluminal angioplasty,PTA)和/或支架植入(stenting)治疗,观察症状的改善,踝肱指数(ankle/brachial index,ABI)的变化,保肢率以及近期通畅率.结果 60例患者(65条肢体)中,技术成功51例,成功率83.3%;临床成功53例,成功率88.3%.症状完全缓解40例(66.7%),部分缓解13例(21.7%),无改善7例(11.6%);ABI从术前0.40±0.18增加到术后0.91±0.22,两者差异有统计学意义(P＜0.01).2例膝下截肢,4例足趾截趾,出院时保肢率为91%.随访54例,随访时间10 d至30个月,平均(14.5±1.2)个月.2例膝上截肢,2例膝下截肢,2例足趾截趾,保肢率88.9%(48例/54例);症状复发5例,复发率9.2%,血管再闭塞或再狭窄10例,通畅率81.5%,1年累积通畅率为57.3%.结论 腔内介入治疗膝下动脉缺血性疾病安全、可行,近期疗效确切,是该类疾病重要的治疗选择.     

The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities.

Analysis of the immediate and long-term results in 180 patients undergoing aortofemoral bypass grafts for occlusive disease of the lower extremities showed the immediate graft limb patency in 360 graft limbs to be 99.2%. The cumulative ten-year graft limb patency was 66%. Factors associated with thrombosis of the graft limb revealed correlations for localized atherosclerotic disease of either the profunda femoris artery or the tibial trifurcation vessels. The highest correlation for graft limb thrombosis was with simultaneous lesions involving both the profunda femoris artery and tibial trifurcation vessels. The acute lower extremity salvage rate was 94%, and the ten-year cumulative extremity salvage for legs at risk of amputation was 85%. Postoperative symtpoms correlated well with patency. Overall operative mortality was five patients out of 180 (2.5%).     

Increased limb salvage with intraoperative and postoperative ankle level urokinase infusion in acute lower extremity ischemia.

Over a 30-month period (May 1988 to November 1990) 143 acutely ischemic lower extremities (126 patients) were treated with an aggressive surgical approach that included ankle level tibial-peroneal artery thromboembolectomy. Twelve lower extremities in 10 patients that remained ischemic were further treated with adjuvant ankle level urokinase infusion. Sixteen ankle level arteries in 12 extremities were infused with an intraoperative bolus (1 to 2) of urokinase (50,000 to 100,000 units). Continuous postoperative urokinase (25,000 to 50,000 units per catheter per hour x 1 to 5 days) was infused through ankle level arteriotomies in 10 extremities (14 arteries) that did not improve with the initial intraoperative bolus. Concomitant bypass grafting was necessary in four extremities. With adequate inflow established, adjuvant ankle level urokinase salvaged all 12 extremities. The mean increase in ankle/brachial pressure index was 0.84. During continuous postoperative urokinase infusion, lower extremity bleeding requiring blood transfusion occurred in four patients (50%). No deaths occurred in the operative period. Although rhabdomyolysis occurred in 90% of patients, no patients had renal insufficiency. The addition of ankle level urokinase delivery increased the potential limb salvage from 90% of the entire 143 extremities treated during this period to an actual limb salvage of 98%. A mean follow up of 13 months (6 to 36 months) identified one late amputation. Despite the demanding postoperative management required in these patients and the frequent need for early reoperation, the limb salvage obtained justifies this aggressive adjuvant technique in the management of the acutely ischemic lower extremity.