肢体缺血性疾病腔内治疗的现代策略

目的探讨应用介入腔内治疗方法为首选,结合传统手术技术治疗肢体缺血性疾病的有效性。方法自2006年1月至2008年3月北京世纪坛医院血管外科应用介入腔内治疗方法为首选,结合传统手术技术治疗肢体缺血性疾病70例。其中年龄最大83岁,最小58岁,平均73岁。男女比例为4∶1。70例中80%有间歇性跛行,跛行最近距离20m, 30%有静息痛,10%足溃疡及坏死。全部病例入院后进行了肢体血管超声、MRA、血管造影检查和踝肱指数（ABI）测定,其中63例（90%）有两个部位以上的动脉狭窄或闭塞病变,56例（80%）累及膝关节以下。治疗前ABI 平均为0.58。全部70例病人进行了腔内治疗同时辅助传统的手术技术。结果腔内手术成功率92%,90%病人得到不同程度的改善,其中疗效达到优秀为39例（56%）、良好为28例（40%）、一般为3例（4%）无不良和死亡病例。手术并发症发生率为7%,治疗后ABI平均为090,平均增长了032。1年通畅率为86%,再狭窄率为6%,二次处理1年通畅率为90%。结论介入腔内治疗方法做为首选,结合传统手术技术能有效的治疗肢体缺血性疾病,同时具有创伤小、恢复快、并发症少、反复应用的优点,值得推荐。     

Intestinal ischaemia following cardiac surgery: a multivariate risk model

Objective: Intestinal ischaemia following cardiac surgery is a serious complication, which carries a high mortality rate. Several studies have examined pre-operative and intra-operative risk factors. We aimed to develop a multivariate risk model to identify those patients at highest risk of intestinal ischaemia. Methods: Data was prospectively collected for 10,976 consecutive cardiac surgery patients from our institution between April 1997 and March 2004. Fifty (0.5%) patients developed post-operative intestinal ischaemia. A forward stepwise multivariate logistic regression analysis was undertaken to identify predictors of developing intestinal ischaemia. Intra-operative and post-operative variables were censored at the time of onset of intestinal ischaemia. Results: The predictors of post-operative intestinal ischaemia were: post-op inotrope and dialysis support (OR 6.7; p < 0.001), post-op ventilation >48 h (OR 5.1; p < 0.001), age at operation (OR 1.06 [for each additional year]; p < 0.001), post-op atrial fibrillation (OR 2.3; p = 0.014) and blood loss in intensive care unit (ICU) >700 ml (OR 2.0; p = 0.037). The predictive ability of this model was very good with an area under the receiver operating characteristic curve of 0.93. In-hospital mortality for the patients who developed intestinal ischaemia was 94% (47/50) compared to 3.6% (390/10,926) for the other patients (p < 0.001). Conclusions: Although the incidence of intestinal ischaemia following cardiac surgery is low, the prognosis for these patients is very poor. We have identified several risk factors, and developed a multivariate prediction tool, which may be useful in identifying patients at high-risk of developing intestinal ischaemia.     

Mesenteric ischaemia

Acute mesenteric ischaemic (AMI) is a life-threatening vascular condition from which outcomes are poor. It results from acute thrombosis or embolization of one or more mesenteric arteries. Chronic mesenteric ischaemia (CMI) is a clinical syndrome of abdominal pain after eating related to stenosis or occlusion of one or more mesenteric vessels associated with other cardiovascular disease. Mesenteric ischaemia can also result from hypoperfusion, non-occlusive mesenteric ischaemia (NOMI), or mesenteric vein thrombosis (MVT).This article looks at the epidemiology, diagnosis, and management of mesenteric ischaemia. It recognizes the need for resuscitation and time-critical resection of non-viable bowel and revascularization in the acute setting. Improving outcomes necessitates a multidisciplinary approach involving emergency medicine, diagnostic radiology, general surgery, vascular surgery, interventional radiology, anaesthetic, and critical care specialists.     

Acute and chronic limb ischaemia

Acute (ALI) and chronic limb ischaemic (CLI) make up a major part of the workload of vascular surgeons and carry considerable morbidity and mortality. Peripheral artery disease (PAD) is the major cause of these conditions. Diagnosis of these conditions involves proper use of imaging including duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), as well as invasive techniques like digital subtraction angiography (DSA). Management ranges from conservative techniques, the mainstay of management in intermittent claudication (IC), with medical optimization, through to endovascular and open revascularization techniques in CLI and ALI. Finally where no revascularization options exist, primary amputation or palliation must be considered.     

Incidence of Arrhythmias and Myocardial Ischaemia During Haemodialysis and Haemofiltration

Thirty-two patients (10 male, 22 female; age 37–82 years)undergoing maintenance haemodialysis or haemofiltration werestudied by means of Holter device capable of simultaneouslyanalysing rhythm and ST changes in three leads. Twenty-fivepatients were on haemodialysis, seven on haemofiltration, meanduration of haemodialysis/haemofiltration being 3.4±3years. Incidence of ventricular tachycardia was low, being detectedonly in 1 of 32 patients. Ventricular premature beats in excessof 10/h during a period of 2 h were found in 8 of 32 patientsand 100 supraventricular premature beats for 2 h or more in4 of 32 patients. Both ventricular premature beats and supraventricularpremature beats were most frequently recorded during the lasthour of haemodialysis/haemofiltration. ECG signs of ischaemiawere detected in eight patients, four of whom were asymptomatic.Ischaemia also occurred predominantly during the last hour ofhaemodialysis/haemofiltration. Two symptomatic patients displayedneither arrhythmias nor ST-changes while being monitored. Thestudy shows that silent ischaemia and arrhythmias in patientsunder going chronic haemodialysis/haemofiltration may not beinfrequent. Recognition of these events could be of importancein the management of these patients.     

Cerebral protection

Ischaemic/hypoxic insults to the brain during surgery and anaesthesiacan result in long-term disability or death. Advances in resuscitationscience encourage progress in clinical management of these problems.However, current practice remains largely founded on extrapolationfrom animal studies and limited clinical investigation. A majorstep was made with demonstration that rapid induction of mildsustained hypothermia in comatose survivors of out-of-hospitalventricular fibrillation cardiac arrest reduces death and neurologicalmorbidity with negligible adverse events. This provides thefirst irrefutable evidence that outcome can be favourably alteredin humans with widely applicable neuroprotection protocols.How far hypothermic protection can be extended to global ischaemiaof other aetiologies remains to be determined. All availableevidence suggests an adverse response to hyperthermia in ischaemicor post-ischaemic brain. Management of other physiological valuescan have dramatic effects in experimental injury models andthis is largely supported by available clinical data. Hyperoxaemiamay be beneficial in transient focal ischaemia but deleteriousin global ischaemia. Hyperglycaemia causes exacerbation of mostforms of cerebral ischaemia and this can be abated by restorationof normoglycaemia. Studies indicate little, if any, role forhyperventilation. There is little evidence in humans that pharmacologicalintervention is advantageous. Anaesthetics consistently andmeaningfully improve outcome from experimental cerebral ischaemia,but only if present during the ischaemic insult. Emerging experimentaldata portend clinical breakthroughs in neuroprotection. In theinterim, organized large-scale clinical trials could serve tobetter define limitations and efficacy of already availablemethods of intervention, aimed primarily at regulation of physiologicalhomeostasis.     

Mesenteric ischaemia

Mesenteric ischaemia is an uncommon but potentially life-threatening condition encompassing a range of pathology and symptoms. This article considers the spectrum of acute mesenteric ischaemia, venous infarction, acute colonic ischaemia, chronic mesenteric ischaemia and ischaemic colitis.     

Mesenteric ischaemia

Mesenteric ischaemia is an uncommon but potentially life-threatening condition encompassing a range of pathology and symptoms. This article considers the spectrum of acute mesenteric ischaemia, venous infarction, acute colonic ischaemia, chronic mesenteric ischaemia and ischaemic colitis.     

Mesenteric ischaemia

Mesenteric ischaemic is a life-threatening condition that occurs as a result of interrupted or reduced blood flow to the bowel. It is categorized as acute or chronic and encompasses a range of pathology and symptoms. This article looks at the presentation, diagnosis and management of acute and chronic mesenteric ischaemia, ischaemic colitis and venous infarction.     

Popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome is a rare abnormality of the anatomical relationship between the popliteal artery and adjacent muscles or fibrous bands in the popliteal fossa. The following is a case report of a 19 year old female, in whom popliteal artery entrapment syndrome was diagnosed, and successfully treated surgically. A review of literature is also presented and provides details on how PAES is classified, diagnosed both clinically and radiologically, and treated surgically.     

Digital ischaemia in a renal transplant patient.

A renal transplant patient presented with a sudden onset ofpainful left index finger (Figure 1). He had     

ARTERIAL LESIONS IN SEVERE LOWER LIMB ISCHAEMIA: A PROSPECTIVE STUDY OF 100 CONSECUTIVE ISCHAEMIC LIMBS IN A HONG KONG CHINESE POPULATION

Background : The pattern and distribution of arterial lesions in a local Chinese population were studied to assess the feasibility of reconstruction and the possibility of avoiding major amputation of ischaemic limbs. Method : Between March 1995 and August 1997, 90 consecutive patients with 100 severely ischaemic lower limbs and their arteriograms were analysed. There were 48 female and 42 male patients with a mean age of 72 years. All the patients were in fair general health, did not have foot pulses and were willing to undergo major arterial reconstruction. Ten patients had bilateral limb ischaemia and 94 of the ischaemic limbs were affected by rest pain with or without ulcer and/or gangrene. The remaining six patients had debilitating claudication. These lesions were classified into low-grade (less than 50% stenosis), high-grade (50–90% stenosis) and critical (> 90% stenosis to occlusion). Results : Critically stenotic or occlusive lesions were present in 16% of aorto-iliac segments; 76% of femoropopliteal arteries; and 82% of trifurcation and infrapopliteal segments. In at least 27 patients one of the two main foot arteries was also severely diseased. The present analysis suggested that 79 of these ischaemic limbs had reconstructable lesions. Sixteen were not suitable for intervention and in five patients the reconstructability was uncertain radiologically. Conclusion : Contrary to local belief, the majority of patients in the Chinese community with severe lower limb ischaemia without foot pulses would have technically reconstructable arterial lesions and could benefit from a revascularization procedure.     

Simultaneous Surgical Treatment of Abdominal Aortic Aneurysm and Bilateral Aneurysms of the Internal Iliac Artery

Introduction: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AaA) and aneurysms in both the internal iliac arteries (IIA) at the same time. Methods: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or-bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurys-morraphy.

Results: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from ‘trash foot’, which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia.

Conclusions: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.     

Strategy for 3-D Computed Tomography Diagnosis and Treatment of Small Pulmonary Arteriovenous Fistula

In a patient with left hemianopsia, computed tomography (CT) and magnetic resonance imaging revealed an intracranial space-occupying lesion in the right occipital region. A cerebral abscess was removed at craniotomy. Enhanced pulmonary CT showed a small coin lesion in the peripheral lingula, and at 3-D CT two nidi with feeding arteries and draining veins were seen, indicating pulmonary arteriovenous fistula. Lingular segmentectomy was performed.     

Hydroxyethyl-starch in transient experimental focal cerebral ischemia

Summary In a model of focal cerebral ischaemia in the cat (transorbital occlusion of the middle cerebral artery for 60 minutes, thereafter 6 hours reperfusion by clip removal), hydroxyethyl-starch (HAES) (ELOHES; Leopold Pharma GmbH, Graz, Austria) was administered intravenously before and during the ischaemic episode as a 6% or as a 10% solution in a randomised manner (6 animals each group).The size of the developing cerebral infarct was not significantly different when comparing the 6% and the 10% group with the controls (SALINE). Collateral circulation to the infarct border (pial arteries on the suprasylvian gyrus) was also not significantly different between the two groups, except for the first hour of reperfusion, where vessels of the 6% group were wider than vessels of the 10% group. At the infarct border (ectosylvian gyrus) small resistance vessels were significantly more dilated in the 6% than in the 10% group both during the occlusion period and during the reperfusion episode after removal of the clip.Pial arteries dilated less in both HAES-groups than in the controls.It can be assumed, that HAES-incuded decrease of plasma viscosity led to an elevation of blood flow velocity and blood flow quantity (CBF). But the latter might be counteracted by autoregulation of CBF, i.e. vasoconstriction. Thus, a possible positive effect of HAES might in part be counteracted by autoregulation, which explaines that no significant therapeutic effect could be achieved.     

RECTAL NECROSIS FOLLOWING ANTERIOR RESECTION OF THE RECTUM

Acute ischaemic colitis is a well recognized complication following abdominal aortic surgery. It may occur spontaneously in older patients and is probably due to diffuse or localized obliterative arterial disease. In contrast, acute ischaemic proctitis is a rare clinical problem. It is caused by an acute surgical or thromboembolic interruption of the major blood supply and or collateral circulation of the rectum. Minor ischaemia may result in superficial mucosal ulceration whereas a major ischaemic episode will result in rectal necrosis with perforation. Acute rectal necrosis has not been reported as a complication following anterior resxtion of the rectum. This paper details a patient who developed necrosis of the rectum and the anal canal following anterior resection of the rectum for cancer of the recto-sigmoid junction.     

URETERIC ISCHAEMIA FOLLOWING MAJOR COLORECTAL RESECTION

An ischaemic injury of the ureter following major colorectal surgery is reported. The aetiology and incidence of this unusual complication is reviewed. Surgical techniques for prevention of such an injury are discussed.