左锁骨下动脉急性闭塞与动脉夹层

目的通过对46例左锁骨下动脉急性闭塞患者的造影诊断和经皮腔内血管成形术治疗,探讨动脉夹层与左锁骨下动脉急性闭塞的关系、病理特点及经股动脉-肱动脉逆行双路径腔内血管支架植入术的治疗方法、疗效、适应证及并发症。方法对46例锁骨下动脉急性闭塞的患者采用经股动脉-肱动脉双路径诊断动脉夹层,采用经股动脉-肱动脉双路径腔内血管支架植入技术治疗左锁骨下动脉急性闭塞患者46例。结果造影证实左锁骨下动脉近端动脉夹层并左锁骨下动脉急性闭塞38例,降主动脉内膜下出血(DebackeyⅢ)不典型型并发左锁骨下动脉急性闭塞8例,植入支架46枚,全部成功,仅4例发生短暂左上肢缺血;支架植入后,造影证实左锁骨下动脉血流方向恢复正常、左椎动脉血流方向恢复正常;术后采用彩色多普勒超声、经颅多普勒超声(TCD)和(或)数字减影血管造影(DSA)复查随访2周至12个月,证实支架位置恒定、血流方向正常、无再狭窄。结论左锁骨下动脉近端动脉夹层、主动脉内膜下出血可引起左锁骨下动脉急性闭塞,而导致锁骨下动脉窃血综合征,经股动脉-肱动脉双路径腔内支架植入术治疗效果可靠、操作方法简单安全。     

髂动脉闭塞内膜下再通治疗与覆膜支架的应用

目的 探讨应用内膜下再通和覆膜支架植入术治疗髂动脉硬化闭塞病变的方法和疗效.方法 5例伴有严重缺血症状的髂动脉完全闭塞病变患者,动脉闭塞长度2.5～12.0 cm.采用顺行途径(经右肱动脉穿刺3例,经对侧股动脉穿刺2例)对闭塞段血管行意向性内膜下途径再通,用直径8 mm球囊对内膜下通道扩张成形并植入镍钛合金覆膜支架,共植入覆膜支架6枚,另在1处狭窄病变植入覆膜支架1枚,1处长段闭塞病变覆膜支架远段和另1处髂动脉狭窄病变中各植入裸支架1枚.结果 内膜下再通操作全部获技术成功,无并发症出现.覆膜支架置放后血管腔内形态良好,血流通畅.临床症状消失或明显改善.患肢踝臂指数(ABI)平均值由0.40±0.32上升至0.89±0.15.近中期随访无症状复发.结论 动脉内膜下再通术联合覆膜支架植入术治疗髂动脉硬化闭塞病变安全、有效,近中期疗效良好.     

同期介入治疗冠心病合并锁骨下动脉硬化闭塞症研究

目的：评价同期介入治疗冠心病合并锁骨下动脉硬化闭塞症的疗效和安全性。方法于2008年1月至2012年12月,对16例冠心病合并锁骨下动脉硬化闭塞症（动脉管腔狭窄至少70％）确诊患者同期行锁骨下动脉及冠状动脉介入治疗,先行球囊血管成形术,再植入支架。在术后6个月和12个月随访时,分别进行彩色超声和血管造影检查,评估再狭窄情况和临床疗效。结果16例患者共计38处动脉狭窄病变,均成功进行了经皮介入治疗,无严重并发症发生。术后彩色超声及血管造影检查均未见动脉管腔再狭窄。结论采用同期介入治疗的方法治疗冠心病合并锁骨下动脉硬化闭塞症,具有微创、效果好、并发症少等优点,可作为临床重要的治疗方法。     

急性下肢动脉闭塞的介入治疗

目的探讨血管腔内技术在急性下肢动脉闭塞治疗中的临床应用价值。方法总结25例急性下肢动脉闭塞介入治疗的经验。采用动脉内直接溶栓和经皮血管腔内成形术（动脉直径〉3mm）治疗下肢动脉闭塞。结果经术后3个月-8年临床观察急性单段动脉闭塞血管再通率为100％（14／14例），多段动脉闭塞血管再通率为54．5％（6／11例），血管总再通率为80％（20／25例）。结论血管腔内介入治疗技术是治疗急性下肢动脉闭塞的一种有效方法，值得临床推广应用。     

腔内修复术中一期覆盖左锁骨下动脉的术后护理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉一期覆盖后的护理要点。方法对40例因近端锚定区过短,腔内修复术中一期完全覆盖左锁骨下动脉患者的术后护理进行总结与分析。结果40例患者一期完全覆盖左锁骨下动脉后,早期窃血综合征发生率为20%(8/40),左肱动脉平均收缩压(62.6±24.2)mmHg,住院期间未出现严重脑及上肢缺血并发症。结论腔内修复术中,一期覆盖左锁骨下动脉是可行的;术后对于上肢血压的监测、上肢血运状况以及窃血综合征的观察是护理的关键。     

无椎动脉反流的锁骨下动脉窃血综合征的彩色多普勒超声表现分析

目的　分析锁骨下动脉窃血综合征 (SSS)的病因 ,血流动力学改变 ,超声表现以及合并其他颈部血管严重病变时的血流动力学改变及其与窃血的关系。方法　分析本院经超声检查并经临床确诊锁骨下动脉或无名动脉起始段重度狭窄或闭塞的患者 49例。结果　锁骨下动脉窃血综合征主要由动脉粥样硬化和多发性大动脉炎所致。结论　当锁骨下动脉或无名动脉起始段病变 ,合并颈部其他血管严重病变时 ,不应单纯依靠椎动脉的血流方向来估测同侧锁骨下动脉或无名动脉的狭窄情况。     

彩色多普勒超声在诊断锁骨下动脉窃血综合征中的应用

目的 探讨彩色多普勒超声在诊断锁骨下动脉窃血综合征中的应用价值.方法 对21例锁骨下动脉窃血综合征的超声声像图表现进行分析,21例均经动脉X线数字减影造影(DSA)证实.结果 21例患者中13例为完全性盗血, 8例为部分性盗血.其中锁骨下动脉起始处闭塞5例,狭窄16例.结论 彩色多普勒超声是检测锁骨下动脉窃血综合征一种非常有效的无创性诊断方法.     

腔内修复术中一期覆盖左锁骨下动脉的术后护理

目的 探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉一期覆盖后的护理要点.方法 对40例因近端锚定区过短,腔内修复术中一期完全覆盖左锁骨下动脉患者的术后护理进行总结与分析.结果 40例患者一期完全覆盖左锁骨下动脉后,早期窃血综合征发生率为20%(8/40),左肱动脉平均收缩压(62.6士24.2)mmHg,住院期间未出现严重脑及上肢缺血并发症.结论 腔内修复术中,一期覆盖左锁骨下动脉是可行的;术后对于上肢血压的监测、上肢血运状况以及窃血综合征的观察是护理的关键.     

腔内修复术中一期覆盖左锁骨下动脉的术后护理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉一期覆盖后的护理要点。方法对40例因近端锚定区过短，腔内修复术中一期完全覆盖左锁骨下动脉患者的术后护理进行总结与分析。结果40例患者一期完全覆盖左锁骨下动脉后，早期窃血综合征发生率为20％（8／40），左肱动脉平均收缩压（62．6±24．2）mmHg，住院期间未出现严重脑及上肢缺血并发症。结论腔内修复术中，一期覆盖左锁骨下动脉是可行的；术后对于上肢血压的监测、上肢血运状况以及窃血综合征的观察是护理的关键。     

锁骨下动脉起始段狭窄与闭塞的血管内治疗

目的探讨应用血管内支架治疗锁骨下动脉起始段狭窄或闭塞的有效治疗方法。方法局麻下,以Seldinger技术穿刺股动脉,置入8F导管鞘,全身肝素化,用5F Pigtail导管、单弯导管行主动脉弓及全脑血管造影。将8F导引导管置于病变锁骨下动脉近端,选择合适球囊扩张狭窄部位。撤出球囊导管,将支架递送系统沿导丝送入狭窄段,路图下准确定位并释放支架。对于锁骨下动脉闭塞患者,将8F导引导管置于闭塞锁骨下动脉近端,用泥鳅导丝小心反复试探至通过闭塞段,再重复上述步骤。若导丝始终不能通过闭塞段,则行肱动脉逆行穿刺,置入7~8F导管鞘,用泥鳅导丝在单弯管配合下小心反复试探逆行开通闭塞段,同法行逆行球囊扩张与支架置入。结果 15例成功植入支架,1例未成功;支架植入后所有患者肱动脉及桡动脉搏动良好,临床症状改善;成功植入支架的15例中有1例12个月后再狭窄,再次植入1枚支架,其余患者随访24个月未见再狭窄;所有患者围手术期未见与手术有关的并发症。结论应用血管内支架治疗锁骨下动脉狭窄或闭塞是一种微创、安全、有效的治疗方法,有望成为主要的治疗手段。     

双向内膜下血管成形术治疗股浅动脉长段硬化性闭塞疾病16例分析

目的探讨经双向内膜下血管成形术(subintimal arterial flossing with antegrade retrograde intervention,SAFARI)治疗股浅动脉长段硬化性闭塞疾病的临床效果和应用价值。方法选择2011年5月—2013年8月收治的经内膜下血管成形术治疗失败的股浅动脉长段硬化性闭塞疾病16例,经SAFARI开通,采用经皮穿刺腔内血管成形术(PTA)联合内支架(stent)置入。结果全组治疗技术成功率为100%,无严重并发症发生;术后平均随访10(3~18)个月,一期通畅率为93.75%(15/16),二期通畅率为100%。踝肱指数由术前的0.25±0.15增加至术后的0.89±0.19(P0.05)。结论 SAFARI是治疗股浅动脉长段硬化性闭塞所致慢性严重肢体缺血的安全有效的方法。     

开窗技术数值模拟在主动脉弓部病变中的应用

目的:探讨主动脉弓部病变中开窗技术的应用对主动脉弓部及弓上分支血管血流动力学的影响。方法:选取2016年11月至2019年5月复旦大学附属中山医院收治的主动脉瓣弓部病变患者10例,均行胸主动脉腔内修复,术中运用开窗技术重建左锁骨下动脉。基于患者术后随访的影像数据,建立个体化的主动脉三维几何模型。运用计算软件,对主动脉三维模型开展数值模拟,评估开窗技术对主动脉弓部及弓上分支血管血流动力学的影响。结果:结合开窗技术的胸主动脉腔内修复术成功率较高(9/10),术后未发生严重并发症,无手术相关死亡,随访期间未发现目标血管丢失。术后开窗支架相对狭窄,在收缩期和舒张期均观察到高速血流;开窗支架进入主动脉弓区域的血流振荡指数增高,表明开窗支架破坏了主动脉弓部的血流稳定;弓上分支血管的血流量分配发生改变,右侧头臂血流增加,左侧头臂血流减少。结论:开窗技术可在胸主动脉腔内修复术中有效重建左锁骨下动脉,但也对主动脉弓部和弓上分支血管血流产生影响;根据数值模拟结果,可对手术方式进行改良,并为手术器械的设计提供参考。     

导丝硬头穿刺技术在血液透析相关上腔静脉闭塞再通术中的应用

目的 探讨导丝硬头穿刺技术在血液透析相关上腔静脉闭塞再通术中应用的安全性及临床疗效. 方法 回顾性分析37例血液透析相关上腔静脉闭塞并接受导丝硬头穿刺再通术患者的临床资料,37例患者均接受上腔静脉再通并计划置入带隧道和涤纶套的透析导管(tunnel-cuffed catheter,TCC).比较术前、术后TCC导管血流...     

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

IntroductionBlunt thoracic aortic injury (BTAI) is rare in elderly patients. As the population ages and life expectancy increases, the frequency of this injury will increase, while the treatment and outcomes remain unclear.MethodsWe retrospectively analyzed the collected data of patients >60 years old with BTAI to investigate the mechanism of trauma; time interval from injury to diagnosis; type and timing of surgical intervention; aortic arch pattern; choice of left subclavian artery reconstruction; endograft to treat BTAI; length of the endovascular procedure; endoleaks; complications including stroke, paraplegia, and renal failure; length of hospital stay (LOS) and intensive care unit stay (L.ICUS); and 30-day mortality.ResultsFive elderly trauma patients were found to have BTAI. Four (80%) were males, the cohort mean age was 68 years, the major mechanism of trauma was fall injury, and the associated injury was thoracic trauma. All patients were transferred to our hospital, and emergency computed tomography angiography showed BTAI in each patient. The average time interval from injury to diagnosis was 2.7 days. Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair, while 3 patients underwent delayed endovascular repair. The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery; the aortic arch pattern was II (80.0%) in 4 cases and III in 1 case (20.0%). The choice of left subclavian artery reconstruction included chimney, double chimney, prefenestration, and chimney combined with in situ fenestration. Endografts to treat BTAI included the Ankura (Lifetech Scientific, Shenzhen, China) and the C-TAG (W.L. Gore & Associates, Flagstaff, AZ USA).The length of the endovascular procedure was 75.4 min; there were no endoleaks and no complications including stroke, paraplegia, or renal failure. The average LOS was 25 days, and the average L.ICUS of 2 patients was 15 days, with no 30-day mortality.ConclusionElderly patients with fall injury should promptly exclude BTAI. Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications. Because of the low incidence of this type of injury, we are unable to provide any evidence to guide the treatment option for this life-threatening condition.     

右锁骨下动脉狭窄和闭塞的腔内治疗

目的:探讨腔内治疗右锁骨下动脉狭窄和闭塞的手术指征、特点和疗效。方法:选择2009年3月—2013年3月复旦大学附属中山医院诊治的右锁骨下动脉狭窄和闭塞患者21例,局麻下腔内治疗后1个月、3个月时门诊随访,此后每隔半年门诊随访,行踝肱指数(ankle-brachial index,ABI)、彩超检查或CT血管成像(CT angiography,CTA)检查。结果:21例患者中右锁骨下动脉闭塞性病变7例,狭窄性病变14例。2例右锁骨下动脉闭塞患者因导丝无法通过闭塞段病变而仅行造影,其余19例均成功行腔内治疗,总成功率为90.5%。19例行腔内治疗的患者术后平均随访19.3个月,通畅率为89.5%(17/19),中度再狭窄率为10.5%(2/19),无支架断裂和打折,无病死病例。结论:右锁骨下动脉狭窄和闭塞有其特殊的解剖学特点,腔内治疗是一种有效的治疗方法。     

二维超声结合时空关联成像诊断胎儿先天性血管环

目的 探讨二维超声结合时空关联成像(STIC)诊断胎儿先天性血管环的价值。方法 对于我院接受胎儿超声心动图、可疑或明确先天性血管环的胎儿进行STIC数据采集,对产前超声诊断结果与产后新生儿超声心动图、CT及引产后胎儿尸体病理解剖结果进行对比分析。结果 二维超声心动图结合STIC共检出胎儿先天性血管环83胎,其中双主动脉弓5胎,右位主动脉弓、左位动脉导管并迷走左锁骨下动脉59胎,左位主动脉弓、左位动脉导管并迷走右锁骨下动脉19胎,漏诊1胎肺动脉吊带。84胎先天性血管环胎儿中,69胎经产后新生儿超声心动图、CT证实,2胎经尸体解剖证实,13胎失访。结论 超声心动图可用于诊断胎儿先天性血管环,STIC技术可更精确、直观地显示先天性血管环的空间位置关系。     

Treatment of the acute thromboembolic event during endovascular embolization of intracranial aneurysm

ObjectiveThe study aimed to discuss the treatment of acute thromboembolic event (TE) during endovascular embolization of intracranial aneurysms.MethodsBetween April 2013 and April 2019, 158 patients with 167 intracranial aneurysms were treated with endovascular embolization in our hospital, in which 9 cases of acute TEs occurred during the embolization procedures. The clinical data, radiological findings and treatments of the 9 patients were reviewed and analyzed.ResultsThe TEs occurred at the aneurysmal neck in 3 patients, at distal part of the parent artery in 3, in the stent in 2, and at the proximal part of the parent artery in 1. Intra-arterial (IA) infusion of tirofiban were performed in 6 patients, mechanical thromboectomy (MT) with a stent in 2 patients, and combined use of the two methods in 1 patients. According to the modified Thrombolysis In Cerebral Infarction (mTICI) score, 7 patients had recanalization of 2b/3a, 1 patients had recanalization of 1, and 1 patients had recanalization of 0. At discharge, the mRS score was 0 in 3 patients, 1 in 3 patients, and 2, 3, 4 in 1 patient each. 6 months after the endovascular treatment, the mRS score was 0 in 5 patients, 1 in 2 patients, and 3 in 1 patient.ConclusionsIA tirofiban and MT are effective remedies for the acute TE during endovascular embolization of intracranial aneurysm, reasonable selection of which may improve the prognosis of patients.     

Laser angioplasty

Summary. The two main aims of lasers in angioplasty are: (1) to increase the number of patients suitable for percutaneous transluminal angioplasty (PTA) by increasing the recanalization rate of chronic occlusions and, (2) to decrease the rate of recurrence of disease. Lasers are able to recanalize about 50% of occlusions in which a conventional attempt using a guidewire and catheter has failed. Unfortunately, in most cases the lumen produced by laser recanalization is not definitive and balloon dilatation is still required. The rate of recurrence is therefore unlikely to differ from that of balloon dilatation alone, and so far the results of randomized trials bear this out. Reports of sole laser therapy are now appearing, but these are still preliminary and it remains to be seen whether this will favourably alter the rate of recurrence.