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.     

内膜下血管成形术治疗股腘动脉硬化闭塞症

目的探讨内膜下血管成形术(SIA)治疗长段股腘动脉硬化闭塞的临床疗效及其技术要点。方法回顾性分析2009年6月～2011年8月我院收治的20例TASCⅡC型、D型股腘动脉硬化闭塞患者的临床资料,采用SIA开通长段闭塞管腔,同时行球囊扩张和支架植入术,以踝/肱指数(ABI)、Fontaine分期、保肢率和通畅率综合评估临床疗效。结果 SIA技术成功率为85%,临床症状改善率为90%,保肢率为95%,一期通畅率为83.3%,ABI从术前0.42±0.07提升至术后0.86±0.14,术前、术后比较差异有统计学意义(P<0.01)。术后随访12～24个月,18例临床症状改善的患者中有3例术后3～6个月症状复发,行第二次介入治疗,其余患者症状均无加重或复发。结论 SIA在治疗股腘动脉硬化闭塞症中具有良好的应用价值,方法安全有效,近期通畅率较好,远期通畅率尚需要进一步随访。     

斑块旋切联合药物涂层球囊在股腘动脉长段重度钙化病变治疗中的临床应用

目的探讨斑块旋切联合药物涂层球囊扩张(DAART)用于股腘动脉长段重度钙化病变腔内治疗的短期疗效。方法回顾性分析2016年9月至2017年3月使用DAART治疗的8例股腘动脉长段重度钙化病变,患者均使用血管腔内超声(IVUS)进行手术前后评估。收集患者基本信息、手术成功率、手术前后踝肱指数(ABI)、IVUS图像资料、术后不良事件、随访结果等信息。结果手术成功率100%,术后无疼痛、出血、肢体肿胀、血栓形成等并发症。患者症状均得到明显改善,1例足趾溃疡2周完全愈合;ABI从术前0.54±0.13上升到术后的0.89±0.05。IVUS成像显示在DAART治疗后钙化斑块得到切除,管腔显著增大。患者术后随访(9.4±1.8)个月,6个月靶血管通畅率100%。3例患者术后随访12个月,血管通畅,无症状复发。结论 DAART技术治疗伴有重度钙化的股腘动脉闭塞性病变安全、有效,短期通畅率良好。     

下肢动脉硬化闭塞症采用血管腔内支架成形术治疗体会

目的探讨下肢动脉硬化闭塞症患者采用血管腔内支架成形术治疗疗效。方法回顾性分析医院2017年5月至2018年5月65例(90条患肢)患者临床诊治资料,所有患者均行血管腔内支架成形术治疗。测量患者治疗前后踝-肱指数(ABI)、记录手术治疗成功率、并发症、肢体术后通畅率。结果 65例患者手术均成功,成功率100.0%;并发症率7.69%(5/65)。术后1天ABI平均为(0.84±0.19)明显高于术前(0.31±0.08),P0.05;术后7天ABI平均为(1.02±0.17)明显高于术后1天ABI平均为(0.84±0.19),P0.05。术后临床症状改善率为93.85%(61/65);随访发现,65例患者初次通畅平均时间为242天,累积通畅率为61.54%(40/65)。结论血管腔内支架成形术治疗下肢动脉硬化闭塞症具有较好疗效,可促进患者下肢功能恢复,具有一定推广价值。     

TASCⅡ C、D型股腘动脉闭塞腔内治疗的操作技巧与疗效分析

目的观察TASCⅡ C、D型股腘动脉闭塞腔内治疗的临床疗效,分析影响治疗效果的可能因素与操作技巧。方法 2009年1月～2010年6月,89例(113条患肢)TASCⅡ C、D型股腘动脉闭塞患者接受腔内治疗。对患者术后3、6和12个月时的临床症状、踝肱指数(ABI)、并发症发生率和累计通畅率进行分析。结果成功开通病变肢体共106条,技术成功率93.8%。36条(34.0%)患肢出现并发症。75例患者(共92条下肢)获得随访,随访率为86.8%。平均随访时间12.5个月。术后3、6和12个月时的平均ABI分别为0.74±0.39、0.68±0.38和0.66±0.31,与术前比较(0.43±0.39),差异均有统计学意义(P<0.01)。术后12个月的一期通畅率、辅助通畅率和二期通畅率分别为64.6%、72.4%和81.5%。结论 TASCⅡ C、D型股腘动脉闭塞腔内治疗是一种安全有效的方法。熟练的腔内操作技术和规范的术后指导是提高技术成功率和维持动脉早中期通畅的关键。     

TASCⅡC、D型股胭动脉闭塞腔内治疗的操作技巧与疗效分析

目的 观察TASCⅡC、D型股胭动脉闭塞腔内治疗的临床疗效,分析影响治疗效果的可能因素与操作技巧.方法 2009年1月～20lO年6月,89例(113条患肢)TAsCⅡC、D型股胭动脉闭塞患者接受腔内治疗.对患者术后3、6和12个月时的临床症状、踝肱指数(ABI)、并发症发生率和累计通畅率进行分析.结果 成功开通病变肢体共106条,技术成功率93.8%.36条(34.0%)患肢出现并发症.75例患者(共92条下肢)获得随访,随访率为86.8%.平均随访时间12.5个月.术后3、6和12个月时的平均ABI分别为0.74±0.39、0.68±0.38和0.66±0.31,与术前比较(0.43±0.39),差异均有统计学意义(P＜0.01).术后12个月的一期通畅率、辅助通畅率和二期通畅率分别为64.6%、72.4%和81.5%.结论 TASCⅡC、D型股腘动脉闭塞腔内治疗是一种安全有效的方法.熟练的腔内操作技术和规范的术后指导是提高技术成功率和维持动脉早中期通畅的关键.     

髂动脉闭塞性病变腔内开通的技术体会和中远期疗效分析

目的 探讨髂动脉闭塞性病变腔内开通方法 和疗效.方法 采用超声引导下穿刺、抓捕导丝、预创建抓捕空间等技术经腔内开通后置入血管内支架治疗髂动脉闭塞性病变34例,并回顾分析其髂动脉闭塞患者的技术成功率、并发症发生率及中远期通畅率.结果 技术成功率100%,除髂动脉破裂1例(2.94%)外,未发生其他严重并发症.踝肱指数(ABI)由术前的0.40±0.14增至术后7 d的0.81±0.13(t=2.67, P=0.02).随访3～42个月,平均(19.32±2.22)个月;7例发生再狭窄,3例闭塞,经PTA和/或置入内支架解除.患者术后6个月,1,2,3年一期通畅率和辅助一期通畅率按随访顺序依次为86.27%,74.40%,61.81%,52.98%和96.43%,92.57%,85.96%,85.96%.二期通畅率4个随访期均为100%.术后6个月,1,2,3年的肢体一期通畅率及辅助一期通畅率依次为88.41%,77.53%,65.79%,57.56%和96.97%,93.51%,87.27%和87.27%.二期通畅率均为100%.结论 超声引导下穿刺、抓捕导丝、预创建抓捕空间等技术的综合运用可提高髂动脉闭塞段开通的成功率;腔内治疗中远期通畅性的维持需要严密随访和对再狭窄、闭塞的及时处理.     

Rotarex系统联合药物涂层球囊治疗股腘动脉长段支架内完全闭塞

目的观察减容装置Rotarex系统联合药物涂层球囊(DCB)治疗股腘动脉(FPA)长段支架内完全闭塞的效果。方法 29例(29肢)FPA长段(病变长度10 cm)支架内完全闭塞患者接受减容装置Rotarex联合DCB(紫杉醇)治疗;观察疗效及并发症,随访统计术后6、12个月一期通畅率和12个月避免靶血管重建(TLR)率。结果 29例治疗技术成功率为100%,无相关严重并发症;术后踝肱指数(ABI)较术前显著提高(t=-15.611,P0.001)。6个月一期通畅率为86.21%(25/29),12个月一期通畅率为72.41%(21/29);12个月避免TLR率为79.31%(23/29);12个月随访期间无死亡或截肢事件发生。结论 Rotarex系统联合DCB治疗FPA长段支架内完全闭塞安全、有效。     

腔内支架植入治疗TASCⅡ C、D型股腘动脉慢性闭塞病变

目的 探讨泛大西洋协作组织(TransAtlantic InterSociety Consensus,TASC)ⅡC、D型股腘动脉慢性闭塞腔内支架治疗的临床疗效.方法 回顾性分析2008年1月至2011年6月46例(51条下肢)TASCⅡC型和D型股腘动脉闭塞患者腔内治疗的临床资料.46例中男27例,女19例,年龄52～88岁,平均(70 ±8)岁.术前Rutherford症状分级:3级重度间歇性跛行29条,4级静息痛12条,5级轻微组织缺损6条,6级组织溃疡、坏疽4条.总结分析技术成功率、患肢术后临床症状、踝肱指数(ankle brachial index,ABI)变化,并发症发生率和通畅率.结果 技术成功率90.2％ (42/51),治疗成功者共植入支架93枚.术后ABI 0.71 ±0.23,较术前0.42 ±0.13提高,两者差异有统计学意义(t=-7.281,P＜0.01).42例技术成功者均获随访,平均随访(14.6±1.2)个月.术后6个月的一期通畅率、辅助通畅率和累积通畅率分别为81.0％、88.1％、90.5％,术后12个月的一期通畅率、辅助通畅率和累积通畅率分别为66.7％、71.8％、79.5％.结论 TASCⅡC、D型股腘动脉慢性闭塞腔内治疗是一种安全有效的方法.     

介入治疗下肢动脉缺血性疾病

目的 评价介入治疗下肢动脉缺血疾病的近、远期疗效.方法 回顾性分析行血管腔内成形术或内支架成形术治疗360例下肢动脉缺血疾病患者的临床资料.结果 本组腔内治疗成功率为93%(335/360),术后静息痛消失、溃疡愈合,术前、后踝眩指数(ABI)分别为0.37±0.16和0.89±0.21,二者比较有显著性差异(P<0.05);25例术后症状无明显改善,其中5例术后1周截肢.312例(86.7%)获得随访,随访时间6个月至8年,术后5年一期通畅率为70%,二期通畅率为82%,糖尿病患者5年一期通畅率为59%,二期通畅率为76%.结论 介入治疗下肢动脉缺血疾病是一种安全有效的治疗方法.     

Semiclosed endarterectomy for long superficial femoral artery atherosclerotic occlusive disease. One-year angiographic results

BACKGROUND: The anatomic results of endarterectomy of long occlusive lesions in the superficial femoral artery (SFA) are required for reconsidering this procedure and comparing the results with those of newly developed endovascular techniques. We designed a prospective study to determine the arteriographic findings one year after a successful semiclosed endarterectomy of long occlusive lesions in the SFA. METHODS: From January 1995 until July 1996, an endarterectomy in the SFA was attempted in 12 successive patients and was successfully performed in 10 patients (6 men and 4 women), with an average age of 73 years (range 66 to 90 years). Indications for successfully performed procedures were claudication in 6, non healing ulcer in 2, local gangrene in 2 patients. The mean length of the occlusion was 17 cm (12-33). Six patients had poor run-off with 0 to 1 patent tibial artery. The mean length of the endarterectomised segment was 31 cm (27-39). An angioscopy and an angiography were performed in all procedures. There were no postoperative complications. All patients had an angiography at 12 months or before because of ipsilateral disease. Primary angiographic patency was defined as patency of the treated artery with stenosis of less than 30%. A short stenosis was defined as <5 cm. These lesions were an indication of percutaneous balloon angioplasty (PTA) and the final results were listed as secondary patency. RESULTS: Angiography revealed 3 patent arteries, 5 short stenosis, 2 long stenosis and no occlusions. The primary patency rate was 30% at 12 months. The secondary patency was 80% with a mean follow-up of 19 months (ranging from 13 to 25 months). The mortality and amputation rate at 12 months was nil. CONCLUSIONS: Despite a modern intraoperative control, there was a high incidence of restenosis after semiclosed endarterectomy performed for long occlusive lesions of the SFA. As a result of a close surveillance and PTA, the secondary patency at one year was good. Before a widespread use of newly developed endovascular techniques, comparative patency studies with the mere endarterectomy should be performed. Endarterectomy followed by a PTA in cases of restenosis, is an alternative to bypass when the vein is not available.     

经皮腔内血管成形术治疗髂-股动脉狭窄或闭塞

目的探讨经皮腔内血管成形术（PTA）及血管内支架植入术治疗髂-股动脉狭窄或闭塞的应用价值。方法 66例髂-股动脉狭窄或闭塞患者,患肢均有不同程度的缺血症状,均采用PTA和（或）支架植入术进行介入治疗,分别于治疗前、后测定踝/肱指数（ABI）。结果 66例患者成功完成介入治疗,共植入支架73枚,其中髂动脉植入27枚,股浅动脉植入32枚,髂-股动脉植入14枚,无严重并发症发生。术后患者患肢缺血症状明显减轻或消失。ABI由术前0.39±0.12上升至0.72±0.15,术后随访3～24个月（平均15个月）,10例患者因复发而再次接受介入治疗。结论 PTA及血管内支架植入术,因其创伤小、可重复性高、疗效显著等特点已成为治疗髂-股动脉狭窄或闭塞的有效手段。     

腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变

目的 评价腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变(CTO)的可行性、有效性及安全性.方法 回顾性分析2006年1月至2010年12月经腔内血管成形术治疗的病变长度＞5 cm的髂动脉CTO患者139例(157条患肢)的临床资料.其中男性93例(105条患肢),女性46例(52条患肢);年龄50 ～96岁,平均年龄(77±10)岁.TASCⅡ分型:B型18例,C型89例,D型32例.采用左肱动脉和(或)股动脉穿刺经内膜下或血管内行髂动脉闭塞的球囊血管成形联合支架植入术治疗.结果 技术成功率96.2％ (151/157).踝肱指数由术前的0.42±0.19上升到术后的0.81±0.26.随访6～53个月,平均随访(30±7)个月,髂动脉支架畅通率94.1％ (111/118),7例发生支架内再狭窄或闭塞,无髂动脉破裂、支架移位、穿刺动脉假性动脉瘤及动静脉瘘的发生.结论 腔内血管成形术治疗髂动脉长段CTO安全、有效,术后支架通畅率高,联合肱动脉和股动脉双向穿刺技术能够显著提高技术成功率.     

股浅动脉首期置入自膨式支架与球囊扩张成形的疗效比较

目的 比较股浅动脉狭窄闭塞长段病变一期置入自膨式支架与一期球囊扩张成形的中期疗效.方法 回顾性分析2005年12月至2007年2月收治的症状性股浅动脉硬化狭窄或闭塞109例患者的临床资料,其中支架组53例(73条肢体)首期置入自膨式支架;扩张组56例(76条肢体)首期单纯球囊扩张成形.比较患者术后6、12及24个月的再狭窄、再闭塞率及临床分级改善程度.结果 支架组与扩张组的治疗段平均长度分别为(16±8)cm和(15±7)cm;经血管超声检杳支架组与扩张组术后6个月再狭窄率分别为13.7%(7例)和30.2%(16例),两组差异有统计学意义(X2=4.09,P<0.05);12个月分别为25.5%(12例)和46.9%(23例),两组差异有统计学意义(X2=4.75,P<0.05);24个月分别为38.1%(16例)和65.9%(29例),两组差异有统计学意义(X2=6.66,P<0.01);且支架组较扩张组临床分级改善显著而持久.结论 对于股浅动脉硬化狭窄或闭塞长段病变,首期置入自膨式支架的中期疗效较单纯球囊扩张血管成形术更为理想.     

移植肾动脉狭窄腔内治疗的中期结果

目的探讨移植肾动脉狭窄经皮血管腔内成形(PTA)及支架置入的安全性及中远期结果。方法回顾性分析2011年1月至2018年12月解放军总医院血管外科收治的18例移植肾动脉狭窄患者的临床资料。结果3例经同侧股动脉,15例经对侧股动脉人路治疗。4例单纯PTA治疗,8例PTA后置入支架,6例直接置入支架。共置入14枚支架,均为球扩式支架,其中2枚为药涂支架,技术成功率100%。平均造影剂用量64ml,治疗前肾动脉狭窄率为50%〜99%,腔内治疗后狭窄率降为10%〜30%。收缩压由术前的(157.2±43.0)mmHg降至术后的(129.8±8.6)mmHg;血清肌酐(SCr)水平由术前的(258.8±214.7)μmol/L降至术后的(176.3±101.1)μmol/L,尿素氮由术前的(15.7±1.6)mmol/L降至术后(10.6±1.1)mmol/L(均P<0.05)。术后中位随访42.4个月(3~93个月),治愈17例,无效1例,1例单纯球囊扩张后术后30 d出现再狭窄,予以置入支架。除1例移植肾动脉出血外无其他并发症。结论移植肾动脉狭窄是导致移植肾失功的常见血管因素,腔内治疗安全、有效。     

Angioplasty or bypass for superficial femoral artery disease? A randomised controlled trial.

AIM: To evaluate whether angioplasty or above-knee bypass is the best treatment for symptomatic superficial femoral artery occlusive lesions, we performed a multicentre randomised trial. PATIENTS AND METHODS: Between October 1995 and August 1998, 56 patients were enrolled, all with symptoms related to a 5-15 cm long occlusive lesion of the superficial femoral artery. Thirty-one patients were randomly assigned to percutaneous transluminal angioplasty (PTA); 25 patients to bypass surgery. All patients were followed at 1, 6 and 12 months after the procedure. The primary outcome of our study was re-occlusion of the femoral artery. RESULTS: Thirty patients underwent the allocated PTA and 24 patients underwent bypass surgery. Cumulative 1-year primary patency after PTA was 43 and 82% after bypass surgery. After PTA more than half of the patients had a re-occlusion with an absolute risk reduction of 31% (CI: 6-56%) in favour of bypass surgery. The hazard ratio for occlusion comparing PTA with bypass surgery is 2.24 (95% CI: 0.9-5.58). CONCLUSION: Despite 18 participating centres only 56 patients were randomised to PTA our bypass surgery. Based on our results, for every three patients treated with bypass surgery instead of PTA, one additional re-occlusion is prevented. Therefore, we conclude that with respect to patency, for long superficial femoral artery (SFA) stenoses or occlusions, surgery is better than PTA.     

节段闭塞性布加综合征的腔内治疗

目的 探讨节段闭塞性布加综合征的腔内治疗经验.方法 回顾性分析45例节段闭塞性布加综合征的临床资料.分别采用下腔静脉开通术、经皮经腔血管成形术(percutaneoustransluminal angiophsty,PTA)及支架植入术治疗.复杂的病例采用三维数字减影血管造影(three-dimensional digital subtraction angiography,3D-DSA)技术进行多角度评估下腔静脉病变,寻找腔内治疗最佳工作角度.结果 本组45例中,43例成功穿通并扩张.下腔静脉压由术前的(35.3±3.9)cm H2O降至术后的(9.5±2.0)cm H2O,两者差异有统计学意义(t=43.68,P<0.01).2例下腔静脉穿通失败,改行腔房人工血管转流术.1例行PTA时发生急性心包填塞.35例获得随访,随访率77.8%(35/45),随访时间3～46个月,平均28.6个月.除1例术后15个月支架内血栓形成而改行腔房人工血管转流术外,其他34例患者无支架移位及肝静脉阻塞.心包填塞病例经手术修补下腔静脉后治愈,随访6个月除肋间神经痛外无其他不适.本组无肺栓塞及死亡病例.结论 节段闭塞性布加综合征腔内治疗的近期、中期疗效较好.3D-DSA技术有助于布加综合征的腔内治疗.     

Duplex selection facilitates single point-of-service endovascular and surgical management of aortoiliac occlusive disease

We attempted to optimize management of aortoiliac occlusive disease by using duplex imaging to aid in selection of favorable lesions for percutaneous transluminal angioplasty (PTA)/stenting, by avoiding nontherapeutic arteriography, and by providing single point-of-service care in which endovascular and open surgical reconstruction were combined. One-hundred consecutive patients with symptomatic (91 claudication, 9 limb threat) inflow occlusive disease based on clinical examination and physiologic testing underwent physician-directed duplex scanning of the infrarenal aorta through the femoral bifurcation. Iliac lesions suited to endovascular intervention were defined as focal (length <5 CM), high-grade stenoses with a peak velocity >300 cm/sec and velocity ratio >2 by duplex and were differentiated from unfavorable (diffuse/long iliac stenosis, occlusions, aneurysms, femoral occlusive disease) inflow lesions. Patients with favorable iliac lesions according to duplex were considered candidates for PTA/stenting in an endo-capable operating room, without prior diagnostic angiography. On the basis of duplex imaging, 38 patients possessed endovascularly favorable iliac lesions, 58 patients had unfavorable aortoiliofemoral disease, and 4 obese patients had inadequate studies. Duplex interpretation correctly classified disease distribution/severity in 92% of 50 patients who subsequently underwent intraoperative or diagnostic arteriography. Thirty-one of the 45 (69%) total interventions performed in this patient group were based on duplex findings alone. Of 29 patients with favorable lesions by duplex scanning who had intervention, 25 (86%) received iliac PTA/stenting, while 4 patients required inflow surgical reconstruction for nonfocal iliac disease demonstrated on operative arteriography. Duplex imaging correctly identified the need for concomitant outflow reconstruction/bypass in 11 of the 25 (44%) patients treated by iliac PTA/stenting. Primary and assisted patency rates of iliac PTA/stenting were 83% and 100% at 24 months by life-table analysis. Duplex imaging in patients with symptomatic aortoiliac occlusive disease can provide sufficient information to permit endovascular and surgical intervention without formal diagnostic arteriography in most patients.     

重症头臂型大动脉炎的血管腔内治疗

目的 探讨腔内治疗重症头臂型大动脉炎的临床疗效及其应用价值.方法 32例重症头臂型大动脉炎患者,女28例(87.5％),男4例;平均年龄(30±8)岁.32例(共35条血管)通过腔内方法治疗,其中15条血管完全闭塞,狭窄程度70％～100％,平均90％±11％;病变长度2.7～5.3 cm,平均(3.1±1.5) cm;其中10例血沉增高(25～37 mm/h).术后6个月及每年进行症状体征随访并应用彩超、CT血管成像、血管造影评估管腔通畅情况.结果 15条完全闭塞血管中开通成功率80％( 12/15),3条未能开通.1例支架置入术中发生栓塞并继发急性血栓形成导致严重卒中事件,技术成功率(残余狭窄＜50％)为88.6％(31/35).31例术后短暂性脑缺血发作症状消失.技术成功的31例中,26例获得随访,随访率83.9％ (26/31).随访时间13 ～40个月,平均(19±10)个月,1例13个月后发生严重再狭窄并导致枕叶脑梗死,2例18个月后发生症状性再狭窄,管腔通畅率为88.5％ (23/26).结论 腔内治疗重症头臂型大动脉炎是一种安全有效方法,严格把握适应证和准确选择靶血管是治疗成功的关键.