急性椎基底动脉闭塞血管内介入治疗的疗效分析

目的 探讨血管内介入治疗急性椎基底动脉闭塞的效果及影响因素。方法 惠州市第一人民医院于2013-01—2016-12间采用血管内介入疗法治疗急性椎基底动脉闭塞患者共13例,其中尿激酶动脉溶栓+碎栓3例,溶栓+碎栓+Solitaire支架拉栓10例,必要时进行球囊扩张血管狭窄处。回顾性分析患者的临床资料、即时取栓效果、疗效,总结并发症的预防经验。结果 术后即刻造影及复查头颅CT显示,血管完全再通10例,部分再通2例,未再通1例,再通率为92%。术后复查CT显示无脑出血病例,较大面积脑干梗死5例。良好功能恢复(MRS评分0~2分)6例,中度残疾(MRS评分3分)2例,严重功能障碍(MRS评分4~5分)3例,死亡1例。结论 血管内介入治疗急性椎基底动脉血栓形成,血管再通率高,安全、有效,部分患者预后良好。     

腔内治疗近肾动脉主-髂动脉硬化闭塞4例

探讨近肾动脉主-髂动脉硬化闭塞症腔内治疗的临床效果。回顾分析山东省菏泽市立医院心脏血管外科2013年3月—2016年3月共4例近肾动脉主-髂动脉硬化闭塞症的临床病例。4例患者均行腔内治疗,给予腹主动脉、髂动脉插管溶栓。其中1例插管溶栓后血管部分再通,未行支架置入;其余3例插管溶栓后给予腔内人工血管支架置入。1例患者平肾动脉狭窄,双肾动脉置入烟囱支架。2例术后出现并发症,其中1例合并肺部感染,1例出现肾功能不全,治疗后康复。4例患者均临床治愈出院。腔内治疗近肾动脉主-髂动脉硬化闭塞症有较好疗效。     

完全腹腔镜手术治疗平肾腹主动脉闭塞症

目的探讨完全腹腔镜手术治疗平肾腹主动脉闭塞症的可行性及疗效。方法对2例病人的临床资料进行回顾性分析。结果 2例病人均诊断为平肾动脉主髂动脉闭塞症。全麻后行完全腹腔镜下腹主动脉切开,Fogarty导管取栓及腹主动脉-股动脉人工血管转流术。2例手术均成功完成。1例术中人工血管栓塞,行人工血管切开取栓;1例术后CTA发现左肾梗塞灶及腹主动脉残余狭窄,再次行腹主动脉支架成形术。患者术后恢复顺利,分别随访14及10个月,人工血管保持通畅。结论完全腹腔镜手术治疗平肾腹主动脉闭塞症创伤小,疗效好,值得推广。结合介入技术可以术中监测疗效,及时进行合理治疗。     

腔内血管成形术治疗膝下动脉长段闭塞

目的分析探讨介入技术治疗动脉硬化闭塞症膝下动脉长段闭塞的再通成功率和临床疗效。方法回顾性分析2007年10月至2008年11月间,介入技术治疗98例(113条动脉)膝下动脉长段闭塞患者的临床资料。结果 88条动脉(72例,78%)介入治疗获得成功。胫前、胫后动脉及腓动脉开通率分别为68%、74%与83%。48例获得随访,随访时间为6～12个月,CTA显示33例(69%)发生再狭窄,15例(31%)发生再闭塞。结论介入技术可以再通膝下动脉长段闭塞,并能取得较好的近期效果,但长期随访显示仍存在很高的术后再狭窄率和再闭塞率。     

介入疗法在急性肢体动脉闭塞治疗中的应用价值

目的探讨介入疗法在急性肢体动脉闭塞治疗中的应用价值。方法回顾性总结28例急性肢体动脉闭塞介入治疗经验。采用经皮血管腔内成形术和动脉内溶栓术治疗上肢动脉闭塞5例、腹主动脉下段闭塞1例、下肢动脉闭塞22例。结果经术后4个月~9年临床观察,急性单段动脉闭塞血管再通率为100%(8/8例)、多段动脉闭塞血管再通率为80%(16/20例),总血管再通率为85.71%(24/28例)。结论介入疗法是治疗急性肢体动脉闭塞的一种有效方法,值得推广应用。     

介入手术治疗复杂主髂动脉闭塞症：附16例分析

目的:探讨经皮腔内介入治疗复杂主髂动脉闭塞症的临床疗效。方法:回顾性分析收治的16例复杂主髂动脉闭塞患者临床资料,患者均行介入手术治疗,通过多穿刺入路途径,采用内膜下血管再通技术和导丝抓捕技术建立工作导丝通道,然后行球囊扩张术及对吻技术支架植入等。结果:16例复杂主髂动脉闭塞的患者,手术均获得成功,手术成功率100%。16例患者中15例患者血管完全通畅,症状明显改善,1例患者症状中度改善,下肢缺血症状消失。1例患者出现穿刺部位血肿,术后并发症发生率为6.25%。所有患者均随访3~48个月,其中有5例患者出现支架内狭窄及血栓形成,经过腔内介入治疗后再次恢复血流。术后12、24、36个月血管通畅率分别为87.5%、81.25%、68.75%。结论:经皮腔内介入治疗复杂主髂动脉闭塞,能够迅速打通血管、恢复血流,且并发症少,临床效果满意。     

经动脉栓塞治疗肾内动静脉畸形后血管再通的治疗

目的探讨经动脉栓塞治疗肾内动静脉畸形后畸形血管再通的原因和治疗。方法回顾性分析4例肾内动静脉畸形经动脉栓塞治疗,术后畸形血管发生血管再通患者的临床资料。本组共4例,男1例,女3例,年龄19~70岁。左肾2例,右肾2例;1支肾动脉2例,2支肾动脉2例。经动脉造影明确诊断,并应用明胶海绵栓塞治疗,术中见栓塞确实,出血停止。术后1~24 h再次出现血尿,发生畸形血管再通。结果行二次动脉造影证实原动静脉畸形处血管再通,应用弹簧圈超选择性栓塞治愈。随诊未发现畸形血管再通。结论经动脉栓塞治疗先天性肾内动静脉畸形应采用超选择性动脉栓塞技术,用明胶海绵栓塞易发生血管再通。应用合适大小的弹簧圈超选择性肾动脉栓塞治疗肾内动静脉畸形可以取得确实疗效。     

介入性再通术治疗下肢动脉平齐闭塞病变

目的探讨介入性再通术治疗下肢动脉平齐闭塞病变的方法和疗效。方法17例经CT血管造影（CTA）或MR血管造影（MRA）诊断的下肢主要动脉起始部平齐闭塞患者,病变分别位于髂总动脉（4例）、髂外动脉（2例）、股浅动脉（8例）、胫后或胫前动脉（3例）,临床表现为静息痛等下肢严重缺血症状。经同侧、对侧股动脉或右肱动脉等途径,主要使用内膜下血管成形方法对平齐闭塞端血管进行顺行开通治疗。结果17例患者中,12例成功使导丝和导管经平齐闭塞端进入并通过闭塞端,完成再通治疗,其中11例（11/12）使用了内膜下血管成形技术,在髂、股动脉共植入支架19枚;1例髂总动脉、2例股浅动脉和2例胫（胫前、胫后）动脉平齐闭塞病变因无法使导管导丝嵌入闭塞起始部而终止再通操作,再通成功率为70.59%（12/17）。未发生与介入操作相关的并发症。再通术后临床症状明显改善或消失,踝臂指数（ABI）平均值从0.47上升至0.71。6个月近期随访无症状复发,8、12和24个月各有1例患者症状加重,其中1例复查CAT显示支架内完全闭塞。结论使用内膜下血管成形术对下肢动脉平齐闭塞病变进行再通治疗可以获得安全而良好的临床疗效,拓展了介入治疗对于复杂、严重下肢缺血病变的适用范围。     

慢性颈内动脉闭塞的研究与治疗进展

现阶段临床工作中对慢性颈内动脉闭塞(ICACTO)治疗的认识有限。本文通过对慢性颈内动脉闭塞的病理、发病机制、临床症状、影像学特征及治疗等进行总结,综述其相关的研究进展。在颈内动脉完全闭塞后脑组织内丰富的侧支血管开放并逐步形成侧支代偿。ICACTO的病理生理特点是脑灌注不足,栓子脱落和认知功能障碍,最后引起多种卒中不良事件的发生。因此大多数ICACTO病例需要治疗。最初采取颈外动脉-颈内动脉搭桥的方法并没有取得满意的治疗效果。近年来闭塞血管的再通被认为是唯一可行的治疗手段,术前需要评估脑血管储备和氧摄取分数,以及颈内动脉(ICA)闭塞的长度、节段和闭塞时间等等多种因素。对合适的患者可以通过血管内介入,颈动脉内膜切除术(CEA)或复合手术等方法进行血管再通。随着生物材料的发展,简单的再通成功率会逐渐提高。但是,CEA+血管内介入的复合手术应该更符合当前的趋势,因为CEA可以切除颅外段颈动脉粥样硬化斑块,为进一步的血管内介入性提供条件。如果再通成功,通常可以长期稳定地改善患者状况。尽管现有的研究已经得出了一定的研究成果,但仍需要进一步的研究和试验来提高当前对ICACTO的了解。     

大隐静脉激光腔内闭合术后的再通率及病理研究

目的研究大隐静脉激光腔内闭合术后早期再通率及由于再通而切除后血管组织学特征。方法 110例(135条肢体)大隐静脉曲张患者接受激光腔内治疗,进行持续12个月的多普勒超声随访,对由于再通而手术切除的血管进行病理检查。结果随访期间,128条肢体(94.8%)的血管稳定闭塞,7条肢体(5.2%)存在大隐静脉完全再通或部分再通。组织病理学模式类似于自发性血栓性浅静脉炎闭塞后再通。结论大隐静脉激光腔内闭合术的疗效可靠,操作简单,临床复发再通率低,其术后复发的主要模式类似于自发性血栓性浅静脉炎再通改变,存在多腔结构。对于主干血管迂曲较严重、曾行硬化剂治疗以及血凝状态异常者,激光治疗时需先行高位结扎术。     

Percutaneous carotid angioplasty and stenting with the use of gadolinium in lieu of iodinated contrast medium: technical case report and review of the literature

OBJECTIVE AND IMPORTANCE: We describe a patient who underwent percutaneous transluminal carotid angioplasty and stent placement with the use of intra-arterial gadolinium (Gd-DTPA) instead of iodinated contrast medium. This represents one of the first published reports of the use of Gd-DTPA as an angiographic contrast agent for an interventional neuroradiological procedure. CLINICAL PRESENTATION: A 75-year-old man with renal insufficiency and multiple comorbidities developed amaurosis fugax. Doppler examination revealed high-grade stenosis of the right internal carotid artery. INTERVENTION: The patient underwent percutaneous transluminal balloon angioplasty with endovascular stent placement for 95% narrowing of the proximal right internal carotid artery. Because of his impaired renal function, the procedure was performed with the use of Gd-DTPA as the sole contrast agent. Approximately 60 ml of contrast medium (twice the volume typically used for a magnetic resonance imaging study) was used. There were no neurological, renal, or other complications. CONCLUSION: Intra-arterially administered Gd-DTPA may be substituted for iodinated contrast agents in complex neuroendovascular procedures. This capacity expands the armamentarium for interventional neuroradiological procedures.     

同种异体肾移植术后移植肾动脉狭窄 介入治疗的临床疗效分析

目的探讨同种异体肾移植术后移植肾动脉狭窄（TRAS）介入治疗的临床疗效。方法介入治疗同种异体肾移植术后TRAS患者22例,其中单纯球囊扩张治疗10例（球囊组）,内支架治疗12例（支架组）。对所有患者术前及术后2年内血压、肾功能以及生活质量进行评估,并与同期接受单纯药物治疗的6例TRAS患者（药物组）进行比较。结果球囊组技术成功率90.00%,支架组技术成功率100%。术后在血压及肾功能改善方面,球囊组和支架组均取得显著疗效,两组近期疗效未见明显差异,药物组疗效不满意。术后随访6个月～2年,支架组再狭窄率16.67%,除1例不明原因治疗无效外,其余11例均能比较健康的生活和工作。球囊组手术失败1例,再狭窄率达40.00%。结论内支架植入术可作为TRAS特别是I型及Ⅱ型狭窄的首选治疗方法。     

Experience with percutaneous transluminal angioplasty for renal artery stenosis at the Cleveland Clinic

From April 1979 to June 1985 percutaneous transluminal angioplasty was attempted in 68 patients at our clinic to treat renovascular hypertension and/or to preserve renal function. The etiology of renal artery disease was atherosclerosis in 55 patients, fibrous dysplasia in 6, renal transplant arterial stenosis in 5 and postoperative saphenous vein graft stenosis in 2. A successful clinical outcome, defined as a decrease in blood pressure and/or improvement in renal function, was achieved in 12 patients (26.1 per cent) with atherosclerotic renal artery disease, 3 (75 per cent) with fibrous dysplasia, 2 (100 per cent) with saphenous vein graft stenosis and all 5 with transplant renal arterial stenosis (100 per cent). Improved results were observed in patients with nonostial atherosclerotic lesions compared to ostial lesions. There were 23 complications (33.8 per cent) after percutaneous transluminal angioplasty and all but 1 occurred with atherosclerosis. Of these complications 13 (19 per cent) were considered major. Since the beginning of 1983, however, only 3 complications occurred among 32 procedures (9.4 per cent) and only 1 of these was of major significance. When technically feasible, percutaneous transluminal angioplasty can provide effective treatment for selected patients with renal artery stenosis.     

Treatment of acute renal artery occlusion after percutaneous transluminal angioplasty

Four patients with occlusive complications after percutaneous transluminal renal artery angioplasty (PTA) have been treated from July 1, 1984, to March 14, 1988. During this interval such renal artery angioplasties were performed in 44 patients. Two resulted in complete main renal artery occlusion, one angioplasty resulted in occlusion of a stenotic renal artery bypass graft, and one renal PTA resulted in segmental branch renal artery narrowing, which was thought to represent a dissection. The latter segmental renal artery narrowing was treated expectantly with good long-term results. One of the main renal artery occlusions was treated by radiologic means by reentry and repeat transluminal dilation. The other two acute complete occlusions, one of an autogenous artery and the other of an aortorenal bypass graft, were treated by aortorenal or ileorenal bypass grafting, respectively. The overall incidence of main renal artery occlusion (including the bypass graft occlusion) after PTA requiring operative intervention was 4.5% (2/44). Revascularization was accomplished after 6 and 8 hours of renal ischemia time for the two surgical procedures. Despite this, the bypass grafts done emergently remain patent, and the involved kidneys appear to be functional. The incidence of main renal artery occlusion after PTA is not as low as would be apparent from a review of the literature. It is proposed that main renal artery occlusion after PTA can be treated successfully by surgical and interventional radiologic techniques because of the presence of protective renal collateral circulation whose formation was stimulated by the renal artery lesion that prompted PTA.     

A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

The hospital records of 22 patients on hemodialysis undergoing coronary artery bypass grafting, and 19 others undergoing percutaneous transluminal coronary angioplasty were reviewed to compare the outcomes of these procedures in this population. Evidence of previous myocardial infarction or triple vessel or left main coronary artery disease was more common in patients undergoing coronary artery bypass graft than those undergoing percutaneous transluminal coronary angioplasty. Perioperative mortality and complication rates following coronary artery bypass graft (4.5% and 41%, respectively) were similar to those following percutaneous transluminal coronary angioplasty (5.3% and 42%). Cardiac event-free rates at 18 months by life-table analysis following coronary artery bypass graft and percutaneous transluminal coronary angioplasty were 87±16% and 40±14%, respectively. Survival at 18 months were 67±17% following coronary artery bypass graft and 69±14% following percutaneous transluminal coronary angioplasty. Cardiac events were observed to occur in three patients undergoing coronary artery bypass graft at a median of 10 months, and in nine patients following percutaneous transluminal coronary angioplasty at a median of 6 months. One patient required percutaneous transluminal coronary angioplasty after the initial coronary artery bypass graft. Seven patients required repeat percutaneous transluminal coronary angioplasty, and two patients underwent coronary artery bypass graft after initial percutaneous transluminal coronary angioplasty. Although these conclusions are limited by the retrospective nature of the study, it is concluded that coronary artery bypass graft can be performed with morbidity and mortality equivalent to percutaneous transluminal coronary angioplasty, and provides better cardiac event-free rates than percutaneous transluminal coronary angioplasty in patients on hemodialysis. Percutaneous transluminal angioplasty does not appear to be justified in this population because of its unacceptably high restenosis and cardiac event rates.     

Nonsurgical treatment of renovascular hypertension by percutaneous transluminal angioplasty

A case of renovascular hypertension treated with percutaneous transluminal angioplasty is reported. Our patient was a 22-year-old housewife with 90 per cent stenosis of the right renal artery due to fibromuscular dysplasia. The renal artery was dilatated by percutaneous transluminal angioplasty with a Grützig balloon catheter to 25 per cent stenosis. Five hours after the procedure, blood pressure decreased from 180/114 mmHg to 130/95 mmHg; one day after, plasma renin activity fell from 4.7 ng/ml/hr to 1.7 ng/ml/hr. The patient was rehospitalized six months after percutaneous transluminal angioplasty to examine restenosis of the dilatated renal artery. Although her blood pressure remained normotensive and plasma renin activity was normal, replasty was performed since selective renal arteriography revealed 50 per cent stenosis.     

Renal artery stenosis in transplanted kidney: management and results in six patients

Severe hypertension and a decrease of renal function, with or without oliguria, suggest renal artery stenosis in the transplanted kidney. 6 renal artery stenoses were observed in 100 transplanted kidneys followed up for more than 3 months. In 4 patients, percutaneous transluminal angioplasty was performed. 1 patient required a new percutaneous transluminal angioplasty 3 months later and a 2nd patient was submitted to surgery after 14 months. Surgery was performed in 2 more cases, with failure in 1. It seems that the endoarteric lesion during cold perfusion could be the main etiopathological factor, when associated with rejection episodes. Percutaneous transluminal angioplasty is the treatment of choice in the management of renal artery stenosis in transplanted kidneys. Surgery must be reserved when it fails.     

Endovascular exclusion of iatrogenic femoral artery pseudoaneurysm with the Wallgraft-Endoprosthesis

Development of femoral artery pseudoaneurysm represents a continuing problem after percutaneous peripheral interventional procedures as well as coronary angioplasty. We report a case of symptomatic, expanding femoral artery pseudoaneurysm in a 60-year-old man who underwent percutaneous transluminal coronary angioplasty and stenting for acute myocardial infarction. A self-expanding Wallgraft Endoprosthesis (Boston Scientific, USA) was delivered under fluoroscopic guidance via contralateral percutaneous femoral approach to the site, resulting in immediate complete exclusion of the pseudoaneurysms. Follow-up color duplex scanning confirmed false aneurysm exclusion 1 year postprocedure. Endovascular treatment of iatrogenic pseudoaneurysm appears to be an attractive alternative to surgical repair in critically ill patients, with a high degree of technical success, low morbidity and short hospital stay.     

Intervention in patients with renovascular hypertension and renal insufficiency

We report on 21 severely hypertensive patients with renal artery stenosis and renal insufficiency in whom percutaneous transluminal angioplasty and/or renal artery surgery was done in an effort to lower blood pressure and to preserve renal function. Of 12 patients who underwent angioplasty renal function and blood pressure improved in 3. Of the 9 patients without improvement 4 suffered permanent oliguric renal failure. An operation was performed in 12 patients, 4 after having failed angioplasty (1 was treated at another institution before referral for surgery). Two patients died postoperatively but 10 improved, with followup in 6 exceeding 3 years. This retrospective experience suggests that percutaneous transluminal angioplasty is not likely to supplant an operation in the treatment of patients with atherosclerotic renovascular hypertension and renal insufficiency.     

Cause of primary vaginal hydrocele and ascites in advanced liver cirrhosis

The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.