经皮血管内治疗症状性基底动脉粥样硬化性狭窄的探讨

目的 探讨经皮腔内血管成形支架置入术治疗症状性基底动脉粥样硬化性狭窄的可行性、安全性及有效性.方法 回顾性分析2003年8月至2009年12月,经皮腔内血管成形支架置入术治疗的40例基底动脉粥样硬化性狭窄患者的临床资料及术后随访结果 .其中男性33例,女性7例;年龄30～75岁,平均58岁.患者均为经药物治疗无效、反复短暂性脑缺血发作或有明显脑缺血症状.结果 40例经皮腔内血管成形支架置入术均获成功,术后平均狭窄率由术前的82%±14%降为14%±11%,术后继续给予抗血小板聚集治疗.38例患者临床脑缺血症状和体征明显改善,2例术后发生脑干缺血症状加重,经治疗后临床症状好转但遗留神经功能障碍.无出血性并发症发生.随访2个月～7年,经颅多普勒复查26例,显示基底动脉血流速度增快2例.行全脑数字减影血管造影复查6例,1例支架内发生再狭窄,因有临床症状而行二次血管成形支架置入术;1例基底动脉支架内闭塞但侧支循环良好,临床上无后循环缺血症状.结论 经皮腔内血管成形支架置入术治疗基底动脉粥样硬化性狭窄是可行、安全、有效的;大样本的长期疗效有待于进一步观察.     

血管内支架成形术治疗脑供血动脉狭窄的研究

目的 探讨血管内支架成形术治疗脑供血动脉狭窄患者的近期疗效,并发症及安全性.方法 行血管内支架成形术治疗的19例脑供血动脉狭窄患者,其中颈内动脉起始段狭窄13例[5例表现为短暂性脑缺血发作(TIA),8例表现为脑梗死],椎动脉开口部狭窄6例,均表现为TIA.结果 19例患者支架全部成功置入,术前动脉狭窄程度平均为86%,术后残余狭窄程度平均为10%;明显增高的血流动力学恢复正常且持续保持;颈内动脉系统腩梗死患者NIHSS评分在术后明显改善.3例颈内动脉支架置入术患者出现一过性心率下降和血压下降,经药物治疗后均恢复正常.随访仅1例颈内动脉支架术后22周症状有所加重;1例椎动脉狭窄患者在术后19周出现1次TIA发作;其余患者术后随访6个月无症状复发.结论 血管内支架成形术是治疗脑供血动脉狭窄的一种安全、有效的治疗方法.     

血管内支架成型术治疗青壮年大脑中动脉狭窄的临床研究

目的:研究青壮年大脑中动脉(MCA)M1段狭窄血管内支架成形术的安全性和疗效。方法:47例大脑中动脉狭窄的患者,在静脉复合麻醉条件下采用球扩支架对大脑中动脉M1段行血管内支架成型术(PTA),术前3～5天口服阿司匹林肠溶片300mg及氯吡格雷片75mg,均为1次/天,术中、术后严格控制血压,监测生命体征。结果:47例患者大脑中动脉M1段狭窄约70%～99%,其中有46例患者支架得以成功置入,残余狭窄约0%～20%,术后大脑中动脉M1段直径狭窄率明显降低,与术前相比有明显差异(P<0.01)。短暂性脑缺血发作症状均得到控制,脑梗死患者症状得到明显改善。结论:支架血管成形术是治疗大脑中动脉狭窄的一种安全、有效的治疗方法,应积极防治再灌注损伤等合并症,对于血管高度迂曲的患者要做好术前评估。     

肾血管性高血压的介入治疗

目的：研究经皮腔内血管成形术加内支架植入术治疗肾动脉狭窄致致肾血管性高山压的临床效果。方法：选用Palmaz支架,对7例大动脉炎、2例动脉弱样硬化,3例纤维肌性发育不良所致肾动脉病变先行经皮腔内血管成形术,然后放置支架,术后患者行常规抗凝治疗,结果：12例患者,经皮腔内血管成形术加支架植入术技术成功率为100％,血压下降60－120／35－100mmHg近期随访－32个月未见复发,结论：经皮腔内血管成形术加支架植入术治疗肾血管性管高血压效果满意,创伤小,患者痛苦少,为肾动脉狭窄所致肾血管性高血压较理想的治疗方法。     

肾血管性高血压金属内支架置入治疗

目的 探讨经皮腔内肾动脉成形术（ＰＴＲＡ）和支架入置入术治疗肾动脉狭窄所致肾血管性高血压的临床效果。方法 对７例大动脉炎和３例动脉粥样 经所致肾动脉狭窄患者先行ＰＴＲＡ术,然后放置支架,术后定期复查血压并采用超声复查支架通畅状况。结果 １０例虱ＰＴＲＡ＾＋支架植入术技术均成功。血压完全恢复正常９例,部分下降１例,无严重并发症发生,随访３～２８个月未见复发。结论 ＰＴＲＡ和支架植入术治疗肾血管性高血     

经皮腔内血管成形术血运重建治疗糖尿病严重肢体缺血

目的探讨膝下动脉经皮腔内血管成形术治疗糖尿病患者严重肢体缺血（CLI）的疗效。方法2006年10月2007年10月对21例糖尿病严重肢体缺血患者采用DEEP球囊行膝下动脉成形术。结果对69条病变血管进行球囊扩张，支架植入12枚，PTA成功率82．61％（57／69），其中2例术后行高位截肢，其余有效。结论经皮腔内血管成形术血运重建可作为治疗糖尿病严重肢体缺血患者的首选治疗方法。     

锁骨下动脉窃血综合征的再认识及血管内治疗

目的 研究评价经皮血管内成形及支架置入术治疗锁骨下动脉窃血综合征(SSS)的疗效和安全性.方法 对2007年1月至2009年12月的32例左侧SSS患者进行介入治疗,术前行数字减影血管造影(DSA)检查和评估、抗血小板药物准备,然后实施球囊扩张+支架置入术,同时注意术中抗凝及术后处理,分别于术后即刻、3、6个月随访复查经颅多普勒超声(TCD)评价其疗效.结果 32例患者术前DSA检查结果显示锁骨下动脉狭窄平均为87.5%,术后降为15.0%,术后TCD检查结果显示椎动脉反向血流消失,放置的支架均无回缩和移位.术前患、健侧收缩压差平均为51.6 mmHg(1 mmHg=0.133 kPa),术后3个月时降为10 mmHg,无栓塞及死亡事件发生.结论 球囊扩张+支架置入术是治疗SSS的首选治疗手段,术后抗凝和抗血小板至关重要,TCD随访简易、安全、有效、可靠.     

经腘动脉入路逆行内膜下血管成形术治疗股浅动脉长段硬化性闭塞症的临床研究

目的:探讨经腘动脉入路逆行内膜下血管成形术/支架置入术处理常规入路腔内顺行开通失败的股浅动脉长段硬化性闭塞症的疗效及可行性。方法:50例股浅动脉长段硬化性闭塞症患者行股动脉病侧顺行或健侧逆行推进导丝、导管时无法通过病变动脉到达闭塞段远端的真腔,遂行经腘动脉逆行入路完成内膜下血管成形术。结果:手术即刻支架置入成功率100%,12个月一期通畅率48.0%,二期通畅率92.0%。与术前比较,患者术后踝肱指数(ABI)明显升高,Rutherford分级明显改善(均P0.05)。5例患者术后出现肢体肿胀,3例患者于术后3个月出现腘动脉假性动脉瘤,经治疗均好转。术后1年,再狭窄患者16例(32.0%)。结论:常规入路腔内顺行开通失败的股浅动脉长段硬化性闭塞症患者转行经腘动脉入路逆行内膜下血管成形术/支架置入术有效、可行。     

髂动脉成形术中发生髂动脉破裂的处理

目的 探讨覆膜支架在髂动脉成形术中发生髂动脉破裂时的应用价值.方法 回顾性分析郑州大学第一附属医院腔内血管外科2010年1月至2012年1月运用覆膜支架行腔内髂动脉成形术中髂动脉破裂9例的临床资料.结果 9例患者覆膜支架均置入成功,8例即刻复查髂动脉造影显示,髂动脉管腔通畅,无造影剂外溢;1例患者覆膜支架近心端出现Ⅰ型内漏,立即开腹行“髂动脉人工血管置换术”.9例患者术后临床症状均缓解,术后失访1例,8例患者随访14 ～45个月,平均(22±9)个月.1例患者术后1年覆膜支架远心端(髂外动脉)狭窄,行髂外动脉球囊扩张裸支架成形术,继续随访5个月,无不良事件发生;人工血管置换术患者1例随访18个月,彩超复查人工血管通畅良好.结论 髂动脉成形术中发生髂动脉破裂时,首选置入覆膜支架治疗.对治疗不满意者,外科治疗是最后的保障.     

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。     

Percutaneous transluminal angioplasty for multiple brachiocephalic artery stenosis: case report

We encountered a patient with multiple stenotic lesions. He was treated by percutaneous transluminal angioplasty (PTA). The patient, a 59 year-old male, complained of right motor weakness. CT scan showed a multiple low density area (LDA) in the distribution of the right middle cerebral artery (MCA), but did not reveal LDA in the distribution of the left MCA on the affected side. After hospitalization, right motor weakness gradually worsened and aphasia became apparent. A repeat CT scan, 8 days after the stroke, disclosed a new LDA in the left watershed zone and the basal ganglia. Angiographical findings revealed a right ICA occlusion, left ICA stenosis, right VA anaplasia and left subclavian artery stenosis, which proved inadequate for anatomical collateral supply. We treated both the left ICA stenosis and the left subclavian artery stenosis by Dotter balloon dilatation catheter, and successfully obtained sufficient dilatation of the vessels concerned. No complication occurred. PTA is a useful method to use in patients with multiple stenotic lesions which might result in ischemic injury if surgical procedures were used. It would also be of value in cases where surgery using general anesthesia might be highly risky.     

Self-expanding stent (Wallstent) supported angioplasty for carotid artery stenosis]

We reported the preliminary results of percutaneous transluminal angioplasty (PTA) supported with a self-expanding stent (Wallstent) for the cervical internal carotid artery (i.c.) stenosis in 6 patients (7 lesions). All were male aged from 60 to 79 (mean 70.8). Three patients were symptomatic and 3 were asymptomatic. The procedure was attempted in patients with severe i.c. stenosis according to criteria of NASCET, ECST or ACAS studies and with high risk if carotid endarterectomy (CEA) were performed. In all cases, vascular access was from the femoral artery and angioplasty was performed without cerebral protection. Successful angioplasty was obtained in all cases with no mortality. Stenosis was improved from 82.7% (74-90%) to 17.4% (10-33%). Perioperative complications were seen in only one case with TIA during the postdilatation period, which was supposed to be due to a distal embolism. The preliminary results of PTA supported with self-expanding stent for severe i.c. stenosis were excellent. These results suggested that some patients with severe i.c. stenosis can be treated safely and effectively by stent-supported PTA. However, it is necessary to mark the indications clear and strict, and to follow up these lesions after the procedure, because of the possibility of perioperative ischemic complications and restenosis.     

Percutaneous transluminal angioplasty in transplant renal artery stenosis: experience and review of the literature

Percutaneous transluminal angioplasty (PTA) was performed in five instances of renal transplant artery stenosis (RTAS) in four patients. Hypertension was present in all cases and improved after angioplasty together with reduction in medicine requirements. Abnormal renal function in four instances also improved after PTA. This reflects the current literature in which 76 of 90 patients were successfully treated by PTA (follow-up to 24 months), with two cases of recurrent stenosis, no mortality, and only a single case of graft loss. Vascular surgical repair succeeded in 130 to 180 patients, but graft loss occurred in 20 cases and recurrent stenosis in 11. Mortality was reported in five cases. Our review of the literature and experience suggests that PTA may be preferred in the treatment of RTAS.     

Surgical reconstruction for radiation-induced extracranial vertebral artery stenosis: a case report]

We report a case of symptomatic extracranial vertebral artery stenosis after radiation therapy. This 49-year-old female received radiation therapy to the neck for nasopharyngeal carcinoma 11 years earlier, was admitted because of continuous dizziness and a floating sensation. Magnetic resonanse imaging showed no abnormalities, but an aortography demonstrated complete occlusion of the right common carotid artery as well as occlusion of the right vertebral artery and severe stenosis of the left vertebral artery at its origin, which was presumed to be the result of previous radiation therapy. Percutaneous transluminal angioplasty (PTA) for the left vertebral artery was performed using conventional balloon treatment, which resulted in wall dissection. Because of this, she underwent end-to-side vertebral artery to subclavian artery transposition, and she has had no further ischemic events science that time. PTA has been successfully performed as the first treatment of choice for vertebral artery stenosis, but surgical reconstruction can be a therapeutic management of choice for cases of failed PTA.     

Surgical Treatment of Coronary Subclavian Steal Syndrome with Carotid Subclavian Bypass

Coronary subclavian steal syndrome (CSS) results from proximal subclavian artery occlusive disease causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass leading to myocardial ischemia. Although percutaneous transluminal angioplasty and stent (PTAS) for subclavian lesions has been successful, it is not always feasible. In this study, the results of carotid subclavian bypass (CSB) for symptomatic CSS due to subclavian occlusion and stenosis not amenable to PTAS were analyzed. The records of patients undergoing CSB for CSS between 1991 and 2001 were reviewed. Patients with lesions not amenable to angioplasty or stent were selected for CSB. Degree of preoperative myocardial ischemia was stratified according to New York Heart Association classification. Graft patency was analyzed by life-table methods. Our results showed that CSB for treatment of symptomatic CSS can be performed safely with excellent mid-term durability. In the setting of proximal subclavian artery disease not amenable to PTAS, CSB provides an acceptable means of treatment for symptomatic CSS.     

Percutaneous transluminal angioplasty in fibromuscular dysplasia of the internal carotid artery: case report

We report a case of symptomatic cervical carotid artery stenosis associated with fibromuscular dysplasia (FMD) successfully treated by percutaneous transluminal angioplasty (PTA). A 49-year-old female presented with repeated ischemic attacks of right hemiparesis and aphasia. Digital subtraction angiography revealed a string of beads appearance of the left internal carotid artery typical of the medial type of FMD, at the level of the C2 vertebra. Similar findings were also evident in the right internal carotid artery at the level of the C1 vertebra, but without significant narrowing. MR angiogram of the left carotid artery revealed a marked flow gap, suggestive of severe stenosis. Forty days after onset PTA was indicated for symptomatic FMD of the left internal carotid artery because of the relative difficulty in approaching and repairing this highly located lesion surgically. The stenotic lesion was very easily dilated without any procedural complications. Although angiography just after PTA showed slight residual irregularity of the wall, this smoothed up with time. Follow-up MR angiography 7 years after PTA demonstrated long-term patency without clinical evidence of deterioration. Patients with the medial type of FMD in the carotid artery seem to be excellent candidates for PTA.     

对侧颈动脉闭塞患者颈动脉成形支架置入术的临床分析

目的 探讨对侧颈动脉闭塞患者颈动脉成形支架置入术(CAS)的有效性及安全性.方法 回顾性分析2001年1月至2010年1月治疗的56例对侧颈动脉闭塞、同侧颈动脉狭窄患者的病例特点及CAS的疗效.患者均经数字减影血管造影(DSA)证实为一侧颈动脉闭塞、另一侧颈动脉狭窄,狭窄程度在50%～90%,平均72%±15%.经常规准备后在远端脑保护装置保护下行CAS.结果 56例对侧颈动脉闭塞、同侧颈动脉狭窄患者行CAS的技术成功率100%,术后颈动脉直径狭窄率即术后残余狭窄率为0～30%,平均为13%±8%.患者术后脑缺血症状均获改善,仅1例于术后3 d发生原脑梗死部位的慢性出血(CAS侧),开颅手术后遗留轻微神经功能障碍,无缺血性并发症发生,无死亡病例.患者随访6个月～3年,平均27个月,均无脑缺血症状发作,经颈部血管彩色超声复查47例、DSA复查2例均未发现支架内再狭窄.结论 对侧颈动脉闭塞的高危患者的CAS治疗是安全、有效的,严格的病例筛选、经验丰富的医生操作及术后严谨的综合处理均可以降低手术并发症的发生.

Abstract：

Objective To discuss the efficiency and safety of carotid angioplasty stenting (CAS) in patients with contralateral carotid artery occlusion. Methods From January 2001 to January 2010,56 carotid artery stenosis patients with contralateral carotid artery occlusion were performed CAS and the feature and results of these cases were analyzed retrospectively. All the cases were confirmed to be carotid artery stenosis with contralateral carotid artery occlusion by digital subtraction angiography (DSA). The diameter stenosis rate was 72% ± 15%. CAS were performed with distal protection device in 56 cases. Results The technique success rate of CAS were 100% in all the 56 patients with contralateral carotid artery occlusion and postprocedure stenosis rate descended to 13% ± 8%, and the symptoms of cerebral ischemia were all improved. Only 1 case occurred remote hemorrhage in the position of previous cerebral infarction in the side of CAS after the procedure, and recovered with light neurological deficit after the craniotomy to remove the hematoma. No ischemic complications or death occurred. During the following up of 6 months to 3 years, no cerebral ischemic symptoms reoccurred. The rechecking results of color Doppler of 47 cases and DSA of 2 cases showed no restenosis in-stent. Conclusions CAS is safe and effective for the patients with contralateral carotid artery occlusion. Critical election of the case, operation of skilled doctors and scrupulous postprocedure general management can decrease the rate of complication.     

Management of Arterial Stenosis Affecting Kidney Graft Perfusion: A Single-Centre Study in 53 Patients

We assessed clinical and duplex sonographic (CDS) findings, and outcome in patients with stenosis of the transplant renal artery (TRAS) or the aorto-iliac segment proximal to the graft (Prox-TRAS) treated with dilatation (PTA), stenting (PTAS) and surgery. From 1988 to 2002, of 1189 patients with renal transplantations, 117 underwent angiography. Fifty-three patients with TRAS (n = 37)/Prox-TRAS (n = 16) were found (4.4%). Clinical presentation included deterioration of hypertension (144 +/- 15/84 +/- 9, 157 +/- 22/90 +/- 10 mmHg; p < 0.001), increase of creatinine (1.7 +/- 0.9, 2.5 +/- 1.3 mg/dL; p = 0.01) and renal failure (n = 12). CDS indicated insufficient perfusion and differentiated between TRAS and Prox-TRAS. From renal transplantation (RTX) until the detection of stenosis pulsatility indices (PI) decreased from 1.2 +/- 0.46 to 0.98 +/- 0.29; (p = 0.001). Fifty-two patients underwent invasive treatment (21 PTA, 10 PTAS and 21 surgery) after which hypertension and creatinine significantly improved. PI increased. Restenosis occurred in 16 (52%) cases of the interventional (PTA 62% and PTAS 30%) and in 3 (14%) of the surgical group (p = 0.011). Hypertension and graft dysfunction due to perfusion problems are rare. Clinical findings are nonspecific but CDS findings are helpful to select patients for angiography. Invasive treatment leads to clinical improvement. Surgery yields better results than PTA, but additional stenting will probably improve the outcome of angioplasty.