一期大隐静脉动脉化治疗下肢血栓闭塞性脉管炎

目的：通过一期大隐静脉动脉化治疗下肢血栓闭塞性脉管炎。方法：通过利用自体头静脉在患肢大隐静脉与患肢股动脉或髂外动脉之间搭桥，为６６例９１侧下肢血栓闭塞性脉管炎患者实施手术。结果：术后下肢缺血性疼痛消失，皮温皮色恢复正常，足趾及跖部创面愈合，多普勒超声探测及动脉造影提示患足血供良好。结论：本术式不影响静脉血回流，简易、经济，效果良好，使用头静脉搭桥可使本术式应用范围更广。     

应用显微外科技术治疗广泛性下肢动脉硬化性闭塞

目的 探讨下肢广泛动脉硬化性闭塞造成的肢体缺血显微外科治疗的临床效果。方法 1998年5月～2003年1月，应用显微外科技术，采用自体长段大隐静脉逆转移植重建血供12例。结果 术后随访3个月～4年，术前的肢体冷与麻木、静息痛和间歇性跛行消失。结论 应用显微外科技术，进行大隐静脉逆转移植及动脉搭桥或静脉动脉化治疗下肢动脉硬化性闭塞，术后可获得良好的远期通畅率及较好的临床效果。     

血管搭桥胫后静脉动脉化治疗下肢严重缺血症

目的：解决静脉动脉化存在的静脉回流障碍、窃血等问题。方法：设计了应用Ｇｏｒｅ－Ｔｅｘ血管搭桥，仅使一条胫后静脉一期动脉化的术式。临床为５例６侧下肢严重缺血的患者实施手术。结果：术后下肢缺血性疼痛消失，无肿胀，１４～８０天创面愈合；动脉造影和多普勒超声探测证实患足血供良好。结论：本术式可以保证其它静脉回流的完整性、窃血也少。应用Ｇｏｒｅ—Ｔｅｘ血管搭桥的长度与粗细不受自身浅静脉条件和动脉闭塞程度的限制。该术式安全、简便、副损伤小、疗效确切。     

显微外科静脉瓣膜切除在下肢静脉动脉化手术中的应用

为探索静脉动脉化重建缺血下肢血循环的新途径，根据大隐静脉瓣膜的解剖观察和抗逆向压力测试结果，应用显微外科技术切除大隐静脉的主要瓣膜，一期完成原位大隐静脉动脉化，以重建严重缺血下肢的血循环。临床治疗重症血栓闭塞性脉管炎、动脉硬化性闭塞所致下肢广泛动脉闭塞共４３例，经随访１～４年，４１例效果满意。文章重点介绍大隐静脉瓣膜的解剖、定位、切除和原位大隐静脉转流的手术要点，并就术式评价、指征等进行讨论。     

血管搭桥胎后静脉动脉化治疗下肢严重缺血平

解决静脉动脉经存在的静脉回流障碍、窃血等问题。设计了应用Ｇｏｒｅ－Ｔｅｘ血管搭桥，仅使一条胫后静脉一期动脉化的术式。临床为５例６侧下肢严重抽血的患者实施手术。术后下肢缺血性消失，无肿胀，１４－８０天创面愈合；动脉造影和多普勒超声探测主宰患足血供育好。     

胫后静脉一期动脉化治疗下肢动脉广泛闭塞

应用在下肢闭塞以上正常动脉与腓静脉入口远侧胫后静脉之间搭桥及破坏胫后静脉远侧瓣膜的方法．一期完成胫后静脉动脉化，用于治疗下肢动脉广泛性闭塞病变15例（17肢），术后观察1～10年，除2例（2肢）又分别行截肢及带蒂网膜移植外。其余15肢效果良好。本法具有手术可一期完成、适应证广、对静脉回流影响小和缺血症状解除快等优点。     

大隐静脉动脉化治疗下肢慢性缺血88例

目的探讨静脉动脉化治疗下肢广泛动脉闭塞的疗效.方法对广泛动脉闭塞无流出道的慢性缺血患者88例（104条肢体）施行大隐静脉原位一期静脉动脉化加腰交感神经节切除.结果104条肢体中,随访82条,随访6个月至6年,平均3年.所有患者间歇性跛行明显减轻,夜间疼痛好转,创面愈合良好,下肢无肿胀.结论本术式可使动脉血流通过大隐静脉通道,改善或重建缺血下肢的血液循环.     

半闭式小切口切取大隐静脉移植物作股动脉搭桥术

为探讨缩小股动脉搭桥术的手术切口。采用自制顶端带孔的大隐静脉圈套器，半闭式小切口取得大隐静脉后，作股动脉搭桥术治疗下肢股动脉硬化闭塞症，共１８例。术后切口均获一期愈合。经６月～４年随访（平均２６月），１５例术后间歇性跛行消失或明显减轻，３例因远端输出道血管不佳，间歇性跛行仍同术前。术前患肢踝／肱指数平均为０４６，术后为０７６，平均提高０３０，证实下肢动脉血流明显改善，疗效满意。结果表明，在作股动脉自体大隐静脉搭桥术时，使用顶端带孔的大隐静脉圈套器可使手术切口缩小，改善手术疗效。     

一期静脉动脉化血运重建治疗四肢广泛性动脉闭塞性缺血

目的　探讨静脉动脉化血运重建对四肢广泛性动脉闭塞性缺血的疗效。　方法　 1 999年 5月～ 2 0 0 1年 8月 ,对有慢性缺血表现的 1 8条下肢和 6条上肢行彩色多普勒超声和数字减影血管造影检查 ,确诊为广泛性肢体动脉闭塞症。根据闭塞平面采用原位高位浅组静脉或低位深组静脉一期静脉动脉化重建血运手术对患肢进行治疗。　结果　术后住院期间除 1条下肢截肢外 ,1 7条下肢和 6条上肢获 3～ 2 6个月随访 ,其中 1条下肢出院 3个月后患肢趾缺血坏死再入院行低位截肢 ,其余 1 6条下肢和 6条上肢疗效满意 ,症状消失。术后彩色多普勒超声复查可见动脉血向缺血肢体灌注。　结论　根据闭塞平面采用高位浅组或低位深组一期静脉动脉化重建血运 ,治疗四肢广泛性动脉闭塞简便易行 ,效果良好     

静脉动脉化治疗严重下肢缺血的远期疗效分析

目的：探索静脉动脉化治疗严重下肢缺血的新术式。方法：在对大隐静脉、胫后静脉瓣膜进行解剖学和生物力学研究的基础上，设计静脉瓣膜切除或破坏、原位一期静脉动脉化两种新术式，治疗动脉广泛闭塞所致严重下肢缺血患者７１例（７４条肢体）。结果：随访１～８年（其中随访５年以上３２例），静息痛消失率９６．５％，间隙性跛行消失率９３．７％，截肢率降至２．７％，获得满意效果。结论：两种新术式通过静脉通道，逆行灌注动脉血，确能改善或重建严重缺血下肢的血循环，具有满意的远期疗效。     

大隐静脉原位转流术重建下肢血液循环

目的:评价大隐静脉原位转流术治疗下肢动脉硬化闭塞症的疗效.方法:运用自制瓣膜切除器开展大隐静脉原位转流术治疗下肢动脉硬化闭塞症38例共40例肢体.患者术前踝肱指数(ABI)为0-0.58(平均0.29),均经动脉造影证实.术后移植物均可扪及搏动,有28条肢体足背或胫后动脉搏动恢复,17例同时行输入输出道动脉重建术,溃疡清创术6例,4例于术后3天内出现移植物搏动消失,行第2次重建术,结果:ABI平均值同术前0.29上升至0.84,严惩缺血肢体挽救率为100%,经寿命表统计分析,1-5年的血管累积通畅率分别为92%,87%,82%,72%和65%,结论:大隐静脉原位转流术是治疗下肢动脉硬化闭塞症的理想方法之一,同时行输入功输出道动脉重建术,对保证移植血管的通畅有着重要的意义.     

大隐静脉-隐神经营养血管皮瓣的临床解剖与应用

目的探索大隐静脉-隐神经营养血管皮瓣游离移植与移位修复的临床解剖与应用.方法选取福尔马林常规固定的成人下肢标本20侧,自愿捐献新鲜成人下肢标本8侧;其中左下肢12侧,右下肢16侧.解剖20侧成人下肢标本,观察大隐静脉、隐神经及其营养血管的起源、大小、分支、分布和吻合;4侧新鲜成人下肢标本股动脉灌注朱砂滤过液,静脉灌注泛影葡胺后,钼靶X线片显示静脉周围血管网分布;另4侧新鲜成人下肢标本行大隐静脉显微解剖,观察静脉周围血管分布及吻合情况.临床应用大隐静脉-隐神经营养血管皮瓣游离修复虎口、带蒂逆行皮瓣修复足跟部及小腿下段、顺行皮瓣修复胫前及膝关节周围创面18例,其中男12例,女6例.年龄7～53岁.车祸伤7例,碾压伤4例,炸伤1例,中厚皮术后瘢痕2例,足底肿瘤扩大切除1例,外伤术后长期溃疡3例.创面部位:虎口1例,小腿上段及膝关节周围3例,小腿下段及足部14例.其中骨质外露7例,肌腱外露3例,钢板外露1例.创面范围:4 cm×4 cm～13 cm×7 cm.皮瓣切取范围6 cm×4 cm～15 cm×8 cm,蒂长8～11 cm,筋膜蒂宽2.5～4.0 cm,蒂部带窄条皮肤宽1～2 cm.结果膝降动脉在股骨内侧髁上9.33±0.81 cm处发出,分出隐动脉支伴隐神经下行,在股骨内侧髁下平均7.21±0.82 cm浅出,位于大隐静脉旁,隐动脉与胫后动脉穿支成"Y"或"T"形吻合,接力构成纵行血管链,达内踝前下方,形成皮瓣的轴心血管.大隐静脉周围5～8 mm内分布有波浪状小血管,直径约0.05～0.10 mm,也吻合成纵行链状,钼靶X线片示小血管沿静脉一侧或双侧呈平行波浪状走行.临床应用18例,术后皮瓣均成活, 2例远端3 cm出现小水泡,经拆线减张、换药后愈合.13例经6～12个月随访,修复后创面获得保护性感觉,功能接近正常,外观满意,无溃疡.结论隐神经及大隐静脉周围均有血管网伴行,大隐静脉-隐神经营养血管皮瓣可游离移植,也可形成近端蒂或远端蒂皮瓣移位修复小腿近侧或足踝部创面.皮瓣血运可靠,不牺牲主要血管,是下肢创面修复的良好供区.     

自体血管移植动静脉造瘘术的临床应用

目的探讨自体血管移植进行动静造瘘术临床应用的可行性. 方法 1997年10月～2002年7月对7例肾功能衰竭患者选择大隐静脉移植,进行前臂的动静脉造瘘术.其中男3例,女4例,年龄47～76岁.慢性肾小球肾炎2例,糖尿病肾病5例.手术选择血管较粗直的大隐静脉,将大隐静脉在前臂内侧行直线或U 形搭桥,进行桡动脉或肱动脉与头静脉、或贵要静脉、或肘正中静脉吻合. 结果术后随访15～32个月,动-静脉瘘管均获成功,全部患者均能在临床定期进行血液透析,无假性动脉瘤形成. 结论自体血管移植动-静脉造瘘术是一种手术操作简便、取材容易、价格低廉和符合临床需要的方法,能够弥补血管造瘘术失败或前臂无血管造瘘的动-静脉造瘘方式.     

Quantification of venous reflux by means of duplex scanning

Venous reflux in milliliters per second has been measured in individual veins with duplex scanning. Forty-six patients (47 legs) with symptomatic varicose veins have been studied while they were in the erect position. Nineteen legs had skin changes whereas the rest (28 legs) had only varicose veins with no skin changes. In 45 limbs, reflux was confined to one vein only: long saphenous vein in 28, short saphenous vein in nine, and femoropopliteal vein in eight. In one limb, reflux was found in the long saphenous, short saphenous, and femoropopliteal veins, and in another it was found in the long and short saphenous veins. In the latter two limbs the amount of reflux found in each vein was added to obtain the total reflux in the limb. In the limbs with skin changes, reflux (median +/- 90% tolerance levels) was 30 (10 to 53) ml/sec; whereas in limbs with no skin changes it was 10 (3 to 44) ml/sec. Reflux greater than 10 ml/sec was associated with a high incidence of skin changes (66%) irrespective of whether this was in the superficial or deep veins; reflux less than 10 ml/sec was not associated with skin changes.     

Great Saphenous Vein Stripping with Liberal Use of Subfascial Endoscopic Perforator Vein Surgery (SEPS)

This study is based on a unique registry of 632 patients who underwent great saphenous vein (GSV) stripping and liberal use of subfascial endoscopic perforator vein surgery (SEPS) for minimal to severe lower limb venous insufficiency. Clinical examinations and color-coded duplex scanning were performed on a randomly selected, manageable sample of 170 limbs to assess the affect of early SEPS on junctional (saphenofemoral [SFJ] and/or saphenopopliteal [SPJ]) and perforator vein (PV) insufficiencies and superficial varicosities at a median of 6.5 years. PV incompetence was present in 68 legs (40%), as the sole transfascial insufficiency in 28 limbs and combined with SFJ or SPJ incompetence in 40 limbs. Junction incompetence alone characterized an additional 38 limbs, bringing the total transfascial insufficiency prevalence to 62%. Superficial varicosities affected 46% of limbs. Overall CEAP clinical class was unimproved beyond preoperative values. PV incompetence was associated with higher CEAP and clinical venous severity scores than were junctional insufficiencies alone. We concluded that PV incompetence alone or combined with junctional insufficiency is associated with increased symptoms and disease progression. The prevalence of SFJ, SPJ, and PV incompetence (62%) and recurrent varicosities (46%) suggests that early use of SEPS does not prevent disease progression and offers no benefit over GSV stripping in the absence of deep vein insufficiency or threatened ulceration.     

Surgical Correction of Main Stem Reflux in the Superficial Venous System: Does It Improve the Blood Flow of Incompetent Perforating Veins?

Fifty-seven limbs (33 patients) with chronic venous ulceration were selected for this study. The criterion for selection was the presence of isolated superficial venous reflux. Long saphenous vein reflux alone was observed in 39 (68.4%) limbs, short saphenous vein reflux alone in 4 (7.0%) limbs, and both long and short saphenous vein reflux in 14 (24.6%) limbs. Surgical correction of the refluxing saphenous system has allowed 46 (80.7%) ulcers to heal. The healing rates for all the ulcerated legs that had long saphenous vein reflux, short saphenous vein reflux, or a combination of the two were 85.4%, 75.0%, and 66.7%, respectively. Incompetent perforating veins (IPVs) were observed in 51 (89.5%) limbs; 74.5% of them regained their competence postoperatively (189 preoperatively vs. 59 postoperatively; p < 0.001), with a significant reduction in their mean diameter (p < 0.001). IPVs remained in 13 (25.5%) limbs: 3 limbs with persistent reflux in the tributaries of the saphenous system, 1 limb with a fixed ankle joint, and nine limbs with no evidence of macrovascular venous disease. In patients with a competent deep venous system, reflux in perforating veins is often abolished after eradication of saphenous reflux.     

大隐静脉曲张手术所致严重血管损伤的治疗

目的 总结大隐静脉曲张手术导致严重血管损伤并发症的治疗经验.方法 回顾性分析2004年12月至2009年4月收治的4例(5条肢体)大隐静脉曲张手术发生严重血管损伤患者的临床资料.对1条股总动脉末端至胫后动脉上段动脉被剥脱的肢体应用人工血管行动脉重建术,术后肢体坏疽行膝上截肢术;对3条股浅动脉被剥脱10～15 cm的肢体取自体大隐静脉行动脉重建术,术后5 d对1条坏死肢体行膝上截肢术.1条股浅静脉被切除2 cm的肢体取自体大隐静脉行股浅静脉重建术.结果 4例患者中,围手术期无死亡病例,4条动脉损伤肢体中2条肢体(50%)行膝上截肢术;2条肢体(50%)得到保伞,随访12～46个月,平均29个月,血管通畅良好.1例股浅静脉损伤患者恢复良好.结论 提高对医源性血管损伤的认识,术中规范操作,辨明解剖,可以减少和预防严重血管并发症的发生;一旦有血管损伤应早期而有效的处理.     

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease

OBJECTIVE: We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. PATIENTS AND METHODS: Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). RESULTS: The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). CONCLUSION: Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.