膝下血管成形术治疗重症肢体缺血的临床疗效

目的评价膝下经皮腔内血管成形术(PTA)治疗重症肢体缺血(CLI)的临床疗效。方法回顾性分析48例(50条患肢)接受膝下PTA治疗的下肢CLI患者,统计PTA的技术成功率、围术期并发症、PTA术后的缺血症状缓解情况、治疗血管的通畅情况和大截肢情况。结果共针对64条膝下动脉施行PTA,技术成功率为85.94%(55/64);围术期并发症发生率为12.50%(6/48)。平均随访(16.25±2.65)个月;PTA术后1、3、6、12、24、36个月的1期血管通畅率分别为92.0%、85.7%、79.0%、75.8%、59.8%、29.9%;保肢率分别为92.0%、92.0%、89.7%、86.4%、82.1%、72.9%。50条患肢中,1、3、6个月时的缺血症状缓解率分别为42.00%(21/50)、70.21%(33/47)和86.36%(38/44)。结论膝下PTA治疗CLI技术可行,安全性高,能有效缓解CLI的静息痛症状、促进肢体溃疡的愈合,避免大截肢的发生。     

腘以远动脉闭塞所致下肢严重缺血的血供重建

目的 评价腘以远动脉闭塞所致下肢严重缺血(critical limb ischemia,CLI)的血供重建.方法 回顾性分析2003年12月至2009年1月,腘以远动脉闭塞所致CLI行经皮血管腔内成形(percutaneous transluminal angioplasty,PTA)和开放性重建(open reconstruction,OR)术的患者,详细记录患者的病史、病变特点、手术过程、并发症和随访信息.采用Kaplan-Meier生存分析重建血管通畅率和救肢率.结果 本组腘以远动脉闭塞所致CLI患者共167例,182条患肢.123条动脉硬化闭塞(arterios-clerosis occlusions,ASO)的患肢行腘以远动脉PTA治疗,33条血栓闭塞性脉管炎(thromboangiitis obliterans,TAO)和23条ASO患肢行腘以远动脉OR手术.PTA再管化通道6、12、24个月的通畅率分别是67%、54%和49%,其救肢率分别是91%、85%和78%,OR术后移植物6、12、24个月的通畅率分别是90%、83%和79%,其救肢率分别是92%、87%和80%,PTA重建血管的通畅率低于开放性手术(P＜0.05),但PTA和OR术的救肢率差异无统计学意义(P＞0.05).结论 对腘以远动脉ASO的CLI患者,PTA有效、安全,可作为首选治疗方式.PTA治疗失败可选择OR术.对TAO患者腘以远动脉闭塞者OR术仍是最好的治疗选择.

Abstract：

Objective To assess reconstructive options for critical limb ischaemia in infrapopliteal arteries. Methods A retrospective review of all CLI patients who underwent infrapopliteal reconstruction was carried out. Patient history, demographics, procedure details, complications, and follow-up information were collected and analyzed. Patency, limb salvage rate was determined by Kaplan-Meier analysis. Results During the period (from December 2003 to January 2008 ), 123 CLI patients with arteriosclerosis occlusions were treated on an intention-to-treat basis with infrapopliteal percutaneous transluminal angioplasty (PTA).Thirty-three thromboangiitis obliterans and twenty-three arteriosclerosis occlusions suffering CLI were treated by infrapopliteal bypass procedures. Primary patency and limb salvage rate of infrapopliteal PTA at 6, 12 and 24 months was 67%, 54%, 49% and 91%, 85%, 78% respectively, Primary patency and limb salvage rate of infrapopliteal surgical bypass at 6, 12 and 24 months was 90%, 83%, 79% and 92%,87%, 80% respectively, the patency of infrapopliteal PTA was lower than infrapopliteal surgical bypass (P ＜0. 01 ), but the limb salvage rate of infrapopliteal PTA and open surgery was no significant difference (P ＞ 0. 05 ). Conclusion Endovascular treatment (PTA) in patients with infrapopliteal arteriosclerosis occlusions and critical ischaemia is safe, effective. Infrapopliteal PTA can be used as the choice of therapy and surgical bypass reserved in those endovascular treatment failed. While in CLI patients with thromboangiitis obliterans infrapopliteal artery bypass remains the best treatment option.     

内膜下血管成形术治疗下肢动脉慢性缺血

目的 探讨内膜下血管成形术治疗下肢动脉慢性缺血的技术可行性、通畅率和临床效果.方法 回顾性分析2003年12月至2008年8月应用内膜下血管成形术(subintimal angioplasty,SIA)治疗的112例患者的122条动脉硬化闭塞患肢的临床资料,动脉闭塞平均长度为10.25 cm(4.5～28 cm),其中23条肢体为生活方式受限性间歇性跛行,99条为严重性缺血.详细纪录患者的病史、病变特点、操作技术过程、并发症和随访信息.采用Kaplan-Meier生存分析法分析患肢通畅率和临床效果(救肢和症状改善).结果 SIA技术成功率为83%,成功进行SIA的患者平均踝肱指数从0.19±0.11增加到0.67±0.29(P<0.01),1年、2年冉管化通道的通畅率和临床有效率分别是54%±5%、45%±4%和82%±5%、79%±4%.没有严重后果的并发症发生. 结论 SIA技术成功率高,临床效果满意,本组无严重并发症,是一种治疗下肢动脉粥样硬化闭塞所致慢性缺血较好可供选择的治疗手段.     

腔内血管成形术治疗膝下动脉缺血的临床研究

目的 评价腔内血管成形术(PTA)治疗膝下动脉闭塞性疾病的疗效及通畅情况.方法 对47例(54肢)膝下动脉缺血患者进行膝下动脉缺血PTA,将其治疗前后踝眩指数(ABI)、治疗后临床疗效及动脉通畅率等进行统计学分析.结果 全组术前ABI平均值为O.34±O.04;术后14天为O.86±O.03.本组无围手术期死亡,术后并发症发生率为7.7%,其动脉累积通畅率1年、2年一期通畅率分别为88.5%及65.2%;二期通畅率分别为96.2%及83.3%;救肢率为100%.结论 PTA作为膝下动脉缺血的治疗方法是可行、安全、有效的,推荐PTA作为首选的治疗方法,其长期通畅性有待进一步观察.     

杂交技术治疗复杂下肢动脉硬化闭塞症疗效分析

目的:探讨采用杂交技术治疗复杂下肢多节段动脉硬化闭塞症的临床疗效。方法:分析2014年3月—2014年9月行杂交技术治疗的30例(30条患肢)复杂下肢动脉硬化闭塞症患资料。30例患者病变部位累及主-髂动脉、股-腘动脉、股深动脉以及膝下动脉;均行血管腔内修复术,20例行动脉内膜剥脱术,10例行动脉取栓术,8例加行股深动脉成形术。结果:30例杂交手术均获得成功,技术成功率100%,围手术期并发症发生率30%(9/30)。临床成功率为96.67%,术后平均踝肱指数较术前提高了0.37±0.19。术后6、12个月一期通畅率分别为90%、73%,12个月救肢率为97.67%。结论:杂交技术治疗复杂下肢动脉硬化闭塞症具有较高的短期通畅率和救肢率。     

远端流出道不良的下肢动脉缺血腔内微创治疗

下肢动脉闭塞缺血症是常见病 ,传统的治疗方法是旁路术。但是在严重肢体缺血 (criticallimbischemia ,CLI)的病例中 ,大约有 2 5 %的病例动脉狭窄部位位于膝关节平面以下[1] ,包括胫腓干狭窄或胫前、胫后和腓动脉三支狭窄 ,这些病人大多数伴有糖尿病。对于这些远端流出道不良的     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

血管腔内成形术治疗膝下动脉硬化闭塞症

近年来血管腔内成形术（PTA）治疗下肢动脉硬化闭塞症（ASO）迅速发展,多种新型介入材料相继问世并且应用于临床,血管腔内治疗的范围已从大中血管向中小血管扩展,腘动脉及远侧胫、腓动脉的治疗也在广泛开展。大量文献报道,PTA治疗膝下ASO成功率高,并发症少,保肢率高,可以作为膝下ASO特别是重症肢体缺血的首选。     

经皮腔内血管成形术治疗膝下动脉粥样硬化闭塞症的评价

目的 评价经皮腔内血管成形术(percutaneous transluminal angioplasty,PTA)治疗膝下动脉粥样硬化闭塞症(arteriosclerosis obliterans,ASO)的疗效.方法 回顾性研究2007年1月至2011年6月我科收治的累及膝下动脉ASO并行PTA治疗的患者的临床资料.结果 138例患者,平均年龄(77.31±7.52)岁,治疗膝下动脉所用球囊平均直径 2.8mm(2～4mm),平均长度110.6mm(40～170mm),术中及术后无严重并发症.术后早期治疗肢体临床症状明显改善率为100%,无截肢患者.平均随访24.1个月(4～58个月),治疗肢体术后2年临床症状明显改善率78.4%,救肢率93.9%.结论 PTA治疗膝下动脉ASO可有效改善临床缺血症状并提高救肢率.     

膝下动脉闭塞症的腔内治疗

目的探讨腔内术对膝下动脉闭塞疾病的治疗价值。方法回顾性分析2006年2月至2008年5月复旦大学附属中山医院血管外科收治的86例患有膝下动脉闭塞症的住院病人的病史资料和术后随访资料。结果86例病人（90条患肢）经经皮腔内血管成形术（PTA）治疗,82条患肢获得影像学成功（残留狭窄率＜30%）。技术成功率为911%（82/90）。术前1周和术后1周行下肢节段测压,踝肱指数（ABI）由术前的034±016提高到085±023。1年累计初次通畅率为612%,24月累积初次通畅率为495%,肢体保全率978%,存活率978%。结论PTA治疗膝下动脉闭塞症临床成功率高,并发症少,保肢率高,可以作为膝下动脉闭塞特别是重症肢体缺血的首选。     

Subintimal angioplasty of tibial vessel occlusions in the treatment of critical limb ischaemia: mid-term results.

OBJECTIVES: to evaluate the feasibility and preliminary results at 1 year of subintimal angioplasty of tibial occlusions in critical limb ischaemia (CLI). MATERIAL: from December 1997 to December 1999, we intended to treat 36 patients and 40 limbs by subintimal angioplasty of occlusions of tibial vessels. Thirty-one had gangrene or ulceration and nine had rest pain. Twenty-seven occlusions were more than 10 cm, 10 were 5 to 10 cm and three were less than 5 cm in length. Three patients had an occluded previous ipsilateral bypass graft. All patients were followed 3 monthly for a median of 10 months by means of clinical and duplex examination. RESULTS: the technical success rate was 78% (31/40). Nine technical failures were treated by conventional surgery or angioplasty of another diseased tibial vessel. The clinical success rate was 68% (27/40). Four below-the-knee amputations were performed despite a patent recanalisation. Primary and secondary patency rates at 12 months were 56% (72% without technical failures). The 12-month limb salvage rate was 81% and survival rate was 78%. Three of five complications were treated by endovascular procedures. The length of occlusion (>10 cm) but not the location of distal re-entry, the type of vessel re-entry and the presence of diabetes are predictors of technical success and patency. CONCLUSIONS: subintimal angioplasty can be used to treat tibial occlusions in patients with CLI. Technical failure does not preclude conventional surgery and complications may often be treated by endovascular procedures. However, the durability of angioplasty is as yet uncertain.     

长段股胭动脉硬化闭塞的腔内治疗

目的 评价血管腔内治疗长段股腘动脉硬化闭塞的临床效果.方法 2006年4月～2009年1月采用血管腔内治疗长段股胭动脉硬化闭塞10例,10条肢体术中同时行股胭动脉血管腔内球囊扩张成及支架植入术.结果 手术技术成功率是90%,放置10个支架,术后12个月通畅率为70%,术后血管再狭窄率30%.结论 血管腔内成形治疗长段股胭动脉硬化闭塞是一种安全有效的治疗方法.     

The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience

OBJECTIVE: To determine the efficacy, safety, and long-term results, including continued clinical improvement and limb salvage, of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). METHODS: From August 1993 to March 2004, 138 limbs in 111 patients with CLI (rest pain in 62 [45%] and ulcer/gangrene in 76 [55%]) were treated by PTA. In iliac lesions, stents were placed selectively for primary PTA failure: residual stenosis (>30%) or pressure gradient (>5 mm Hg). Stent placement was limited in infrainguinal lesions. The most distal affected arteries treated with angioplasty were the iliac artery in 45 limbs (33%; iliac group), the femoropopliteal artery in 41 limbs (30%; FP group), and tibial arteries in 52 limbs (37%; BK group). All analysis was performed according to an intent-to-treat basis. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed to evaluate initial success, and late follow-up status was evaluated with the Kaplan-Meier method. Patency was evaluated by using ultrasound scanning and ankle-brachial pressure index measurement. RESULTS: There was one (0.9%) perioperative death. Twenty stents were placed selectively in 14 iliac arteries. Mean follow-up was 14.7 months (range, 1-75 months). Overall, initial technical and clinical success rates were 96.4% and 92.8%, respectively. The cumulative primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates +/- SE at 5 years were 31.4% +/- 10.4%, 75.5% +/- 5.7%, 79.6% +/- 5.5%, 36.1% +/- 10.0%, and 89.1% +/- 4.0%, respectively. In each subgroup, the primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates at 3 years were 51.6%, 94.7%, 97.8%, 65.1%, and 95.0%, respectively, in the iliac group; 49.4%, 72.2%, 76.4%, 57.4%, and 92.7%, respectively, in the FP group; and 23.5%, 41.8%, 46.1%, 51.1%, and 77.3%, respectively, in the BK group. Of the 12 predictable variables, hypertension, multiple segment lesions, more distal lesions, and TransAtlantic Inter-Society Consensus classification type D were significant independent risk factors for the outcomes ( P < .05; univariate log-rank test and Cox regression multivariate analysis). CONCLUSIONS: PTA is a feasible, safe, and effective procedure for the treatment of CLI. The high limb salvage rate is attributed to the high assisted primary and secondary patency rates despite the low primary patency rate. Angioplasty can be the primary choice for the treatment of CLI due to iliac and infrainguinal arterial occlusive disease.     

Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs

OBJECTIVE: Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification. METHODS: From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined. RESULTS: Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates. CONCLUSION: Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.     

Subintimal angioplasty as the first-choice revascularization technique for infrainguinal arterial occlusions in patients with critical limb ischemia

Our aim was to appraise the feasibility and outcomes of subintimal angioplasty (SA) for the percutaneous revascularization of infrainguinal arterial occlusions in patients with critical limb ischemia (CLI). We retrospectively assessed 117 SA procedures in 109 limbs with complete infrainguinal occlusions from 105 patients with CLI. Among these, the superficial femoral artery (SFA) was the only occluded vessel in 27 limbs, while infrapopliteal (IP) occlusions occurred in 82. Average clinical follow-up was 13.5 months (range 1-37). Outcomes were assessed according to the site of SA (SFA vs. IP) and the length of the occlusion (< vs. > or =10 cm). Univariate analyses for the rate of limb salvage and patient survival according to the Kaplan-Meier method were performed. SA-based revascularization had a success rate of 84.4% per limb (89% in SFA and 83% in IP occlusions). During follow-up 12 patients (11.3%) underwent major limb amputation, 11 (10.3%) underwent bypass surgery, and 14 (13.7%) died. Most amputations occurred in patients in whom SA had been unsuccessful and were associated with long (> or =10 cm) occlusions (p = 0.055). Clinical restenosis occurred in seven (6.6%) patients. Survival analysis showed at 6, 12, and 24 months limb salvage rates of 90%, 87%, and 85% and overall survival rates of 90%, 88%, and 83%, respectively. Complications of SA were uncommon (4.7%) and all were successfully managed percutaneously. Infrainguinal SA is an effective revascularization technique that provides a high likelihood of limb salvage and should be the first-choice strategy in the management of patients with CLI.     

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia

INTRODUCTION: Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique. METHODS: Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency. RESULTS: Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037). CONCLUSIONS: In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.     

Peripheral Angioplasty as the First-choice Revascularization Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study of 993 Consecutive Patients Hospitalized and Followed Between 1999 and 2003

OBJECTIVE: To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI). DESIGN: Prospective study. METHODS: PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003. RESULTS: PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year. CONCLUSIONS: PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.