复合式手术分期治疗下肢多节段动脉硬化闭塞症

为探讨采用复合式手术分期治疗下肢多节段动脉硬化闭塞症的临床疗效,通过CTA或DSA检查明确下肢多节段动脉硬化闭塞症病变部位及长度后，先对髂动脉病变行血管内超声消融术、球囊扩张及支架置入术等微创方法开通血管，择期再对股腘段病变行人工血管旁路转流术。结果示，全组29例患者均手术成功，踝肱指数由术前0.20±0.14增至术后0.71±0.21(t=2.462, P=0.02)。平均随访19个月（3～48个月），一期肢体通畅率82.8%（29/35）。提示复合式手术治疗下肢多节段动脉硬化闭塞症并分期进行，可降低手术难度与复杂性，术后并发症和病死率减少，并可提高手术成功率。     

努力提高下肢动脉粥样硬化闭塞症外科治疗的疗效

动脉粥样硬化性病变是一种全身性动脉疾患 ,可发生于全身各主干动脉。近年来 ,动脉粥样硬化闭塞症的发病率有上升的趋势 ,因此 ,进一步提高其诊治水平显得特别重要。动脉内膜剥脱术和旁路转流术 ,这两种经典的手术治疗方式 ,被认为是治疗下肢动脉硬化闭塞症的主要方式。前者直接切开病变血管 ,将内膜及其相连的血栓性纤维组织一并切除 ,然后再缝合血管外膜。为防止术后管腔狭窄 ,可加作血管补片。由于此手术术后复发率较高 ,且近年来优质人造血管问世和技术的发展 ,此手术只适用于动脉主干短段狭窄或闭塞的患者。旁路转流术按移植血管的行径…     

血管旁路治疗下肢动脉闭塞症30例分析

下肢动脉闭塞症目前已成为患者肢体坏疽的主要疾病。动脉粥样硬化、创伤是发生下肢动脉闭塞症的常见原因。外科治疗下肢动脉闭塞症是一种理想的方法。本院于2003年1月至2007年6月采用旁路转流术治疗下肢动脉闭塞症患者30例，效果满意，现报告如下。     

支架植入联合旁路转流术治疗下肢多平面动脉闭塞症

目的探讨联合腔内支架植入和旁路转流术治疗下肢多平面动脉闭塞症的初步临床经验。方法1998年11月～2002年12月,14例病人(20条肢体)多平面动脉硬化闭塞症病人同时进行髂动脉支架植入(16条肢体)和远端动脉旁路转流术(20条肢体)。结果16条肢体中14例髂动脉支架植入成功。远端动脉旁路转流术包括膝上6条,膝下14条。20条肢体术前平均踝肱指数为0.32±9.40,术后为0.77±7.30,二者相比有显著差异(P<0.01)。平均随访24(3～49)个月,髂动脉支架一期通畅率为92.8%(13/14),二期通畅率为100%(14/14);远端动脉旁路转流手术一期通畅率为85%(17/20),二期通畅率为95%(19/20)。全组无手术死亡。结论支架植入联合旁路转流治疗下肢多平面动脉闭塞症,技术安全,初步结果满意,长期结果有待进一步随访。     

股腘动脉闭塞腔内成形术与旁路转流术的临床疗效对比分析

目的探讨股腘动脉闭塞行腔内治疗和旁路转流术的临床疗效。方法回顾性分析2008年1月至2011年12月本院收治的60例(67条肢体)股腘动脉闭塞(TASCⅡC/D型)患者的临床资料,其中腔内治疗41例(47条肢体,腔内治疗组),旁路转流术19例(20条肢体,旁路转流术组),比较两组患者的手术时间、术中出血量、术后恢复行走时间、踝肱指数(ABI)及随访1~4年的通畅率及保肢率。结果腔内治疗组术中出血量、手术时间及术后恢复行走时间明显少于旁路转流术组(P0.01);两组术后ABI及技术成功率比较差异无统计学意义(P0.05)。术后6~12个月的随访,腔内治疗组一期通畅率与旁路转流术组的通畅率比较,差异无统计学意义(43.6%vs 50.0%,P0.05);术后18~48个月的随访,腔内治疗组二期通畅率及保肢率高于旁路转流术组,两组比较差异有统计学意义(79.5%vs 50.0%,P0.05)。结论腔内治疗与旁路转流术治疗TASCⅡC/D型股腘动脉闭塞患者在短期内均能取得满意临床疗效及较好通畅率;但腔内治疗有着微创、术后恢复快等优点,且具有可重复操作性,有助于提高患肢远期血管通畅率。     

138例下肢动脉硬化闭塞症外科治疗经验探讨

目的 探讨下肢动脉硬化闭塞症(ASO)的外科治疗经验.方法 回顾性分析本院自2004年1月至2007年1月外科治疗下肢ASO138例患者的临床资料.结果 本组138例接受包括动脉旁路转流术、介入治疗、动脉内膜剥脱术、股深动脉成形术等在内的一种术式或多种术式联合的外科治疗172例(次).随访119例,随访率86.2%,平均随访18.2个月.围手术期死亡率43%.全组截肢率5.8%.腹主(髂)-股动脉旁路转流术后6个月、1年、2年的通畅率高于股-股动脉人工血管旁路转流术,差异有显著性(P<0.01);股-咽动脉旁路转流中应用自体大隐静脉转流病例术后6个月、1年、2年的通畅率高于应用人工血管转流病例,差异有显著性(P<0.01);原位大隐静脉旁路转流围手术期并发症较倒置大隐静脉旁路转流低,但二者术后通畅率比较无显著性(P>0.05).结论 下肢ASO病变的复杂性决定了其外科治疗方法的多样性,且往往需要将各种外科治疗方法进行结合才能取得较好的临床疗效.     

血管腔内成形术联合旁路术治疗动脉硬化闭塞症

动脉硬化闭塞症(arteriosclerosisobliterans,ASO)是动脉粥样硬化病变引起的慢性动脉闭塞性疾病,主要侵犯腹主动脉下段、髂股动脉等大、中型动脉,表现为下肢动脉缺血。随着人们饮食结构的改变,摄入含脂肪、胆固醇食物增多,ASO的发病率呈上升趋势,目前已是国内外血管外科的主要疾病之一。目前,治疗ASO的方法主要有传统的动脉旁路术、动脉内膜剥除术,血管腔内技术包括球囊扩张血管成形术、激光血管成形术、机械经皮腔内斑块旋切术、腔内血管超声消融、支架放置术及腔内联合旁路术。本文将对ASO的治疗方法进行总结比较,并着重讨论血管腔内…     

血管腔内支架成形术治疗下肢动脉硬化闭塞症45例

目的探讨血管腔内支架成形术治疗下肢动脉硬化闭塞症的疗效。方法采用经皮穿刺股动脉或切开动脉直视下穿刺,造影明确病变动脉部位及病变长度后,利用导丝或超声消融导管开通闭塞段,球囊导管行扩张成形后置入血管内支架。结果45例(53条患肢)血管腔内支架均释放成功,踝肱指数由0.36±0.14增至术后7 d 0.77±0.21(t=2.397,P=0.021),45例随访6~54个月,平均23个月,一期肢体通畅率90.6%(48/53)。结论血管腔内支架成形术操作简便、微创、安全是治疗下肢动脉硬化闭塞症的有效方法。     

血管腔内技术与手术治疗锁骨下动脉闭塞症

目的探讨血管腔内技术与手术治疗锁骨下动脉闭塞症的临床效果及合适的治疗程序。方法1997年6月至2004年5月采取血管腔内技术与手术治疗锁骨下动脉闭塞症39例。26例患者采用血管腔内治疗,置入27枚支架,14例经股动脉途径,12例经肱动脉逆行支架置入,其中8例在彩色多普勒超声定位下穿刺肱动脉。13例未能行支架置入,行血管旁路转流术。9例伴有颈动脉或椎动脉严重狭窄者行支架置入。结果39例患者术后患侧与健侧血压差<10mmHg(1mmHg=0.133kPa),患侧/健侧血压指数由术前的平均0.62±0.11提高至0.98±0.04(t=4.738,P<0.01);腔内治疗患者与手术患者平均血管通畅时间分别为(57.6±3.7)和(60.2±7.2)个月。结论血管腔内治疗与手术治疗锁骨下动脉闭塞症疗效相当,由于血管腔内治疗的微创性和安全性,应优先选择血管腔内治疗。     

下肢动脉硬化闭塞症的超声消融治疗--附13例报告

目的 探讨应用Acolysis血栓超声消融仪治疗13例下肢动脉硬化闭塞症的可行性及疗效。方法首先行Seldinger法股动脉造影，再小切口暴露股浅、股深动脉分叉处，直视穿刺，引入超声消融导管，数字减影血管造影(DSA)监视下消融，至血管再通。结果 消融时间458s～1112s，平均801s，最长消融段35cm。全部病例术中造影证实血流通畅。同侧胫后、足背动脉立即恢复搏动9例；其余4例踝肱指数(Ankle／Brachial Index，ABI)分别由术前的0，5，0，32，0，6和0，55提高到术后的0，8，0．58，0，84和0．76，动脉多普勒血流图较术前改善。结论超声消融治疗下肢动脉硬化闭塞症可行，近期效果较好。     

Percutaneous transluminal balloon angioplasty of the iliac artery for contralateral ischemia

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.     

Successful percutaneous angioplasty after failed femorodistal bypass

Although balloon angioplasty for the management of failing bypass grafts has been well documented, little mention has been made of its use in treating the occlusive lesion within the native artery after a failed bypass graft. We report our experience with five patients in whom successful balloon angioplasty was carried out subsequent to failure of a femoral popliteal bypass graft. Increasingly aggressive percutaneous therapy of arterial occlusive disease may now be expanded to include a unique group of patients with chronically failed bypass grafts and occlusive disease within the native artery conducive to percutaneous transluminal angioplasty. This group of patients would previously have been relegated to repeat bypass grafts with its inherently inferior patency and recognized added technical demands. Percutaneous balloon angioplasty appears to be a plausible alternative in selected cases for repeat lower extremity revascularization.     

Disrupted coronary artery caused by angioplasty: supportive and surgical considerations

Of 2,859 patients having percutaneous transluminal coronary angioplasty, 201 (7%) underwent emergency coronary artery bypass grafting. Two categories of patients were reviewed. Group 1 consisted of 126 patients of 2,304 who had immediate coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Ninety-eight of these patients had angiographic evidence of occlusion of a coronary artery, and 28 had angiographic evidence of coronary artery dissection. Epicardial hemorrhage was observed at operation in 20% (25 patients). Three deaths (2.4%) occurred in group 1, and an average of 3.3 grafts was performed per patient. Group 2 comprised 75 of 555 patients who had unsuccessful attempted percutaneous transluminal coronary angioplasty during an evolving myocardial infarction and required immediate coronary artery bypass grafting. Angiography revealed coronary artery occlusion in 61 patients with dissection in 14. All group 2 patients had evidence of myocardial injury by electrocardiographic and enzymatic (myocardial-specific isoenzyme of creatine kinase) criteria. Three deaths (4%) occurred in this group, and there was an average of 3.4 grafts per patient. Percutaneous transluminal coronary angioplasty is routinely performed without surgical consultation, although an operating room and team are usually available. Supportive techniques include the intraaortic balloon pump and percutaneous cardiopulmonary bypass. In those patients with coronary artery dissection, care must be taken to reestablish the true lumen of the coronary artery. Hemopericardium should be surgically explored and broken guidewires or other foreign bodies or debris removed. From 1979 through 1986, the number of patients requiring emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty steadily declined to less than 5%.     

经皮血管内支架成形术治疗下肢动脉硬化性闭塞疾病

目的 评价经皮血管内支架成形术（PTAS）,治疗下肢动脉硬化闭塞症（LEAOD）临床效果和应用价值。方法127例LEAOD患者接受了PTAS治疗,制订治疗成功标准并疗效随访,对术前术后踝／肱指数（ABI）统计学分析。结果全组治疗成功率97．64%（124／127）,除3例LEAOD患者PTAS失败外,其余病例均成功,临床症状消失或好转,踝／肱指数（ABI）由0．37±0．15上升为0．87±0．18（P〈0．05）。随访3～60个月,53例髂动脉均血流通畅,临床症状无复发;45例股浅动脉中、上2／3段阻塞和29例股浅动脉下1／3段阻塞,PTAS后6、12、36、60个月的通畅率分别为97．78％、91．11％、84．44％、75．56％及89．66％、79．31％、72．41％、65．52％。结论经皮腔内血管成形术（PTA）和支架成形术（PTAS）治疗LEAOD,可使闭塞血管得到长期的有效开通,显著提高血流动力学指标,是安全有效的治疗方法。     

Combined iliac angioplasty and infrainguinal revascularization surgery are effective in diabetic patients with multilevel arterial disease

The success of percutaneous transluminal angioplasty (PTA) in the treatment of common and external iliac atherosclerotic lesions has been established for the general population. However, several studies have suggested that the presence of diabetes may reduce the effectiveness of iliac angioplasty, particularly in the setting of limb-threatening ischemia requiring concomitant lower extremity revascularization. This study compared the results of iliac artery PTA performed in conjunction with infrainguinal bypass for limb-threatening ischemia for diabetic (DM) and nondiabetic (non-DM) patients. Between 1991 and 2000, 159 PTA were performed in 126 patients (DM = 99/79%, non-DM = 27/21%) in conjunction with subsequent infrainguinal bypass for limb-threatening ischemia (gangrene = 42%, ulcer = 36%, rest pain = 22%). These patients were followed prospectively using a computerized vascular registry. Stents were placed in 34 (21.4%) cases for suboptimal angioplasty results. In this study the combined use of standard surgical and endoluminal modalities for the treatment of multilevel arterial occlusive disease resulted in excellent cumulative patency and limb salvage rates. The presence of diabetes did not alter these favorable results. Multimodal vascular therapy may be used effectively in diabetic patients with limb-threatening ischemia due to multiple levels of arterial occlusion. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

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.     

Proximal percutaneous balloon angioplasty and distal bypass for multilevel arterial occlusion

Multiple sites of atherosclerotic occlusion in high risk patients may be treated by angioplasty of the iliac obstruction and distal reconstruction. We report 18 male patients with symptomatic peripheral vascular disease in whom proximal iliac percutaneous transluminal angioplasty was combined with femoropopliteal bypass (11), femorotibial bypass (2), or femorofemoral bypass (5). There were no operative deaths. The pretreatment ankle brachial index of 0.40 ± 0.04 was increased to 0.64 ± 0.04 by discharge (p=0.0001), and remained significantly increased through 27 months (0.65 ± 0.07) (p=0.0001). During the follow-up period of 2–57 (mean 27 months) one dilated iliac artery required repeated percutaneous transluminal angioplasty and revision of the femoropopliteal bypass at three months. Two late amputations of study limbs occurred at two years and three years due to progression of distal disease in the infrapopliteal segment. Four patients died during the follow-up period of ischemic heart disease (3) and lung carcinoma (1). Life table analysis shows a 76% success rate for the combined procedures at two years. In selected, high risk patients, proximal iliac dilatation and distal bypass is an acceptable alternative reconstruction for multilevel occlusion.     

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.     

血管腔内介入联合外科手术治疗下肢多节段动脉硬化闭塞症

目的: 探讨下肢多节段动脉硬化闭塞症的治疗手段及临床疗效。方法:2004年3月—2006年1月，采用髂动脉球囊扩张和支架植入结合动脉旁路术、股深动脉成形术治疗下肢多节段动脉硬化闭塞症21例(24条患肢)。24条患肢行髂动脉球囊扩张和支架植入术，其中12条患肢加行股深动脉成形术，14条患肢加行股-腘动脉人工血管转流术。结果:手术均获得成功，未出现严重并发症。术后踝肱指数0.63 ±0.18与术前0.24±0.13相比有明显提高（P<0.05）。平均随访13个月(1~23个月)。与术前相比患者症状明显改善，仅4例残余有间歇性跛行（跛行距离300~500m），其中3例术后3个月行干细胞移植术后症状明显好转，跛行距离加大（>1 000m）。结论:髂动脉腔内介入结合动脉旁路术、股深动脉成形术是治疗多节段多平面下肢动脉硬化闭塞症的有效方法。手术创伤小，操作方便。手术方式灵活，尤适用于高危重症患者。     

Follow-up of renal artery stenosis by duplex ultrasound

We have previously shown that duplex ultrasound is an accurate method of diagnosing renal artery stenosis (93% accuracy compared with angiography in the diagnosis of less than 60% stenosis, 60% to 99% stenosis, or occlusion). With this method we have now serially observed 35 renal arteries with 60% to 99% renal artery stenosis in 27 patients. Nineteen stenotic renal arteries in 15 patients were observed without intervention. There was a significant decrease in kidney size (mean difference - 1.0 cm; p less than 0.01; mean follow-up 13 months) but all 19 renal arteries remained patent. Percutaneous transluminal angioplasty (PTA) was performed in five patients (six renal arteries) for renovascular hypertension. Renal duplex scanning documented relief of renal artery stenosis in two patients whose hypertension improved after PTA and confirmed residual 60% to 99% renal artery stenosis in three patients whose hypertension did not improve after PTA (mean follow-up 6.5 months). Aortorenal bypass was performed for 10 stenotic renal arteries in seven patients. At a mean follow-up of 9 months duplex ultrasound documented eight patent and two occluded aortorenal bypass grafts. Duplex ultrasound is useful both for defining the natural history of untreated renal artery stenosis and assessing the results of renal artery angioplasty or bypass.