Epidemiology, classification, and modifiable risk factors of peripheral arterial disease

Peripheral arterial disease (PAD) is part of a global vascular problem of diffuse atherosclerosis. PAD patients die mostly of cardiac and cerebrovascular-related events and much less frequently due to obstructive disease of the lower extremities. Aggressive risk factors modification is needed to reduce cardiac mortality in PAD patients. These include smoking cessation, reduction of blood pressure to current guidelines, aggressive low density lipoprotein lowering, losing weight, controlling diabetes and the use of oral antiplatelet drugs such as aspirin or clopidogrel. In addition to quitting smoking and exercise, cilostazol and statins have been shown to reduce claudication in patients with PAD. Patients with critical rest limb ischemia or severe progressive claudication need to be treated with revascularization to minimize the chance of limb loss, reduce symptoms, and improve quality of life.     

Management of peripheral arterial disease and intermittent claudication

BACKGROUND: Peripheral arterial disease (PAD) is the chronic obstruction of the arteries supplying the lower extremities. The most common symptom is intermittent claudication resulting in aching pain, numbness, weakness, or fatigue in the muscle groups of the lower extremities. METHODS: Using the key words "peripheral arterial disease," "intermittent claudication," "atherosclerosis," and "cardiovascular disease," MEDLINE databases were searched from 1970 to the present. The most recent articles pertinent to current treatment recommendations for PAD and intermittent claudication were selected to document this review. RESULTS AND CONCLUSIONS: Symptoms of intermittent claudication are induced by walking or exercise and usually resolve with rest. Disease severity varies from patients who are asymptomatic to those who have unremitting symptoms. A high overlap exists between PAD and coronary artery and cerebrovascular disease. Risks for long-term morbidity and mortality are identical for PAD, intermittent claudication, and coronary artery disease. Treatment of PAD is aimed at maintaining or improving functional status, reducing or eliminating ischemic symptoms, and preventing disease progression. Exercise and aggressive risk factor modification represent the cornerstones of treatment. Risk factors include smoking, diabetes, lipid abnormalities, hypertension, C-reactive protein, lipoprotein(a), and hyperhomocystinemia. Antiplatelet and lipid-altering therapies decrease risk of atherosclerotic vascular complications and are being studied to improve intermittent claudication. Cilostazol, a new antiplatelet, antithrombotic agent, reduces claudication symptoms. Angiogenic growth factors have shown preliminary success in patients with rest pain and ischemic ulcers and are being investigated for use in patients with intermittent claudication. Invasive revascularization procedures can be considered for patients with critical limb ischemia or when medical therapy fails.     

经腘动脉逆行内膜下成形术治疗长段股浅动脉闭塞的临床观察

目的探讨经胭动脉逆行内膜下成形术治疗长段股浅动脉闭塞的临床经验。方法2006年2月-2007年5月,经胭动脉逆行内膜下成形术治疗长段股浅动脉闭塞5例。结果5例病人下肢动脉均完全开通,技术成功率为100．0％,无严重并发症和手术死亡：术后6个月、1年累计开通率分别为80．0％和60．0％,所有病例无严重并发症。结论经胭动脉逆行内膜下成形术是治疗下肢动脉长段硬化闭塞所致慢性严重肢体缺血的安全有效的方法。     

手术联合腔内治疗合并动脉硬化的急性下肢动脉缺血的临床观察

目的观察手术联合腔内治疗对合并动脉硬化的急性下肢动脉缺血的临床效果。方法回顾性分析20例(24肢)经手术联合腔内治疗的合并动脉硬化的急性下肢动脉缺血患者的临床资料和治疗效果。结果 24肢中,治疗成功20肢,截肢1例,死亡1例。结论采用个体化疗法的手术联合腔内治疗,对合并动脉硬化的急性下肢动脉缺血的高龄患者治疗效果较好,下肢动脉供血的救治率得到提高。     

留置溶栓导管介入治疗急性下肢动脉血栓栓塞的临床研究

目的 探讨急性下肢动脉血栓栓塞患者留置溶栓导管介入治疗的方法与疗效.方法 112例急性下肢动脉血栓形成或栓塞患者,其中冠心病或风湿性心脏病合并心房颤动致下肢动脉栓塞85例,各种原因导致的血栓形成27例;所有患者均采用留置溶栓导管局部持续溶栓的方法介入治疗.结果 112例患者中77例(68.8%)患者经介入留置溶栓导管溶栓后栓塞血管完全再通;23例(20.5%)患者栓塞血管部分再通,肢体得以保全,但后期随访16例患者仍有肢体慢性缺血症状;9例(8.0%)因肢体缺血时间过长,发生不可逆性坏死而行截肢术;3例(2.7%)因发生急性再灌注损伤并发急性肾衰竭或再发脑梗死而死亡.结论 留置溶栓导管介入治疗急性下肢动脉血栓栓塞安全、有效,截肢率低.

Abstract：

Objective To study the methods and effects by using thrombolytic catheter in interventional treatment for patients with acute lower limb arterial thrombosis or embolism. Methods One hundred and twelve patients suffered acute lower limb arterial thrombosis or embolism. There were 85 cases of acute lower limb arterial embolism induced by atrial fibrillation in coronary or rheumatic heart disease,other 27 cases of arterial thrombosis caused by different reasons. Interventional treatment by inlying thrombolytic catheter was applied and continuous perfusion was received locally in all patients. Results Complete recanalization was got in 77 cases (68.8%) of 112 cases. Partial re canalization was got in 23 cases (20.5%), and ischemia limbs were saved in spite of chronic limb ischemia(chronic spasmodic limb) occurring in the later follow-up. Nine cases (8.0%) were amputated as a result of irreversible limbs necrosis, 3 cases (2.7%) died from acute renal failure resulting from reperfusion injury or recurrent cerebral embolism.Conclusion Interventional treatment by inlying thrombolytic catheter is a safe and effective method with lower amputation rate for acute lower limb arterial thrombosis or embolism in patients.     

四肢创面修复应用皮肤牵张闭合器的可行性研究

目的:探讨四肢创面修复应用皮肤牵张闭合器的可行性。方法:纳入本院40例2017年2月~2018年1月四肢创面患者。随机数字表分组,负压封闭引流术组采取负压封闭引流术治疗,皮肤牵张闭合器治疗组则采取皮肤牵张闭合器治疗。比较负压封闭引流术组、皮肤牵张闭合器治疗组疗效;四肢创面平均愈合的时间、术后抗感染药物的使用时间、持续镇痛时间;治疗前后患者创面VAS评分、创面白细胞计数;二次手术实施率。结果:皮肤牵张闭合器治疗组疗效、四肢创面平均愈合的时间、术后抗感染药物的使用时间、持续镇痛时间、创面VAS评分、创面白细胞计数相比较负压封闭引流术组更好,P<0.05。皮肤牵张闭合器治疗组二次手术实施率低于负压封闭引流术组,P<0.05。结论:皮肤牵张闭合器治疗四肢创面的效果理想,可有效控制炎症和缓解疼痛,加速创面愈合,减少抗感染药物的使用,减少二次手术。     

Vascular endothelial growth factor gene expression in patients' ischemic skeletal muscle with diabetic foot

OBJECTIVE: To investigate the relationship between the endogenous vascular endothelial growth factor (VEGF) gene expression in diabetics' calf ischemic skeletal muscle and the pathogeny of diabetic foot. METHODS: Twenty-four patients (33 limbs) were divided into 3 groups: diabetes mellitus (DM) without lower extremity ischemia (n = 5) (10 limbs); arteriosclerosis obliterans (ASO) without diabetes mellitus (n = 10) (13 limbs); diabetic lower limb arteriosclerosis obliterans (DLASO) (n = 9) (10 limbs). Control group consisted of normal volunteers (NOR) (n = 5) (10 limbs). The calf skeletal muscle tissue was obtained through muscle biopsy. RT-PCR was applied to determine the expression of hVEGF165mRNA. RESULTS: There was no expression in the calf skeletal muscle tissue of normal volunteers and DM. The calf skeletal muscle tissue in DLASO had the expression of hVEGF165mRNA (0.021 +/- 0.013) micro g, but obviously lower than ASO (0.133 +/- 0.024) micro g, (t = 13.32, P < 0.01). CONCLUSIONS: The endogenous VEGF gene expression in ischemic lower extremity of DLASO is obviously lower than that of ASO. It is the important endogenic cause of the genesis and development of diabetic foot ulcer.     

Lower leg amputation due to critical limb ischaemia: morbidity, mortality and rehabilitation potential

A total of 3 patients, a female aged 66 years, a male aged 67 years and a female aged 82 years, presented with rest pain or gangrene of their lower extremities as a result of critical limb ischemia (CLI). Radiographic studies showed non-reconstructable arterial obstructive disease in the 66-year-old female patient, who underwent an uncomplicated primary amputation and subsequent rehabilitation. Bypass surgery was initially performed in the male patient. However, failed reconstruction and progression of ischaemia necessitated transfemoral amputations to be performed, which was followed by impaired rehabilitation. In the 82-year-old female patient gangrene was the indication for primary amputation. She died due to progressive sepsis following surgery. In about 40% of patients with CLI, major lower extremity amputation is the ultimate solution. The morbidity, mortality and rehabilitation potential in CLI and the factors that influence these outcomes are discussed. The most clinically relevant determinants of morbidity, mortality and rehabilitation following major lower extremity amputation are comorbidity, age, preoperative mobility and amputation level.     

Actualité de la prise en charge de l’infarctus mésentérique à la phase aiguë

Intestinal ischemic injuries are the result of an inadequate blood supply to the gastrointestinal tract, secondary to arterial or venous origin. Venous intestinal ischemic injuries are mainly caused by thrombosis or compression. Arterial inadequate perfusion states are more frequent and related, in occlusive intestinal ischemic injuries, to thrombosis, atheroma, cardiac embole, vasculitis, dissection, extrinsic compression or trauma, whereas non occlusive ischemia are secondary to systemic or regional low flow states or vasoconstriction. Cute and chronic intestinal ischemic injuries have different clinical presentations and necessitate dedicated multimodal treatments. One should distinguish early forms of acute intestinal ischemic injuries, potentially reversible without resection and late intestinal ischemic injuries, associated with intestinal necrosis and with a poor prognosis and high mortality without treatment. Clinical and biological signs are unspecific, explaining why diagnostic of acute intestinal ischemic injuries is frequently delayed. The therapeutic strategy should focus on intestinal viability with triple goals : avoid general worsening with introduction of multimodal medical “anti-ischemic” treatment, preserve non-ischemic bowel by revascularization and resect all non viable bowel. This multimodal and multidisciplinary management involves gastroenterologists, radiologists, cardiologists, anesthesiologists, intensivists and vascular and digestive surgeons. Diagnosis of chronic mesenteric ischemia is fundamental because of the risk of acute evolution and life-threatening malnutrition. The improvement of the management of this life-threatening condition need the creation of dedicated intestinal stroke centers each time possible.     

自体骨髓单个核细胞移植治疗糖尿病性下肢缺血的临床观察

目的观察自体骨髓单个核细胞移植治疗糖尿病性下肢缺血的疗效。方法应用自体骨髓单个核细胞移植治疗20例22条糖尿病性下肢缺血。全部为2型糖尿病的下肢血管并发症。结果总的疼痛缓解率为85.0%,截肢3例(13.6%)。对缓解患者的冷、凉感觉,总有效率为100.0%。7例患者接受了下肢动脉造影显示有不同程度的新生侧支血管形成。踝部经皮氧分压测定显示绝大多数高于临床上截肢的最低临界值20mmHg(1mmHg=0.133kPa)。结论自体骨髓单个核细胞移植治疗糖尿病性下肢缺血是一种相对简单、安全、有效的方法。     

Foot ulcers in the diabetic patient, prevention and treatment

Lower extremity complications in persons with diabetes have become an increasingly significant public health concern in both the developed and developing world. These complications, beginning with neuropathy and subsequent diabetic foot wounds frequently lead to infection and lower extremity amputation even in the absence of critical limb ischemia. In order to diminish the detrimental consequences associated with diabetic foot ulcers, a common-sense-based treatment approach must be implemented. Many of the etiological factors contributing to the formation of diabetic foot ulceration may be identified using simple, inexpensive equipment in a clinical setting. Prevention of diabetic foot ulcers can be accomplished in a primary care setting with a brief history and screening for loss of protective sensation via the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy, plantar foot pressure, and assess vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, may enable clinicians to stratify patients based on risk and help determine the type of intervention. Other effective clinical interventions may include patient education, optimizing glycemic control, smoking cessation, and diligent foot care. Recent technological advanced combined with better understanding of the wound healing process have resulted in a myriad of advanced wound healing modalities in the treatment of diabetic foot ulcers. However, it is imperative to remember the fundamental basics in the healing of diabetic foot ulcers: adequate perfusion, debridement, infection control, and pressure mitigation. Early recognition of the etiological factors along with prompt management of diabetic foot ulcers is essential for successful outcome.     

Emerging therapies for refractory angina

In recent years, improvements in both pharmacologic and revascularization therapies have greatly increased life expectancy for patients with coronary artery disease (CAD). As patients with more extensive CAD live longer, many develop myocardial ischemia and clinical angina that is not amenable to traditional revascularization therapy. Patients with severe, symptomatic, chronic CAD have been described as having refractory angina; they have also been termed "no-option" patients. This article discusses clinical management of this unique and growing group of patients and emerging therapeutic options including pharmacologic agents, enhanced external counterpulsation therapy, therapeutic angiogenesis, neurostimulation, and transmyocardial revascularization.     

多节段、多平面下肢动脉硬化闭塞症的临床治疗

目的 探讨多节段、多平面下肢动脉硬化闭塞症的临床治疗方法.方法 按照个体化原则,采用单一的动脉旁路重建术、序列式动脉旁路重建术和经皮血管腔内成形术联合动脉旁路重建术治疗多节段、多平面下肢动脉硬化闭塞症患者25例.结果 随访6个月至3年,25例患者肢体缺血症状明显减轻或消失,原溃疡面愈合.4例足趾干性坏疽,截趾后创面2～4个月愈合,2例移植物在术后6个月内闭塞,但肢体缺血症状明显改善,本组无重要脏器并发症和手术死亡病例,移植物通畅率92%(23/25),治愈率100%.结论 按照个体化原则,选择单一动脉旁路重建术、序列式动脉旁路重建术和经皮血管腔内成形术联合动脉旁路重建术是治疗多节段、多平面下肢动脉硬化闭塞症的有效方法.     

综合牵引床、褥疮防治床垫治疗老年性下肢骨折疗效分析

目的:综合牵引床、褥疮防治床垫治疗老年下肢骨折,并作出临床疗效分析。方法:对132例老年下肢骨折患者采取牵引术结合褥疮防治床垫进行治疗,观察患者骨折愈合情况,并于1a后进行随访,观察治疗效果。结果:132例患者经过系统治疗后其中129例康复出院;3例患者骨折处呈纤维愈合,肢体功能得到部分恢复。随访1a,80%以上患者骨折处无疼痛,活动功能尚可。结论:牵引床结合褥疮防治床垫对老年性下肢骨折的治疗具有较好疗效。     

64-MSCT血管成像技术在下肢动脉硬化闭塞症中的应用浅探

目的探讨64层螺旋CT血管造影(64-Multislice spiral CT angiography,64-MSCTA)技术在下肢动脉硬化闭塞症(arteriosclerosis obliterans,ASO)的临床应用价值。方法回顾性分析2010年4月—2011年12月期间在该院血管外科诊断为下肢ASO,并行64-MSCTA检查的60例住院患者病例资料和图像质量,依据下肢动脉及静脉显影分级标准进行图像质量评估,探讨64-MSCTA下肢动脉成像技术的扫描和重建技巧。结果 60例64-MSCTA均获得较满意的原始图像及后处理图像,能够满足影像诊断的需要。结论 64-MSCTA在观测下肢血管分级、狭窄部位及临床分型等方面,具有与下肢动脉DSA相同的检查效果,可作为下肢动脉硬化闭塞症诊断的首选筛查手段。     

The influence of polymorbidity, revascularization, and wound therapy on the healing of arterial ulceration

Objective

An ulcer categorized as Fontaine’s stage IV represents a chronic wound, risk factor of arteriosclerosis, and co-morbidities which disturb wound healing. Our objective was to analyze wound healing and to assess potential factors affecting the healing process.

Methods

199 patients were included in this 5-year study. The significance levels were determined by chi-squared and log-rank tests. The calculation of patency rate followed the Kaplan-Meier method.

Results

Mean age and co-morbidities did not differ from those in current epidemiological studies. Of the patients with ulcer latency of more than 13 weeks (up to one year), 40% required vascular surgery. Vascular surgery was not possible for 53 patients and they were treated conservatively. The amputation rate in the conservatively treated group was 37%, whereas in the revascularizated group it was only 16%. Ulcers in patients with revascularization healed in 92% of cases after 24 weeks. In contrast, we found a healing rate of only 40% in the conservatively treated group (p < 0.001). Revascularization appeared more often in diabetic patients (n = 110; p < 0.01) and the wound size and number of infections were elevated (p = 0.03). Among those treated conservatively, wound healing was decelerated (p = 0.01/0.02; χ² test).

Conclusions

The success of revascularization, presence of diabetes mellitus, and wound treatment proved to be prognostic factors for wound healing in arterial ulcers.     

下肢动脉旁路移植术后人工血管闭塞的再手术治疗

目的 总结下肢动脉旁路移植术后人工血管闭塞的再手术治疗经验.方法 回顾性分析21例下肢动脉旁路移植术后人工血管闭塞患者再手术的治疗效果.结果 21例患者术后均获随访,随访时间6～36(12±3)个月.肢体存活率71.4%(15/21),截肢率28.6%(6/21),9例最后通过股深动脉供血的患者肢体全部存活.结论 下肢动脉旁路移植术后人工血管闭塞的主要原因是内膜增生或流人道及流出道的狭窄闭塞,再手术前应仔细分析闭塞原因以选择合适的手术方式.股深动脉重建对于人工血管闭塞的再手术治疗非常重要.

Abstract：

Objective To review reoperation on blood vessel prosthesis occlusion after arterial bypass graft in lower limbs. Method The treatment effect of 21 patients with reoperation on blood vessel prothesis occlusion after arterial bypass graft in lower limbs was analyzed retrospectively. Results All the cases were followed up 6-36 (12 ±3) months. The limb salvage rate was 71.4%(15/21) ,the amputation rate was 28.6% (6/21). All 9 limbs that underwent revascularization from deep femoral artery reserved. Conclusions Endomembrane hyperplasy, occlusion of the inflow and outflow tracts are the major reasons for the occlusion of blood vessel prosthesis after arterial bypass graft in lower limbs. Appropriate procedures should be based on careful consideration of the occlusion reasons. Profundaplasty is an effective therapy for those who are treated by reoperation on blood vessel prosthesis occlusion in lower limbs.     

Symptomless (silent) myocardial ischemia and its prognostic significance

The authors studied the prognostic significance of Silent myocardial ischemia. To study the correlation between the silent ischemia before the operation of coronary revascularization and the perioperative complications (infarction, mortality) Holter-monitoring (HM) was performed with 26 patients. The average time of HM was 43 +/- 3.1 h. During the observation period total 138 silent ischemic episodes were registered with 7 patients. The average heart rate observed during the ischemic event did not differ from that observed in other periods. Three myocardial infarctions occurred in the perioperative period one of them was of lethal outcome. Silent ischemia was detected in 2 of 3 patients before operation. The patient who displayed the gravest ischemic alteration died of perioperative myocardial infarction. On the basis of their observations the authors attribute prognostic significance to the preoperative silent myocardial ischemia.     

早期骨肉瘤患者动脉介入治疗疗效观察

目的 探讨早期骨肉瘤患者行动脉介入治疗后的临床疗效.方法 对38例早期骨肉瘤患者行动脉栓塞化疗及手术治疗,36例(94.7%)患者行保肢手术;同时治疗前后分别行碱性磷酸酶测定.结果 手术后所有患者碱性磷酸酶水平[平均(191.7±107.0)u/L)]较介入治疗前[平均(1129.1±572.3)U/L)]明显降低(t=10.290,P＜0.01).随访12～60个月,1、3、5年生存率分别为97%、79%、50%;肿瘤复发及转移率为24%.结论 对早期骨肉瘤患者行动脉栓塞联合化疗治疗可有效改善临床症状,提高生存率,减轻复发和转移,保留患肢;碘油作为栓塞材料效果最明显.     

320排螺旋CT血管成像在双下肢动脉狭窄闭塞性疾病诊断中的应用

目的:分析320排螺旋CT血管成像在双下肢动脉狭窄闭塞性疾病诊断中的应用。方法:在2018年5月~2019年5月选取本院接受320排螺旋CT血管造影成像检查的100例患者作为案例进行研究分析。所有患者均接受320排螺旋CT血管造影成像检查。总结100例患者的检查结果。结果:100例患者均存在一定程度腹主动脉粥样硬化表现。100例患者中合并腹主动脉瘤患者6例,髂总动脉狭窄患者26例,髂内与外动脉狭窄患者28例,闭塞患者6例,股动脉狭窄患者46例,闭塞患者7例,颈前后动脉狭窄患者23例,多动脉多发节段型狭窄患者26例。结论:320排螺旋CT血管成像在下肢动脉狭窄闭塞性疾病诊断中的应用价值显著,能够准确判断患者的下肢动脉狭窄闭塞性疾病方面的作用明显,并且对患者的辐射影响较小。