内膜下血管成形术并发症的防治

目的 评价内膜下血管成形术治疗下肢动脉硬化闭塞症并发症的防治.方法 从2003年12月至2008年5月,106 条下肢动脉硬化闭塞的患肢进行了内膜下血管成形术治疗,动脉闭塞的平均长度为10.8(4.5耀28)cm,其中21 条肢体为生活方式受限性间歇性跛行,85 条肢体为威胁肢体生存的严重性缺血.分析评价的主要参数为并发症的发生和防治措施.结果 有5 条患肢穿刺部位皮下出现轻度淤血,未发生动脉栓塞;有7 条患肢发生动脉穿孔(6豫),但未引起严重的临床后果;有1 例因影响动脉重要分支而致截肢;有3 条患肢发生再管化通道急性闭塞,其中1 例SIA 后导致动脉旁路吻合口下移.结论 SIA 手术可发生动脉穿孔、影响动脉主要分支、再通血管急性闭塞和栓塞等并发症,但这些并发症绝大部分可进行防治,很少引起严重的后果.     

内膜下血管成形术并发症的防治

目的 评价内膜下血管成形术(SIA)治疗下肢动脉硬化闭塞症并发症的防治.方法 从2003年12月至2008年5月,106条下肢动脉硬化闭塞的患肢进行了SIA治疗,动脉闭塞长度4.5～28.0 cm,平均10.8 cm,其中21条肢体为生活方式受限性间歇性跛行,85条肢体为威胁肢体生存的严重性缺血.分析评价的主要参数为并发症的发生和防治措施.采取的防治措施主要包括:所有SIA再管化过程均在DSA设定的路径下进行;每完成一个操作,向导管内注入少量的造影剂以确定导管的位置;长段动脉闭塞选择相对较长、合适的球囊导管进行扩张;抗凝治疗持续3～5 d,然后抗血小板治疗6个月.结果 有5条患肢穿刺部位皮下出现轻度淤血,未发生动脉柃塞;有7条患肢发生动脉穿孔(6%),但未引起严重的临床后果;有1例因影响动脉重要分支而致截肢;有3条患肢发生再管化通道急性闭塞,其中1例SIA后导致动脉旁路吻合口下移.结论 SIA手术可发生动脉穿孔、影响动脉主要分支、再通血管急性闭塞和栓塞等并发症,但绝大部分町防治,很少引起严重的后果.     

髂动脉硬化闭塞性病变的介入治疗技术及体会

目的探讨应用内膜下血管成形术(SIA)联合经皮血管腔内成形术(PTA)介入治疗髂动脉硬化闭塞性病变的技术方法和疗效。方法对15例伴有严重缺血症状的髂动脉硬化闭塞性病变患者,采用顺行途径穿刺,经左肱动脉穿刺3例,经对侧股动脉穿刺12例。通过SIA对闭塞段动脉进行再通,应用球囊扩张成形并植入支架(裸支架18枚,覆膜支架4枚)。结果内膜下血管成形术技术成功率100%,支架植入后髂动脉闭塞段管腔形态良好,血流通畅,无严重并发症出现,临床症状消失或明显改善。患肢踝肱指数由术前的0.41±0.12增至术后7天的0.81±0.13(t=8.76,P0.0001)。近中期随访2例发生再狭窄,经PTA解除,术后12个月支架一期通畅率为85.71%(12/14)。结论 SIA联合支架植入术治疗髂动脉硬化闭塞性病变安全、有效,近、中期疗效良好。     

支架成形术治疗髂动脉慢性闭塞症的中长期疗效分析

目的:评价支架成形术治疗髂动脉慢性闭塞症的中长期疗效。方法 :回顾性分析我科自2004年1月至2009年12月经支架成形术治疗的髂动脉慢性闭塞病人的技术成功率、支架通畅率及介入并发症。结果:髂动脉慢性闭塞症病人167例(194条患肢)纳入研究,男103例(126条患肢),女64例(68条患肢);平均年龄(71.3±12.4)岁。TASC B型47例(54条患肢),TASC C型88例(102条患肢),TASC D型32例(38条患肢)。TASC B型、C型、D型技术成功率分别为98.1%(53/54)、97.1%(99/102)、94.7%(36/38),各组比较无统计学差异;髂动脉支架成形术后1年一期通畅率、一期辅助通畅率和二期通畅率分别为94.6%、98.8%和98.8%,2年分别为90.0%、94.5%和96.2%,5年分别为78.8%、89.4%和93.5%,TASC各型之间无统计学差异。肱动脉穿刺部位血肿多于股动脉(P=0.047)。结论:支架成形术治疗髂动脉慢性闭塞安全、有效,技术成功率、支架通畅率和并发症发生率与TASCⅡ分型无相关性。     

腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变

目的 评价腔内血管成形术治疗髂动脉长段慢性完全闭塞性病变(CTO)的可行性、有效性及安全性.方法 回顾性分析2006年1月至2010年12月经腔内血管成形术治疗的病变长度＞5 cm的髂动脉CTO患者139例(157条患肢)的临床资料.其中男性93例(105条患肢),女性46例(52条患肢);年龄50 ～96岁,平均年龄(77±10)岁.TASCⅡ分型:B型18例,C型89例,D型32例.采用左肱动脉和(或)股动脉穿刺经内膜下或血管内行髂动脉闭塞的球囊血管成形联合支架植入术治疗.结果 技术成功率96.2％ (151/157).踝肱指数由术前的0.42±0.19上升到术后的0.81±0.26.随访6～53个月,平均随访(30±7)个月,髂动脉支架畅通率94.1％ (111/118),7例发生支架内再狭窄或闭塞,无髂动脉破裂、支架移位、穿刺动脉假性动脉瘤及动静脉瘘的发生.结论 腔内血管成形术治疗髂动脉长段CTO安全、有效,术后支架通畅率高,联合肱动脉和股动脉双向穿刺技术能够显著提高技术成功率.     

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。     

PTA及血管内支架治疗下肢多节段动脉硬化闭塞症的应用

目的 探讨经皮腔内球囊扩张血管成形术及血管内支架治疗下肢多节段动脉硬化闭塞症的临床应用价值.方法 全组11例,共18条患肢(闭塞病变22个节段).15段闭塞长度在7cm以内者作PTA,病灶分别位于髂总动脉6段、器外动脉2段、股浅动脉7段;15段中有4段与PTA同时置入血管内支架.另外长段闭塞的7段,于短段作PTA同时或在术后1周内作动脉重建术,其中腹主-股总动脉转流术1段、腹主-股深动脉1段、股-腘动脉3段、腘动脉间置移植术1段、股深动脉成形术1段.结果 1条患肢因PTA失败即改作转流术,2条患肢术后并发股浅动脉急性栓塞,作取栓治疗后,均恢复血循环.术后近期内,全组18条患肢临床症状改善,其中16条末梢动脉搏动恢复,踝/肱指数由术前0.54±0.11增高至0.79±0.15.随访6～72个月后,2条作PTA患肢的股浅动脉分别于1年和5年后再次闭塞.结论 经皮腔内球囊扩张血管成形术是治疗下肢动脉闭塞性疾病的有效方法,血管内支架置放有助于提高通畅率,多节段动脉闭塞性病变联合手术重建,可简化手术操作,缩小手术创伤.     

胫腓动脉血管成形术治疗下肢严重缺血35例

目的 评价胫腓动脉经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)治疗下肢严重缺血的可行性、安全性和有效性.方法 对2004年6月至2007年5月收治的35例胫腓动脉闭塞的下肢严重缺血(critical limb ischemia,CLI)患者应用PTA治疗.评价的主要参数为:胫腓动脉PTA技术成功率、通畅率、救肢率和并发症.结果 胫腓动脉PTA的技术成功率为83%,平均随访11.5个月,通畅率为57%,救肢率82%.胫腓动脉平均扩张长度9.5 cm(4.5～14 cm),19例患者同时行髂或股胭动脉PTA或支架术.有3例并发症发生,其中1例动脉痉挛和血栓形成,经溶柃、解痉等治疗缓解;2例动脉穿孔,未有严重后果.结论 PTA治疗CLI合并胫腓动脉闭塞具有较高技术成功率和救肢率,较少发生严重并发症,是一种安全、有效可供选择的治疗方法.     

老年人下肢动脉闭塞的血管重建术262例分析

目的 总结对下肢缺血老年患者进行动脉重建术的手术效果及影响预后的因素.方法 回顾性分析从2006年1月至2008年11月收治的262例下肢动脉缺血的老年患者的临床资料.总结对老年患者行下肢动脉重建术围手术期的关注要点及影响远期预后的因素.结果 本组262例老年患者(323条患肢),下肢动脉血管旁路术102条,腔内治疗98条,单纯取栓/内膜剥脱术67条,手术(血管搭桥/取栓/内膜剥脱术)结合腔内治疗多节段病变56条.手术成功率94.7%,围手术期死亡2例(30 d内),围手术期严重并发症15例.262例中245例患者获得术后获有效随访,随防率93.5%,随访时间1～35个月,平均(18±10)个月.随访期内,死亡15例,血管Ⅰ期通畅率80.5%,Ⅱ期通畅率92.7%,保肢率95.2%.危险因素分析提示:有冠心病病史和年龄大于70岁的病例组在随访期内死亡明显高于其他组.合并糖尿病、病情严重、病变范围广导致术后血管再闭塞发生率高,且截肢数量增加.结论 重症下肢动脉闭塞症的动脉重建术依赖于熟练的手术经验,综合性的多科室协作,合理的手术方案以及围手术期的细致管理.     

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 for the treatment of claudication and critical limb ischemia: 3-year results

OBJECTIVE: Subintimal angioplasty (SIA) is an increasingly used method of lower extremity revascularization for patients with chronic arterial occlusions. To assess the technical feasibility, safety, and 3-year outcomes of patients treated with SIA, we performed a retrospective review of our early experience. METHODS: Patient information-including demographics, indications, procedures, noninvasive arterial studies, and postprocedural events-was recorded in a database. Outcomes were determined on an intention-to-treat basis, as well as by technical success, by using Kaplan-Meier survival analysis. Continuous data were compared by using the Student t test, and survival curves were compared by log-rank testing. RESULTS: From December 2002 through December 2003, 104 patients (105 limbs) underwent SIA of 159 occlusive lesions involving the iliac (n = 10), superficial femoral (n = 85), popliteal (n = 48), or tibial (n = 16) arteries. Sixty-six (62.9%) patients were treated for critical limb ischemia, and 39 patients (37.1%) were treated for disabling claudication. Technical success was achieved in 91 procedures (86.7%) and resulted in a mean increase in ankle-brachial index of 0.36 +/- 0.16. The mean follow-up was 23.4 months (range, 0-46 months). During this period, 18 patients (17.0%) died, and 15 amputations (14.3%) were performed, 6 of which were performed for patients on whom SIA had been unsuccessful. In patients undergoing successful SIA, the primary patency was 55%, 43%, and 35% at 12, 24, and 36 months, respectively. Twenty-one patients underwent a total of 23 percutaneous procedures to maintain or restore patency of the SIA during the study period. This resulted in secondary patency rates of 71%, 63%, and 51% at 12, 24, and 36 months, respectively. Multivariate analysis revealed critical limb ischemia to be the only predictor of reduced primary patency. Fifteen patients with inoperable critical limb ischemia underwent successful SIA. Limb salvage in this group was 54% and 43% at 12 and 36 months, respectively. Limb salvage in operative candidates was 100% and 88% at the same intervals. In patients with disabling claudication, 94% experienced improvement in symptoms 3 months after the procedure, and 68% of patients reported sustained improvement at 36 months. In all operative candidates successfully treated with SIA, freedom from surgical bypass was 83% and 73% at 12 and 36 months, respectively. CONCLUSIONS: SIA for the treatment of lower extremity chronic arterial occlusions is technically feasible, results in minimal morbidity, and provides satisfactory revascularization without surgical bypass. Secondary patency is comparable to that of autologous vein bypass and is achieved with a low rate of reintervention. When used as first-line therapy, SIA provides most patients with limb salvage and freedom from surgical bypass at 3 years.     

杂交手术治疗下肢多节段动脉闭塞32例

目的 探讨杂交手术对下肢多节段动脉闭塞性病变的治疗效果.方法 回顾性分析2007年5月至2009年8月接受杂交手术的32例(35条下肢)多节段动脉闭塞性病变的临床资料,探讨杂交手术的适应证、治疗效果、并发症、围手术期死亡率、血管通畅率及保肢率.结果 33条患肢获得手术成功,成功率为94%(33/35).患者术后次日、术后6个月的踝肱指数(ABI)分别为1.06±0.17与0.96±0.16.与术前(0.49±0.18)相比,差异有统计学意义(P＜0.05).2例手术失败中1例因术中并发脑梗死,终止手术;1例膝下动脉开通失败而截肢,无围手术期死亡病例.26例患者获得随访,随访率87%(26/30);随访时间2～28个月,平均随访(11.0±1.3)个月.术后6个月动脉通畅率为93%(26/28),保肢率为96%(27/28).2例术后5～6个月膝下动脉再闭塞,其中1例引起肢端坏疽加重行膝下截肢术,另1例给予保守治疗.结论 杂交手术对于下肢动脉多节段闭塞性病变具有较好效果,风险相对较低,近期通畅率较高.

Abstract：

Objective To evaluate hybrid operation for arteriosclerosis obliterans (ASO) of the lower extremity. Methods Clinical data of 35 ischemic limbs in 32 ASO cases receiving hybrid operation from May, 2007 to August, 2009 were retrospectively analysed. The indications, clinical result,complications, perioperative mortality, vascular patency rate and limb salvage rate was evaluated.Results Thirty-five ischemic limbs in 32 cases underwent hybrid operation. Procedures were successful in 94％ cases (33/35). The average postoperative ABI significantly increased from 0.49 ±0. 18 to 1.06 ± 0. 17 ( one day after surgery) or 0. 96 ± 0. 16 ( six months after therapy). One patient suffered limb amputation due to surgical failure, one case was complicated with cerebral infarction and the operation was terminated. No patient died in perioperative period. Twenty-six cases (28 ischemia limbs) were followed-up from 2 month to 28 months, the follow-up rate was 87％ (26/30). Vascular patency rate in 6 months after operation was 93％ (26/28), and limb salvage rate was 96％ (27/28). Two cases suffered from below-knee reocclusion 5 -6 months after therapy, and one of these two cases needed a limb amputation.Conclusion Hybrid operation is the therapy of choice for multifocal lesions in arteriosclerosis obliterans of the lower extremities with a low risk and higher patency in short term.     

内膜下血管成形术治疗股腘动脉硬化闭塞症

目的探讨内膜下血管成形术(SIA)治疗长段股腘动脉硬化闭塞的临床疗效及其技术要点。方法回顾性分析2009年6月～2011年8月我院收治的20例TASCⅡC型、D型股腘动脉硬化闭塞患者的临床资料,采用SIA开通长段闭塞管腔,同时行球囊扩张和支架植入术,以踝/肱指数(ABI)、Fontaine分期、保肢率和通畅率综合评估临床疗效。结果 SIA技术成功率为85%,临床症状改善率为90%,保肢率为95%,一期通畅率为83.3%,ABI从术前0.42±0.07提升至术后0.86±0.14,术前、术后比较差异有统计学意义(P<0.01)。术后随访12～24个月,18例临床症状改善的患者中有3例术后3～6个月症状复发,行第二次介入治疗,其余患者症状均无加重或复发。结论 SIA在治疗股腘动脉硬化闭塞症中具有良好的应用价值,方法安全有效,近期通畅率较好,远期通畅率尚需要进一步随访。     

Patency of infrainguinal polytetrafluoroethylene bypass grafts with distal interposition vein cuffs

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2–30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.     

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.     

Subintimal angioplasty in the management of lower limb ischaemia

It is now almost 20 years since subintimal angioplasty (SIA) was pioneered. This cost-effective technique has over the past few years enjoyed a dramatic resurgence of interest and application, particularly after having been identified as a safe and practicable approach to vascular recanalisation in several international publications. Originally used in the femoropopliteal segment, its role has been extended to the treatment of infrapopliteal lesions, including the recanalization of the trifurcation and long tibial occlusions. Experienced centres have repeatedly reported primary success rates of around 90% in the infrainguinal vessels, as well as 1-year limb salvage rates as high as 85% to 90%, and 5-year primary assisted patency rates of 64% whilst not interfering with subsequent vascular surgery. Indeed SIA has not only proved to be very effective in lower limb ischaemia management, both for intermittent claudication and critical ischaemia, but in the last few years it has moved from the shadows and into the limelight of modern endovascular therapy.     

膝下动脉球囊血管成形术治疗重症下肢缺血的临床研究

目的 评价膝下动脉闭塞首选球囊血管成形术的临床治疗效果.方法 2005年12月至2009年5月,对于连续收治且符合手术指征的54例(61条肢体)膝下动脉重度狭窄或闭塞的重症下肢缺血患者,采用膝下动脉球囊血管成形术进行治疗.其中男性37例,女性17例,平均年龄66岁.术前踝肱指数平均0.43±0.27.根据病变部位选择手术方法,膝下动脉病变首选球囊血管成形术,合并髂股动脉病变同时进行血管重建(支架置入或动脉旁路术).结果 髂股动脉重建(28条肢体行支架置入,5条肢体行动脉旁路术)均一期成功.膝下动脉球囊血管成形术57条肢体获得一期成功,技术成功率93.4%.围手术期主要并发症为小腿血肿3例(4.9%),膝下截肢2例(3.3%).术后踝肱指数增加至0.86±0.21,与术前相比差异有统计学意义(P<0.01).本组平均随访时间(16±11)个月,一期通畅率61.1%,21条肢体发生再狭窄(38.9%),其中10条肢体再次接受外科干预,二期通畅率75.9%.截肢3条肢体,总的救肢率91.8%.结论 球囊血管成形术是治疗重症下肢缺血安全有效的方法,可以作为膝下动脉病变首选的外科干预手段.     

Efficacy of Hemobahn in the treatment of superficial femoral artery lesions in patients with acute or critical ischemia: a comparative study with claudicants.

PURPOSE: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. METHOD: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). RESULTS: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II. CONCLUSION: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.