冠状动脉旁路移植术前行左锁骨下动脉狭窄筛查及诊治的临床研究

摘要： 目的 探讨冠状动脉旁路移植术前进行左锁骨下动脉狭窄筛查及诊治的意义和方法。方法 对天津市胸科医院612例冠状动脉旁路移植术患者术前采用无创动脉硬化检测技术筛查合并左锁骨下动脉重度狭窄或闭塞患者， 用电子计算机断层扫描血管造影 （CTA） 明确诊断， 然后行左锁骨下动脉支架成形术， 术后1周行非体外循环冠状动脉旁路移植术， 术中均使用左乳内动脉与前降支吻合。结果 使用无创动脉硬化检测技术筛查出5例左锁骨下动脉狭窄病变患者， 且均得到了CTA确诊。左锁骨下动脉支架成形术成功率为100% （5/5）， 术后残余狭窄率均小于 10%， 症状性患者的症状均消失， 双侧上臂收缩压差均小于20 mmHg。使用左乳内动脉与冠状动脉前降支搭桥术中左乳内动脉血流量正常， 术后心绞痛症状均消失， 未发现冠状动脉-锁骨下动脉窃血综合征。围手术期无脑卒中、 心肌梗死及死亡并发症。随访6~12个月， 平均10个月， 无后循环缺血、 上肢缺血、 心肌缺血相关症状， 双侧上臂收缩压差均小于20 mmHg。结论 无创动脉硬化检测技术对锁骨下动脉狭窄的筛查有独到的价值。     

头臂动脉狭窄的介入治疗（附5例报告）

目的 探讨介入治疗头臂动脉狭窄的方法与价值。方法 本组5例，颈总动脉狭窄2例．其中1例行经皮血管内成形术，1例行血管内支架置入治疗。锁骨下动脉狭窄3例．其中2例行经皮血管内成形术，1例行血管内支架治疗。结果 对5例头臂动脉狭窄病例进行了介入治疗全部成功。治疗后血管恢复通畅，患者临床症状消失。结论介入治疗头臂动脉狭窄性病变创伤小，并发症少，安全有效。     

无脉症的血管造影观察

本文报告34例无脉症的血管造影结果。除7例仅累及头臂动脉外,27例(79.4％)同时累及了主动脉及其它分支。34例共累及137支动脉,平均每例为4.02支。34例的锁骨下动脉均受累,其中双侧病变19例,单侧15例,左右两侧受犯数相近(29:27例)。侵及椎动脉口以近者占37％(右)和53.6％(左)。7例出现锁骨下动脉窃血综合征。无脉症在血管造影上主要表现为动脉的狭窄或闭塞性改变。     

锁骨下动脉狭窄患者的临床症状与DSA表现的相关性

目的锁骨下动脉狭窄的临床症状与DSA改变的相关性。方法DSA证实锁骨下动脉狭窄28例,并把患者分为症状组18例及无症状组10例,分析两组患者的锁骨下动脉狭窄程度、侧支代偿与临床症状的关系。结果锁骨下动脉狭窄患者狭窄程度与临床症状无关,与侧支代偿有关。结论DSA能更好明确病变的程度和范围,评估侧支代偿,为临床诊断和治疗提供了的依据。     

彩色多普勒超声在锁骨下动脉盗血综合征诊断中的应用

目的分析比较14例锁骨下动脉盗血综合症患者锁骨下动脉、椎动脉和上肢动脉的血流动力学、频谱特点、狭窄程度与盗血关系,探讨如何提高锁骨下动脉盗血综合症的超声诊断符合率。方法应用Philips公司生产的iu22彩色多普勒超声诊断仪,回顾性分析我院检出的14例锁骨下动脉盗血综合症患者资料,选择高频探头探查颈动脉、椎动脉、锁骨下动脉远端及上肢动脉,选择低频小探头探查锁骨下动脉起始段。将其分为三型:完全型(椎动脉频谱完全呈反向),部分型(椎动脉频谱收缩期出现反向血流),隐匿型(椎动脉频谱收缩期出现切迹)。结果14例患者均由动脉粥样硬化引起,其中锁骨下动脉闭塞4例,均引起完全型盗血,狭窄10例,完全型盗血2例,部分型盗血5例,隐匿型盗血4例。结论彩色多普勒显像可对完全型动脉盗血综合症做出诊断,部分型及隐匿型动脉盗血综合症可辅助于脉冲多普勒和束臂试验以明确诊断。锁骨下动脉盗血与狭窄程度相关。对隐匿型盗血应充分认识椎动脉频谱早期特征性改变,从而避免漏诊的发生。     

彩色多普勒超声对锁骨下动脉盗血综合征的血流动力学观察

目的:探讨32例锁骨下动脉盗血综合征(SSS)患者锁骨下动脉、椎动脉和桡动脉的血流动力学、频谱特点及狭窄程度与盗血的关系等.方法:32例患者均经临床检查、超声诊断以及相关检查确诊.彩色多普勒超声常规显示颈动脉、椎动脉、桡动脉、锁骨下动脉的内径、内膜和血流方向及速度,将其分为三型:完全型(椎动脉频谱完全呈反向),部分型(椎动脉频谱收缩期出现反向频谱),隐匿型(椎动脉频谱收缩期出现切迹).结果:32例患者中,锁骨下动脉狭窄24例,内径1.2～4.1 mm,血流速度120～480 cm/s,其中部分型盗血15例,隐匿型盗血9例;8例锁骨下动脉闭塞,引起完全型盗血.结论:彩色多普勒超声血流显像(CDFD可对完全型SSS做出诊断,部分型及隐匿型SSS可辅助于脉冲多普勒和束臂试验明确诊断.盗血与锁骨下动脉狭窄程度有关.对隐匿型盗血应注意椎动脉频谱早期的特征性改变,避免漏诊.     

锁骨下动脉盗血TCD、颈部加强MRA检测及束臂实验观察

锁骨下动脉盗血综合征(SSS)临床可表现为不同类型的综合征,如考虑不周或经验不足,常易误诊.经颅多普勒超声诊断仪(TCD)诊断锁骨下动脉(Subcl)盗血显示了特有的优势,在这方面已有很多报道.本文观察了17例锁骨下动脉盗血患者狭窄侧束臂试验时血流改变过程及颈部加强磁共振血管成像(MRA)表现,现报道如下.     

主动脉弓分支及变异

主动脉弓位于上纵隔内．胸骨角平面以上一段。起于右第二胸肋关节水平．然后从右前方弯向左后方。头颈部血供来源于主动脉弓的大血管。通常主动脉弓由左而右发出头臂干、左颈总动脉和左锁骨下动脉．头臂干又分出右侧锁骨下动脉和右侧颈总动脉．双侧椎动脉一般发自双侧锁骨下动脉．约占人群的2／3．但有许多变异．从主动脉弓分出的大血管可少到2支．多达6支。现将我院近年脑动脉造影所见的几种主动脉弓分支变异报道如下：     

多普勒超声在诊断锁骨下动脉盗血综合征中的应用价值

目的 探讨多普勒超声在锁骨下动脉盗血综合征(subclavina steal syndrome,SSS)诊断中的应用价值.方法 回顾性分析经血管造影(DSA)证实为SSS患者41例,且同期均做过颈部血管超声检查,两种检查方法进行比较,重点观察狭窄处流速与椎动脉反向流速的关系、多普勒超声诊断SSS的准确率、盗血分级与狭窄程度的比较.结果 41例SSS患者中超声诊断40例,发生于右侧者20例,左侧者20例,部位均发生在锁骨下动脉起始段.椎动脉Ⅰ级盗血10例,Ⅱ级盗血26例,Ⅲ级盗血4例.锁骨下动脉狭窄处流速均大于170 cm/s.在Ⅱ级盗血中,随锁骨下动脉狭窄处流速的增加(200~439 cm/s),椎动脉反向流速随之增高(5~45 cm/s).随狭窄程度的增加,超声诊断SSS准确率相应提高,总的诊断准确率为97.6%.同一狭窄程度组别,超声诊断SSS与DSA比较,差异无统计学意义(P<0.05).不同狭窄程度组,超声诊断SSS差异无统计学意义(P>0.05).Ⅰ级盗血中,轻度狭窄多见为70.0%;Ⅱ级盗血中,中-重度狭窄多见为84.6%;Ⅲ级盗血中,全部闭塞,为100%.结论 多普勒超声不但诊断SSS准确率高,而且能够较准确的评估锁骨下动脉狭窄程度,在临床应用中拥有很高的价值.     

血管内支架成形术在锁骨下动脉闭塞患者中的临床观察与随访

目的探讨血管内支架成形术治疗锁骨下动脉闭塞患者的安全性与有效性。方法对18例经DSA或CTA证实锁骨下动脉闭塞的患者实施血管内支架植入,观察血管狭窄程度在术前、术后以及术后6个月的变化,以及相关并发症。术后随访6个月,行Malek评分。结果 18例患者中13例成功植入支架,锁骨下动脉狭窄率从术前100%下降至术后的18%[（22±10）%],除1例出现穿刺点皮下血肿5例出现动脉夹层,未发生其他围手术期并发症。在6个月的临床随访中,12例患者症状明显改善,1例患者发生再狭窄,Malek评分显著改善。结论锁骨下动脉闭塞的血管内支架成形术是一种安全有效的治疗锁骨下动脉闭塞的方法,但远期疗效仍需要前瞻性大规模的临床研究进一步观察。     

Coronary Artery Toxicity in Beagle Dogs Given Indolidan, a Type III Phosphodiesterase Inhibitor

The hemodynamic changes and cardiovascular lesions producedby a single iv dose of 2.0 mg/kg indolidan were evaluated infour beagle (two male, two female) dogs. Four additional dogs(two male, two female) served as vehicle controls. This wasfollowed by a multidose study in which the same dose of indolidanor vehicle was given iv to dogs (4/group) on 4 consecutive days.Both studies were followed for 4 days postdose before termination.Clinical signs, mean arterial blood pressure, and heart ratewere evaluated. Seven sections of the heart, approximately 25sections of the coronary arteries, and 3 sections of the carotid,subclavian, spermatic or ovarian, renal, and femoral arterieswere examined. Mean blood pressure was decreased 20 to 25% overa 24-hr period and heart rates were increased 40 to 50% aftertreatment and remained elevated for at least a 24-hr periodin both single and multidose treated groups. The earliest lesionsoccurred in three of four treated dogs after a single intravenousdose of 2.0 mg/kg. The main lesion was sporadic in distributionand seen in the outer one-half of the smooth muscle media ofthe coronary arteries. Smooth muscle degeneration and necrosiswere present, with little secondary inflammation. No lesionswere observed in the peripheral arteries or the myocardium.The coronary arterial lesions observed after the multidose studywere more extensive and severe. The lesions were seen in largeextramural and large intramural coronary arteries. These werecharacterized by marked smooth muscle necrosis involving mostof the media, destruction of the internal elastic membrane,and marked adventitial fibroplasia. The inflammatory infiltratevaried from mild to moderate and was usually seen in the adventitia.No lesions were observed in the peripheral arteries or the myocardiumin the multidose study.     

Blood pressure during a combination of ketanserin and hydrochlorothiazide

The antihypertensive effectiveness of a combination of ketanserin 20 mg plus hydrochlorothiazide 25 mg has been evaluated in 20 patients with arterial hypertension of mild to moderate degree in the age group over 50 years (age range 50-78 years). After a wash-out period of at least two weeks, patients were given a single oral dose of ketanserin 20 mg or thiazide 25 mg in a randomized order at two-day intervals and blood pressure, heart rate and cardiac workload (systolic blood pressure x heart rate) were measured during the following 24 h by an automatic recorder. Thereafter patients were given the combination of the two drugs for six weeks and 24 h blood pressure was assessed after the first dose and at the end of the treatment. A significant fall in systolic and diastolic blood pressure was rapidly induced by ketanserin from 2 to 8 h after dosing; thiazide on the other hand did not induce any change in these parameters (169 +/- 15/95 +/- 6 mmHg (22.5 +/- 2.0/12.7 +/- 0.8 kPa) at baseline versus 153 +/- 17/89 +/- 7 mmHg (20.4 +/- 2.3/11.9 +/- 0.9 kPa) at 2 h and 157 +/- 19/87 +/- 8 mmHg (20.9 +/- 2.5/11.6 +/- 1.1 kPa) at 8 h on ketanserin; 166 +/- 15/93 +/- 6 mmHg (22.1 +/- 2.0/12.4 +/- 0.8 kPa) at baseline versus 160 +/- 12/89 +/- 6 mmHg (21.3 +/- 1.6/11.9 +/- 0.8 kPa) at 2 h and 157 +/- 15/89 +/- 5 mmHg (20.9 +/- 2.0/11.9 +/- 0.7 kPa) at 8 h on thiazide).(ABSTRACT TRUNCATED AT 250 WORDS)     

Nicardipine versus nifedipine: multicentre controlled trial in essential hypertension

Ninety-five hypertensive outpatients of both sexes, aged 23 to 65 years with diastolic blood pressures above 105 but below 120 mmHg (greater than 14.0 but less than 16.0 kPa), after one week on a placebo were randomly assigned either to nicardipine plus a placebo (40 mg/day - 48 patients) or nifedipine sustained-release plus a placebo (20 mg/day - 47 patients) for an additional six weeks. The study groups were homogeneous and comparable. After the run-in period the average blood pressure was 181 +/- 17/116 +/- 9 mmHg (24.1 +/- 2.3/15.5 +/- 1.2 kPa) in the nicardipine and 177 +/- 22/116 +/- 9 mmHg (23.6 +/- 2.9/15.5 +/- 1.2 kPa) in the nifedipine group (p greater than 0.10). In the acute oral test (nicardipine 40 mg to all the subjects; blood pressure measured at 30 min intervals during two hours) almost identical hypotensive effects within and between groups were observed (mean arterial pressure decrease of 11%, after 120 min; p less than 0.05). At the end of this trial blood pressure decreased further to 152 +/- 12/94 +/- 11 mgHg (20.3 +/- 1.6/12.5 +/- 1.5 kPa) (mean decrease of 20%; p less than 0.01) on nicardipine and to 145 +/- 12/94 +/- 11 mmHg (19.3 +/- 1.6/12.5 +/- 1.5 kPa) (mean decrease of 20%; p less than 0.01) on nifedipine. There were no significant changes in pulse rate. The observed between-group differences were trivial (p greater than 0.10). The laboratory data did not alter appreciably during this study. Three patients on nicardipine and four on nifedipine reported headache, palpitations and flushing: one patient on nicardipine and two on nifedipine were as a result excluded from the trial. It was concluded that nicardipine and nifedipine sustained-release were comparably effective and well-tolerated drugs suitable as the first-line agents for the management of mild to moderate hypertension.     

早期尼卡地平用于蛛网膜下腔出血对患者脑血流的改善及CVS的预防作用

目的 研究早期尼卡地平对蛛网膜下腔出血患者脑血流的改善及脑血管痉挛(CVS)的预防作用.方法 选取本院2015年1月10月收治的70例蛛网膜下腔出血患者为研究对象,将以上患者抽签随机分为观察组与对照组,每组35例.对照组常规镇静、镇痛、控制颅内压、预防再出血,治疗前检测患者颅内压、脑血流;观察组在对照组基础上采取尼卡地平治疗.于入院即刻,治疗后7、14、21 d比较两组脑血流、颅内压的改变,并且观察CVS发生情况及预后.结果 两组颅内压及脑血流入院即刻比较,差异无统计学意义(P＞0.05);治疗后7、14、21 d,观察组颅内压分别为(19.42±3.42) mmHg(1 mmHg=0.133 kPa)、(13.05±1.86)mmHg、(11.74±2.54) mmHg,显著低于对照组[(27.42±5.01)mmHg、(16.75±1.67) mmHg、(20.60±1.85) mmHg](P＜0.05);治疗后7、14、21d,观察组脑血流速度分别为(104.25±20.41) cm/s、(101.55±10.25)cm/s、(94.81±9.6)cm/s,显著低于对照组[(134.24±28.66) cm/s、(117.25±25.41) cm/s、(113.66±8.68) cm/s] (P＜0.05).观察组CVS发生率及重残患者比例分别为2.86％、8.57％,显著低于对照组的17.14％、28.57％ (P＜0.05);两组良好、中残所占比例比较,差异无统计学意义(P＞0.05).结论 尼卡地平治疗蛛网膜下腔出血效果显著,对脑血流及颅内压的改善及CVS的预防作用显著,且可改善患者预后,有较高的临床应用价值.     

Clinical evaluation of amlodipine, a new long-acting calcium antagonist, in mild and moderate hypertension.

The antihypertensive efficacy of amlodipine was studied in 22 patients (16 female, six male) with mild-to-moderate hypertension. Following an initial two-week placebo run in, patients with a sitting diastolic blood pressure in the range 95-115 mmHg (12.7-15.3 kPa) began the 12-week active treatment phase with amlodipine at a dose of 5 mg once daily. If the sitting diastolic blood pressure was not reduced to less than or equal to 90 mmHg (12.0 kPa) after four weeks' treatment, the amlodipine dose could be adjusted to 10 mg once daily. The final four weeks of active treatment comprised of a maintenance phase during which the dose, which had produced the desired therapeutic response in each patient, remained constant. At the end of the trial, 18 patients (85.7%) were classified as therapeutic successes (reduction in diastolic blood pressure to less than or equal to 90 mmHg [12.0 kPa] with a greater than or equal to 5 mmHg [0.7 kPa] from baseline values or a greater than or equal to 10 mmHg [1.3 kPa] decrease from baseline). Of these patients, 16 received the 5 mg dose throughout the study and only two required an increase to 10 mg once daily. Patients generally tolerated amlodipine treatment well.     

急性脑梗死患者心脏功能和颅内外动脉血流动力学的临床研究

目的　应用超声检测方法研究急性脑梗死患者心脏功能和颅内外动脉血流动力学变化。方法　选择2019年1月至12月连云港市第二人民医院神经内科住院的急性脑梗死（acute cerebral infarction,ACI）患者79例（ACI组）,男50例,女29例,年龄42～87（66.27±9.89）岁;对照组为同期健康体检者33例,男19例,女14例,年龄41～86（64.15±10.11）岁。两组行心脏彩超检查获取心脏结构和功能指标,动脉超声检查获取动脉内径、血流速度、阻力指数和动脉内膜中层厚度;经颅多普勒超声检查获取颅内动脉血流速度。计量资料采用独立样本t检验,率的比较采用χ²检验。结果　（1）ACI组左房内径为（39.40±3.13）mm、左室舒张末期内径为（50.26±3.48）mm、右室内径为（23.93±1.89）mm、肺动脉压为（38.11±3.37）mmHg（1 mmHg=0.133 kPa）,均较对照组增加［分别为（38.00±3.32）mm、（48.82±2.51）mm、（22.89±1.23）mm、（36.08±2.35）mmHg］,差异均有统计学意义（t=2.007、2.276、2.677、2.907,P=0.048、0.026、0.009、0.005）。（2）ACI组左、右颈总动脉舒张末期血流速度（Vd）,左颈内动脉Vd及右颈内动脉收缩期峰值血流速度（Vs）均低于对照组,差异均有统计学意义（均P<0.05）;ACI组左、右颈总动脉阻力指数高于对照组,差异均有统计学意义（均P<0.05）。ACI组两侧椎动脉舒张末期流速差（ΔVd）高于对照组,差异有统计学意义（P<0.05）。（3）ACI组右侧大脑前动脉Vd高于对照组,差异有统计学意义（P<0.05）;ACI组两侧大脑前动脉ΔVd,两侧大脑中动脉ΔVd,两侧椎动脉ΔVd高于对照组,差异均有统计学意义（均P<0.05）。结论　ACI患者通过调节心脏结构与颅内外动脉血流速度以改善脑的供血。     

社区护士介入社区老年原发性高血压患者降压药用药清单管理效果

目的探讨社区护士介入社区老年原发性高血压患者降压药用药清单管理效果。方法选取2021年9月至2022年3月济南市妇幼保健院舜玉路社区门诊收治的480例社区老年原发性高血压患者进行随机对照试验, 采用随机数字表法将其分对照组与研究组, 各240例。对照组开展常规降压药物指导, 研究组开展社区护士介入社区老年原发性高血压患者降压药用药清单管理, 均持续3个月。采用Morisky用药依从性8条目量表(MMAS-8)评价入组时、干预1个月、干预3个月降压药物服用依从性;并记录入组时、干预1个月、干预3个月收缩压(DBP)与舒张压(SBP), 计算血压控制达标率。采用独立样本t检验、χ2检验和方差分析。结果对照组219例, 研究组221例纳入最终分析。对照组男126例, 女93例, 年龄62～87(76.40±8.26)岁, 高血压病程(6.82±2.64)年。研究组男132例, 女89例, 年龄61～90(76.28±8.41)岁, 高血压病程(6.76±2.72)年。干预后1个月、3个月研究组MMAS-8评分[(6.25±0.91)分比(5.36±0.84)分、(6.78±0.83)分比(5...     

分水岭脑梗死部位与颈、脑大动脉病变的关系

目的探讨脑分水岭梗死（CWI）部位与颈、脑大动脉狭窄及闭塞的关系。方法对52例常规头颅CT和MRI检查证实为分水岭梗死脑梗死患者行MRA检查颈、脑大动脉病变情况。结果52例患者大动脉狭窄、闭塞总发生率92．3％（48／52），其中颈内动脉及大脑中动脉占84．7％。皮质前型病灶颈内动脉病变59．3％（16／27），大脑中动脉病变40．7％（11／27），皮质下型病灶颈内动脉病变40％（12／30），大脑中动脉病变60％（18／30）。皮质后型病灶颈内及大脑中动脉病变87．5％（14／16），大脑后动脉病变37．5％（6／16），基底动脉病变18．75％（3／16）。结论颈内动脉及大脑中动脉狭窄或闭塞是脑分水岭梗死的主要病理基础。