股浅动脉闭塞支架术后再狭窄的危险因素分析

目的:研究卢瑟福分级为3~6级股浅动脉闭塞支架治疗术后支架内再狭窄(ISR)的相关危险因素。方法:回顾性分析我院自2009年1月1日至2013年12月31日,因股浅动脉闭塞行镍钛金属裸支架置入术的85例患者(卢瑟福3~6级)93例患肢。术后定期行下肢动脉彩超、Doppler或CTA检查观察支架内通畅情况,并收集相关临床资料加以统计分析。结果:全组手术技术成功率为100%。共为93例患肢置入173枚镍钛金属裸支架。术后第1天,复查彩超示无残余狭窄、无支架内血栓形成、无支架两端夹层形成;复查Doppler示患肢踝肱比(ABI)平均为(0.95±0.18),较术前0.48±0.18明显提高(t=-21.694,P=0.000)。术后平均随访时间16.0±15.0(0.27~58.0)个月,第3、6、12个月的一期通畅率分别为83.9%、67.1%、49.4%。病变总长度(P=0.031)、TASC II C/D级病变(P=0.034)和糖尿病(P=0.031)与ISR的发生密切相关。结论:股浅动脉病变总长度、TASC II C/D级病变及糖尿病是卢瑟福分级为3~6级股浅动脉闭塞支架术后ISR的危险因素。     

老年TASCⅡC、D型LEAOD完全闭塞病变腔内治疗的疗效

目的探讨血管腔内治疗老年主-髂动脉闭塞(TASC)ⅡC、D型下肢动脉硬化闭塞症(LEAOD)完全闭塞病变的可行性及近期临床疗效。方法回顾性分析采用腔内治疗的27条患肢(21例患者)老年下肢TASCⅡC、D型LEAOD的临床资料。结果手术成功率为88.9%(24/27),其中经皮腔内血管成形术(PTA)治疗3条,PTA联合支架植入术(PTAS)治疗21条,共置入支架57枚。手术成功病例平均随访8.75个月(6¹8个月),术后3个月足背动脉踝肱指数(ABI)由术前的0.39±0.14上升至0.8±0.19(P<0.01);胫后动脉ABI由术前的0.45±0.12上升至0.90±0.10(P<0.01)。术后6个月动脉通畅率83.3%(20/24),保肢率95.8%(23/24)。结论对于老年TASCⅡC、D型LEAOD完全闭塞病变,血管腔内治疗安全有效,创伤小,近期临床疗效满意。     

血管腔内治疗脑梗死合并下肢严重缺血的探讨

目的 观察血管腔内治疗脑梗死患者合并下肢严重缺血病变的技术成功率和临床疗效。方法 回顾性地分析2008年1月至2014年12月期间收治的Fontaine分级Ⅲ～Ⅳ级脑梗死伴肢体活动障碍患者280例（326条患肢）,采用以血管腔内治疗为主治疗。观察技术成功率、并发症、临床疗效、踝/肱指数（ABI）、治疗血管再狭窄等。结果 280例患者（326条患肢）共进行342次血管腔内治疗,309条患肢治疗成功,技术成功率为94.8%（309/326）,无严重并发症。患者手术成功后临床症状均明显改善。术前所有患者ABI为0.26±0.24,成功治疗术后ABI为0.72±0.29,手术前后患者ABI差异有统计学意义（P＜0.05）。共有210例患者（242条患肢）经术后＞6个月随访,平均随访27个月（3～90个月）,术后6个月、12个月ABI分别为0.65±0.26、0.54±0.31,均较术前显著增加;超声检查示术后1年随访期间有87条患肢（35.9%）治疗血管再狭窄或闭塞,其中70例（28.9%）症状复发再次行血管腔内治疗。结论 下肢动脉病变行血管腔内治疗手术技术成功率较高、并发症发生率较低、疗效确切,可作为下肢动脉病变的首选治疗;由于脑梗死肢体活动障碍患者术后功能锻炼受限,血管再狭窄发生率较高,需进一步研究以提高闭塞性病变的手术成功率和术后治疗血管的通畅率。     

合并髂动脉病变的腹主动脉瘤腔内处理方案探讨

目的探讨合并髂动脉病变的腹主动脉瘤(AAA)的腔内处理方案。方法回顾性分析2008年1月至2016年12月北京积水潭医院血管外科收治的AAA行腔内治疗的52例患者临床资料,包括性别、年龄、患者临床特点(冠心病、高血压、糖尿病、高脂血症)、股深动脉及股浅动脉通畅率,按照是否存在严重髂动脉病变将患者分为髂动脉通畅组和髂动脉狭窄或闭塞组,分别进行腔内治疗,并于术后接受抗凝、抗血小板治疗以防动脉粥样硬化。根据数据类型,组间比较采用t检验或x~2检验(Fisher确切概率法)。结果 52例患者被分为髂动脉通畅组41例和髂动脉狭窄或闭塞组11例,其中通畅组髂动脉严重扭曲2例(3.8%,2/52),狭窄或闭塞组髂动脉狭窄9例(17.3%,9/52)及闭塞2例(3.8%,2/52),术前两组患者性别、年龄、患者临床特点(冠心病、高血压、糖尿病、高脂血症)、股深动脉及股浅动脉通畅率比较,差异均无统计学意义(P0.05)。两组患者均成功实施了AAA腔内修复(EVAR)术,其中通常组扭曲者通过特硬导丝纠正髂动脉成角后支架顺利通过,狭窄或闭塞组给予患侧或对侧球囊扩张或逆行开通股动脉进行扩张,支架最终顺利通过。随访了12~24个月,狭窄或闭塞组出现一侧髂动脉腿支的闭塞2例(P0.05),1例行右髂序贯放置髂腿支架1枚+双侧股动脉人工血管转流术,术后双下肢动脉供血良好。结论合并髂动脉病变会导致AAA腔内治疗困难,运用合理的手术技巧和器材的配合,AAA患者行EVAR术均可以获得成功,远期通畅率较好。     

股深动脉优势供血治疗TASC D型动脉硬化下肢缺血的疗效分析

目的 探讨髂动脉通畅的泛大西洋协作组织共识（TASC） D型动脉硬化下肢缺血的治疗方式,比较股浅动脉支架植入术与股深动脉成形术的疗效。方法 回顾性地分析2007年1月至2010年12月北京积水潭医院血管外科收治的32例TASC D型下肢缺血患者临床资料,随机分为股浅动脉治疗组（行股浅动脉球囊扩张+支架植入术）16例和股深动脉治疗组16例,并进行对照分析。通过对比手术前后踝肱指数（ABI）、手术后3年截肢率及症状改善情况评价两种方法的疗效。结果 两组患者术后ABI均明显高于术前（P＜0.05）;且股浅动脉治疗组术后ABI高于股深动脉治疗组（P＜0.05）。两组3年后跛行距离＜200米和行截肢手术患者比较,差异均无统计学意义（P＞0.05）。结论 髂动脉通畅的TASC D型动脉硬化下肢缺血患者,无论腔内股浅动脉支架植入术还是股深动脉成形术均可改善患者症状,增加肢体血供;股浅动脉支架植入对患者近期远端肢体血供改善优于股深动脉成形术。     

血浆 IP10水平与冠心病患者 PCI 术后支架内再狭窄的关系

目的：探讨血浆IP10水平与冠心病患者经皮冠状动脉介入治疗（PCI）术后支架内再狭窄的关系。方法选取行PCI的冠心病患者（均植入冠状动脉支架）, PCI术后半年复查冠状动脉造影,结果示支架内再狭窄且狭窄程度≥参照血管50％患者17例为支架内再狭窄组（ ISR组）;造影提示支架内再狭窄＜50％或无再狭窄患者95例为支架内无再狭窄组（ NSR组）;另选冠状动脉造影示冠状动脉狭窄程度＜50％的胸痛患者106例作为对照组。比较三组血浆IP10水平。结果 NSR组血浆IP10水平高于对照组,但两组比较P＞0．05;ISR组血浆IP10水平明显高于NSR组（P＜0．05）。结论支架内再狭窄患者血浆IP10水平明显高于支架内无再狭窄者;IP10有可能作为评价PCI术后支架内再狭窄发生风险的一项独立预测指标。     

老年病人股浅动脉支架植入术后再狭窄的临床干预及效果

目的探讨老年病人股浅动脉支架植入术后再狭窄临床处理方式及优化腔内干预、外科干预选择及操作手段。方法回顾性分析该科自2010年1月至2014年7月112例65岁以上股浅动脉支架植入术后再狭窄患者(共计133条患肢),该组患者年龄中位数为71岁(年龄范围:66~92岁),根据临床处理方式分为外科治疗组和介入治疗组,随访观察两组病例术后近、远期通畅率、再狭窄率、TASC分型、踝肱指数、心脑血管重大事件发生率、严重并发症发生率等,讨论分析腔内干预、外科干预二者的适应证及优化方向。结果 112例患者共计133支病变血管,术后绝大部分患者下肢缺血情况获得明显缓解,其中介入干预64例(77条患肢),无严重并发症;外科干预48例(56条患肢),3例发生术后切口愈合不良,1例发生移植人工血管内血栓形成。术后心脑血管重大事件发生率分别为4.7%和12.1%。结论介入手术治疗与外科开放手术治疗均为处理老年病人股浅动脉支架术后再狭窄的有效手段,但介入治疗组病人的心脑血管重大事件发生率及严重并发症发生率明显降低。     

髂动脉病变腔内治疗围手术期并发症的防治

目的:探讨应用腔内技术,治疗髂动脉动脉硬化性狭窄或闭塞术中,围手术期常见并发症及其处理。方法:自2006年6月至2010年6月,105例患者的130条髂动脉病变血管,应用腔内成形术及支架植入术。结果:128条髂动脉病变血管腔内治疗操作获成功,2条髂动脉闭塞尝试开通失败。术后患者踝臂指数(ABI)由术前的0.44±0.15,提高至0.79±0.22,二者差异有统计学意义(P<0.01)。围手术期并发症发生率14.2%,包括术前1例急性心肌梗死,1例肺部感染,术中1例闭塞髂动脉开通中破裂,2例肱动脉血栓形成,2例术中出现对侧肢体栓塞,术后2例患者股动脉术后出现假性动脉瘤,穿刺部位血肿4例,肺部感染2例,消化道出血2例。其中1例患者术后出现应激性溃疡消化道出血,后并发多脏器功能衰竭死亡,围手术期病死率为0.9%。随访12个月的一期通畅率为94.3%,二期通畅率为100%。结论:腔内治疗对于髂动脉病变有良好的治疗效果,但治疗同时尽可能减少围手术期局部及全身并发症。     

药物涂层球囊对老年患者下肢动脉粥样硬化闭塞症支架内再狭窄的疗效

目的探究老年下肢动脉粥样硬化闭塞症中股浅动脉支架内再狭窄行药物球囊治疗后效果。方法 28例(28条肢体)股浅动脉支架后再狭窄患者中狭窄19例,闭塞9例。根据临床治疗方式分为普通球囊血管成形术14例(A组)和药物涂层球囊血管成形术14例(B组)。结果28例均手术成功,手术时间60~100 min,术中均未出现相关并发症。术后数字化减影血管造影术(DSA)显示靶血管形态及通畅性均良好。术后给予常规用药,住院1 w,出院后常规双抗用药;均获得随访3~12个月。术后6个月通畅率A组78.60%(11/14)、B组100.00%(14/14);12个月通畅率A组64.30%(9/14)、B组85.70%(12/14);两组差异显著(P<0.05)。术后无截肢或死亡病例。结论对于股浅动脉支架内再狭窄患者行药物涂层球囊治疗较普通球囊血管成形术的近中期通畅率有显著提高。     

股动脉内膜切除术联合腔内治疗多阶段下肢动脉闭塞

目的 探讨股总动脉(common femoral artery, CFA)内膜切除联合腔内治疗下肢动脉多节段狭窄闭塞的有效性和安全性。方法 自2010年2月至2013年4月,对于累及CFA和股浅动脉(superficial femoral artery,SFA)及股深动脉(femoral profound artery, FPA)起始处的多节段狭窄闭塞病变的65条肢体(61例);同期采用CFA内膜切除和腔内技术治疗髂动脉(iliac artery,IA)、SFA、腘动脉及膝下动脉的复合术式进行处理。判定技术和血流动力学的成功,术后第6、12、24、36个月进行随访,记录患者的临床症状、踝肱指数(ankle-brachial index,ABI)和下肢动脉多普勒超声,统计初次通畅率和二次通畅率。 结果 所有手术操作都取得了成功,ABI由术前的0.32±0.22 增至术后的0.83±0.34 (P<0.01)。围手术期没有死亡和严重截肢病例。61例患者平均随访时间30个月(14-36个月)。随访期间4例死亡;股浅动脉支架共18例(32.7%)发生再狭窄,再狭窄者中的5例接受了再干预,12、24、36个月的初次通畅率分别为92.3%、77.8%、65.3%;二次通畅率分别为95.3%, 89.2%, 76.7%。髂动脉支架2例发生再狭窄,未干预。股总动脉随访期间无再狭窄发生。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.