血管腔内介入治疗下肢动脉硬化闭塞症40例

目的：探讨下肢动脉硬化闭塞症腔内治疗的临床经验。方法：采用血管腔内介入方法治疗下肢动脉硬化性闭塞症（ASO）患者40例（44条肢体）,包括髂动脉病变18例,其中单纯球囊扩张术（PTA）6例,内置支架术（PTA＋stenting）12例;股浅动脉病变13例,其中PTA5例,PTA＋stenting8例;腘动脉病变2例,行PTA治疗;膝下动脉病变7例,单纯deep球囊扩张,不放置支架。结果：本组无手术死亡。髂动脉18例手术全部获得成功;股浅动脉13例,11例获得成功,1例致血栓形成取栓治疗成功,1例介入失败转为人工血管转流手术;腘动脉2例获得成功;膝下动脉7例中5例获得成功。结论：血管腔内介入治疗下肢ASO,操作简单,短期效果良好,值得临床推广应用;     

股腘动脉人工血管旁路术中膝周肌瓣构建侧支血管在下肢动脉硬化闭塞症治疗中的应用与观察

目的 探讨股腘动脉人工血管旁路术中膝周肌瓣构建对下肢动脉硬化闭塞症（ASO）患者术后人工血管闭塞后膝下血供的代偿作用。方法 回顾性描述性研究。选取皖南医学院附属弋矶山医院血管外科2012年6月—2020年7月ASO患者31例,其中男22例、女9例,年龄52~87（72.3±3.6）岁。均为单侧肢体病变,左侧14例、右侧17例,Rutherford分期3级以上,踝肱指数（ABI）为0.32±0.13。均行股腘动脉人工血管旁路术治疗,术中将离断的腓肠肌内侧头与同侧的半膜肌、半腱肌及缝匠肌瓦合叠加缝合,以膝周肌瓣构建侧支血管。术后,在超声检查人工血管闭塞（无血流信号）后,观察患者肢体缺血情况,同时观察并比较患者手术前后ABI;出院时按照Rutherford标准评价患者手术疗效;随访期间观察并统计患者截肢率,观察成功保肢患者的生活状态。结果 31例患者手术均顺利完成,无围术期死亡患者。术后1周ABI为0.58±0.19,高于术前的0.32±0.13,差异有统计学意义（t=3.02, P=0.002）。出院时手术疗效评价：显著有效15例、有效10例、无效4例、恶化2例。术后随访6~60个月,平均24.6个月。患者在人工血管闭塞后,下肢虽有一过性疼痛、发凉等缺血症状,但经抗凝治疗症状缓解。术后2、24个月分别有1例患者死于心肌梗死,术后3年1例死于脑梗死,生前均无下肢静息痛症状,可作室内活动;2例因股深动脉多节段闭塞、膝下组织血供不足,分别于术后6、15个月行截肢术,余26例患者成功保肢,随访6个月~5年,均无需行临床再干预,均无静息痛。结论 股腘动脉旁路术治疗的ASO患者,采用腓肠肌肌瓣在膝周构建侧支血管,在人工血管闭塞后,下肢缺血无明显加重,说明肌瓣构建对缓解患者膝下肢体缺血状态有一定的作用。     

股腘动脉人工血管旁路术中膝周肌瓣构建侧支血管在下肢动脉硬化闭塞症治疗中的应用与观察

目的探讨股腘动脉人工血管旁路术中膝周肌瓣构建对下肢动脉硬化闭塞症(ASO)患者术后人工血管闭塞后膝下血供的代偿作用。方法回顾性描述性研究。选取皖南医学院附属弋矶山医院血管外科2012年6月—2020年7月ASO患者31例, 其中男22例、女9例, 年龄52～87(72.3±3.6)岁。均为单侧肢体病变, 左侧14例、右侧17例, Rutherford分期3级以上, 踝肱指数(ABI)为0.32±0.13。均行股腘动脉人工血管旁路术治疗, 术中将离断的腓肠肌内侧头与同侧的半膜肌、半腱肌及缝匠肌瓦合叠加缝合, 以膝周肌瓣构建侧支血管。术后, 在超声检查人工血管闭塞(无血流信号)后, 观察患者肢体缺血情况, 同时观察并比较患者手术前后ABI;出院时按照Rutherford标准评价患者手术疗效;随访期间观察并统计患者截肢率, 观察成功保肢患者的生活状态。结果 31例患者手术均顺利完成, 无围术期死亡患者。术后1周ABI为0.58±0.19, 高于术前的0.32±0.13, 差异有统计学意义(t=3.02, P=0.002)。出院时手术疗效评价:显著有效15例、有效10例、无效4例、恶化2例。术...     

后踝上皮瓣血供的解剖观察及临床应用

目的 探讨后踝上皮瓣的解剖特点,总结后踝上皮瓣治疗足踝部软组织缺损的临床经验,为后踝上皮瓣的临床应用提供依据。方法 2012年8—10月收集8侧新鲜成人下肢标本,股动脉灌注红色乳胶,解剖观察胫后动脉在小腿下段内侧的皮穿支及其营养腓肠神经、腓肠外侧皮神经的情况;观察腘窝外侧皮动脉穿出部位、走行、分布及与胫后动脉踝上穿支吻合情况,测量腘窝外侧皮动脉长度及直径。回顾性分析2007年2月—2012年6月兰州军区兰州总医院全军创伤骨科中心采用后踝上皮瓣移植修复的15例足踝部软组织缺损患者的临床资料,其中男11例,女4例;年龄18～49 岁,平均33岁;创面位于小腿下1/3段3例,足踝部7例,足底负重区5例。15例患者均采用后踝上皮瓣移植修复;术后观察患者皮瓣成活情况,创面完全愈合后1个月,有骨折者骨折临床愈合后3个月采用美国矫形足踝协会(AOFAS)评分系统评定踝关节功能。结果 8侧下肢标本观察示,胫后动脉在小腿下段发出2～4支肌间隙皮动脉,均有分支向外上方走行,供应腓肠神经及腓肠外侧皮神经,并与腘窝外侧皮动脉间有确定的吻合支;均见腘窝外侧皮动脉,起于股骨内外髁连线上方(1.8±0.47)cm处,于腘窝后正中线外侧(1.1±0.14)cm处穿出深筋膜并沿腓肠肌外侧头表面下行;腘窝外侧皮动脉均与腓肠外侧皮神经伴行,腘窝外侧皮动脉全长(14.21±3.89)cm、直径(1.23±0.24)mm。临床应用后踝上皮瓣移植修复足踝部软组织缺损15例,移植皮瓣全部成活13例,2例远端部分坏死。12例患者获随访6～18个月,平均11个月。患者皮瓣质地及外观良好,术后踝关节功能优8例,良4例。结论 后踝上皮瓣血管蒂位置相对隐蔽,外伤后不易损伤,且修复范围大,成活率高,是治疗足踝部软组织大面积缺损的一种较好的选择。     

腘动脉起源变异一例报告

<正> 我在尸体解剖中,发现一例双下肢腘动脉由臀下动脉延续而来的变异,似属少见报道,为了收集资料,现报道如下:女性成年尸,双下肢股动脉在腹股沟韧带下方4厘米处发出股深动脉后,主干逐渐变细在进入内收肌管前,就分成三条分支,分布于股前区肌肉,未见主干延续为腘动脉。当解剖下肢后部时,才发现腘动脉是     

动静脉转流术在下肢动脉硬化闭塞症中的应用

目的探讨动静脉转流术治疗下肢动脉硬化闭塞症,研究其技术操作及临床应用.方法对6例下肢动脉硬化闭塞症患者行腘动脉胫后静脉转流术.结果疗效优良5例,好转1例,术后只有一足趾截去.结论此方法不易导致心衰,可挽救缺血肢体,避免截肢,疗效满意.     

CDUS与A/BI联合检测对慢性下肢动脉闭塞症的应用价值

目的以彩色多普勒超声（CDUS）与踝／肱指数（A／BI）联合检测，对下肢慢性动脉闭塞疾病的诊断及对治疗前、后评价的价值。方法以下肢动脉血管造影确诊的120条动脉硬化性闭塞症（ASO）和血栓性脉管炎（TAO）60条为标准，用以确定CDUS检测的阳性诊断率，并加以分析：同时对180条下肢动脉的踩肱指数和89条下肢动脉闭塞症的术前、术后踝／肱指数变化予以测定并进行比较。结果CDUS检查结果与动脉血管造影（PAG）检查结果无显著差异，CDUS与A／BI联合检测对提高诊断率有较高准确性。A／BI测定对了解术前及术后供血有否改善提供重要参考依据。结论彩色多普勒超声检查与踝／肱指数测定是对ASO和ATO诊断及评价治疗效果、术后复查的首选方法。     

膝上外侧逆行皮瓣修复腘窝创面的解剖学基础与临床

目的：为膝上外侧逆行皮瓣修复腘窝创面的新术式提供解剖学基础。方法：20侧新鲜成人下肢标本灌注红色乳胶，解剖观察膝上外侧动脉，旋股外侧动脉降支的走行，分支，分布及其远端吻合情况。在研究基础上设计膝上外侧逆行皮瓣修复腘窝创面。结果：膝上外侧动脉，旋股外侧动脉降支等发出的肌间隙皮支，肌皮动脉有丰富的吻合，吻合支口径在0.6-1.5mm之间，临床应用30例，皮瓣长宽比例达5：1，全部成活，效果良好，结论：以膝上外侧动脉为蒂，可形成膝上外侧逆行皮瓣，转位修复严重腘窝瘢痕孪缩。     

下肢动脉血管再通修复重建对下肢动脉缺血导致创面修复的影响

目的 探讨下肢动脉血管再通修复重建对下肢动脉缺血导致创面修复的影响。方法 2003年6月至2007年5月对226例下肢动脉缺血导致创面的患者分为未行下肢动脉血管再通修复重建的患者118例和行下肢动脉血管再通修复重建的患者（包括经皮腔内血管成形修复及支架置入术、人工或自体血管搭桥动脉旁路移植术、动脉血管内膜硬化斑剥脱血管成型修复、动脉血管切开取栓和大网膜移植血流再通重建术）108例共两组，采用超声彩色多普勒和选择性血管造影进行检查是否存在下肢动脉的缺血，分析创面的愈合情况（包括创面愈合时间、截肢率和复发率等）。结果 （1）226例下肢动脉缺血形成的创面中足部感染或溃疡197例（87％，197／226），小腿皮肤慢性感染和溃疡29例（13％，29／226）。创面〈1cm者59例（26％，59／226），创面1～2cm者77例（34％，77／226），创面2～5cm者63例（28％，63／226），创面〉5cm者27例（12％，27／226）；（2）226例行超声彩色多普勒检查阳性结果201例（阳性率89％，201／226），其中完全闭塞者48例（24％，48／201），重度狭窄者71例（35％，71／201），中度狭窄者82例（41％，82／201）；（3）行选择性血管造影者192例，检测阳性结果为167例（87％，167／192），其中髂总动脉＋髂外动脉＋股动脉闭塞或狭窄者23例（14％，23／167），髂外动脉＋股动脉闭塞或狭窄者39例（23％，39／167），股动脉＋腘动脉闭塞或狭窄者58例（35％，58／167），腘动脉下动脉血管闭塞或狭窄者47例（28％，47／167）；（4）在108例下肢动脉血管再通修复重建的患者中，经皮腔内血管成形修复再通重建（PTA）及支架置入术32例（30％，32／108），人工或自体血管搭桥动脉旁路移植血管修复再通重建（髂-股动脉、髂-腘动脉、股-股动脉、股-腘动脉、股-胫前或后动脉）术36例（33％，36／108），动脉血管内膜硬化斑剥脱血管成型修复再通重建术25例（23％，25／108），动脉血管切开取栓再通术11例（10％，11／108），大网膜移植血流再通重建术4例（4％，4／108）；（5）行和未行下肢动脉血管再通修复重建的患者相比，创面愈合的天数平均缩短（25±3）天（P〈0．05），行下肢动脉血管再通修复重建的患者截肢率为7％（7／108），复发率为8％（8／108），未行下肢动脉血管再通修复重建的患者截肢率为14％（16／118），复发率为27％（32／118）。结论 在下肢动脉缺血导致下肢或足部创面的愈合的过程中，下肢动脉血管再通修复重建起非常关键的作用。     

带蒂股后皮神经营养血管皮瓣的解剖与临床应用

目的：报道股后皮神经营养血管带蒂皮瓣的解剖特点与临床应用疗效。方法：在10侧经动脉灌注红色乳胶成人新鲜下肢标本上，解剖观测股后皮神经血供及其筋膜皮支的分布范围，设计股后皮神经营养血管岛状皮瓣转移修复腘窝、髋关节周围软组织缺损6例。结果：股后皮神经营养血管主要来源臀下动脉、穿动脉和腘动脉后侧穿支的升皮支，并在股后区形成网状吻合营养股后侧皮肤。皮瓣5例全部成活，1例皮瓣远端少量坏死，换药后愈合。经12～44个月随访，皮瓣无破溃，膝、髋关节功能活动良好。结论：股后皮神经营养血管岛状皮瓣转位是一种修复腘窝、髋关节周围软组织缺损良好的方法。     

Accessory tissue of the tricuspid valve protruding into the left ventricle through a septal defect

We report the pathologic findings in 13 cases with accessory tissue originating from the tricuspid valve and protruding into the left ventricular outflow tract through a ventricular septal defect (VSD). In eight cases the accessory tissue formed a pouch, the walls of which were similar to the tissue of the normal tricuspid valve. In five cases, papillarylike masses of young connective tissue formed the accessory tissue. The degree of left ventricular outflow tract obstruction was mild in five cases, intermediate in five, and severe in three. Adhesions to the rims of the VSD causing obstruction of the VSD were seen in ten cases. Associated anomalies were present in all cases. The most frequent associated anomalies other than the tricuspid valvular anomalies and the VSDs were transposition of the great arteries and a variety of vascular anomalies.     

Pulmonary artery sarcomas. A review and report of a case

We examined a case of primary pulmonary artery sarcoma and reviewed 45 cases that we found previously reported in the English literature, with particular attention given to the pathologic features. These sarcomas involve the pulmonary arterial trunk, left and right main pulmonary arteries, pulmonary valve, and right ventricular outflow tract. They have prominent intravascular growth along the arterial intima. Lung involvement commonly occurs by direct extension through the pulmonary vasculature or by distant metastases. These sarcomas contain a variety of heterologous components and areas of bone, cartilage, and fibrous tissue may be remarkably well-differentiated. Management of these sarcomas will be aided by an understanding of their biologic behavior and pathologic features.     

Inactivation of Bmp4 from the Tbx1 expression domain causes abnormal pharyngeal arch artery and cardiac outflow tract remodeling

Maldevelopment of outflow tract and aortic arch arteries is among the most common forms of human congenital heart diseases. Both Bmp4 and Tbx1 are known to play critical roles during cardiovascular development. Expression of these two genes partially overlaps in pharyngeal arch areas in mouse embryos. In this study, we applied a conditional gene inactivation approach to test the hypothesis that Bmp4 expressed from the Tbx1 expression domain plays a critical role for normal development of outflow tract and pharyngeal arch arteries. We showed that inactivation of Bmp4 from Tbx1-expressing cells leads to the spectrum of deformities resembling the cardiovascular defects observed in human DiGeorge syndrome patients. Inactivation of Bmp4 from the Tbx1 expression domain did not cause patterning defects, but affected remodeling of outflow tract and pharyngeal arch arteries. Our further examination revealed that Bmp4 is required for normal recruitment/differentiation of smooth muscle cells surrounding the PAA4 and survival of outflow tract cushion mesenchymal cells.     

Dual role for neural crest cells during outflow tract septation in the neural crest-deficient mutant Splotch2H

Splotch^2H ( Sp^2H ) is a well-recognized mouse model of neural crest cell (NCC) deficiency that develops a spectrum of cardiac outflow tract malformations including common arterial trunk, double outlet right ventricle, ventricular septal defects and pharyngeal arch artery patterning defects, as well as defects in other neural-crest derived organ systems. These defects have been ascribed to reduced NCC in the pharyngeal and outflow regions. Here we provide a detailed map of NCC within the pharyngeal arches and outflow tract of Sp^2H/Sp^2H embryos and fetuses, relating this to the development of the abnormal anatomy of these structures. In the majority of Sp^2H/Sp^2H embryos we show that deficiency of NCC in the pharyngeal region results in a failure to stabilize, and early loss of, posterior pharyngeal arch arteries. Furthermore, marked reduction in the NCC-derived mesenchyme in the dorsal wall of the aortic sac disrupts fusion with the distal outflow tract cushions, preventing the initiation of outflow tract septation and resulting in common arterial trunk. In around 25% of Sp^2H/Sp^2H embryos, posterior arch arteries are stabilized and fusion occurs between the dorsal wall of the aortic sac and the outflow cushions, initiating outflow tract septation; these embryos develop double outlet right ventricle. Thus, NCC are required in the pharyngeal region both for stabilization of posterior arch arteries and initiation of outflow tract septation. Loss of NCC also disrupts the distribution of second heart field cells in the pharyngeal and outflow regions. These secondary effects of NCC deficiency likely contribute to the overall outflow phenotype, suggesting that disrupted interactions between these two cell types may underlie many common outflow defects.     

Pathology of coronary narrowing after arterial switch operation: autopsy findings in two patients who died within 3 months of surgical treatment and review of the literature.

The arterial switch operation (ASO) has become the surgical treatment of choice for transposition of the great arteries (TGA). Myocardial ischemia owing to coronary complication remains the commonest cause of mortality and morbidity following ASO. The main clinical manifestations of coronary obstruction reported after a switch procedure are heart failure, arrhythmias, or sudden death. Coronary complications are responsible for about 50% of early death and for almost all late deaths. We describe pathologic and anatomic findings in two cases of late sudden death after an ASO. Critical intimal thickening and acute take-off of coronary trunks were the main pathological substrates of death. Histological examination revealed an obstructive coronary proliferation characterised by a concentric stratum of intimal smooth muscle cell hyperplasia with preserved tunica media. Pathogenetic assessment of intimal coronary lesions after an ASO should consider the role of endothelium and vascular parietal wall in the unavoidable response to injury caused by arterial reconstruction. Since a rapidly progressive proliferative disease is suspected, to explain coronary narrowing, understanding endothelial biology and improving surgical technique should help to prevent late coronary events.     

The right outflow tract sulcus in embryonic human hearts

The right outflow tract sulcus occurs in a region of complex and rapidly changing embryonic anatomy where cardiac septa and valve rings fuse, but its importance in cardiogenesis is unknown. Regions of the heart which include this sulcus were reconstructed from nine normal human embryos from the Carnegie Embryological Collection using images of serial histological sections and a computer-based three-dimensional (3-D) reconstruction system. The sulcus appears in Carnegie stage 9 as one of the paired cardiogenic folds and persists through stage 19. It maintains a consistent position on the right lateral aspect of the outflow tract, where the outflow tract bends posteriorly. The sulcus elongates in proportion to the increased diameter of the outflow tract to stage 16. With rotation of the outflow tract and division into separate circulations in subsequent stages, the right outflow tract sulcus becomes related only to the left ventricular outflow tract. Between stages 10 and 16, the portion of the outflow tract extending from the right outflow tract sulcus to the aortic sac or great arteries elongates. Subsequent to outflow tract rotation and division, this distance decreases. The right outflow tract sulcus appears to be of importance in contributing to the final cardiac topography where interatrial, atrioventricular, interventricular, and outflow tract sulci meet and where the junction of atrioventricular and semilunar valve rings occurs.     

3D morphometric analysis of the arterial switch operation using in vivo MRI data

The arterial switch operation (ASO) is widely used nowadays as the surgical strategy of choice to repair transposition of the great arteries (TGA). Residual morphological and geometrical abnormalities of the aorta, pulmonary arteries and coronary arteries, however, have not been fully studied in a three‐dimensional (3D) domain. These morphometric complications might have implications on long‐term outcomes of ASO patients, hence the need to explore them in detail and study them with reference to healthy controls of comparable age and body surface area. These anatomical characteristics were examined using 3D patient‐specific anatomical models reconstructed from cardiovascular magnetic resonance (CMR) images of 20 ASO patients (mean age 14.4 ± 2.4 years, 16 males and 4 females) compared with healthy controls (mean age 15.2 ± 2.0 years, 17 males and 3 females). It was found that the aorta, pulmonary arteries and re‐implanted coronary arteries of ASO patients were significantly different morphologically and geometrically to those of healthy controls. In particular, the aortic root was dilated, with abnormal 3D angulation and additional acute angulation of the curvature of the aortic arch in the ASO group compared with controls. This could theoretically impinge on aortic flow profiles and physiological stresses, which can act as a primer for the development of early atherosclerotic disease in the ASO population. Clin. Anat. 27:1212–1222, 2014. © 2014 Wiley Periodicals, Inc.     

Rotation of the junction of the outflow tract and great arteries in the embryonic human heart

The factors which give rise to the normal relationship between the great arteries and their respective ventricles are unknown. The developmental anatomy of this region was studied by using frontal, sagittal, or transverse serial histologic sections of 17 normal human embryos of Carnegie stages 15-19 from the Carnegie Embryological Collection. Distances and angles between major anatomic landmarks were determined by using computer reconstructions of the serially sectioned embryos, three-dimensional analytic geometry, and Euclidean distance formulas. The findings show that between stages 15 and 19 there is a marked rotation of the axis of the semilunar valves: frontal 121 degrees counterclockwise, sagittal 196 degrees counterclockwise, and transverse 240 degrees clockwise. Simultaneously the great arteries lengthen at a faster rate than the rest of the heart; and there is also an increase in the caliber and wall thickness of the great arteries. These results suggest that the changing rate of growth between the great arteries and the heart is necessary to align the great arteries, the semilunar valves, and the muscular outflow tract septum appropriately with respect to the interventricular septum. Reductions in the rate of growth of the great arteries relative to the heart could, by causing changes in the rotation of great arteries and outflow tract septum, have a role in the pathogenesis of cardiovascular malformations such as tetralogy of Fallot and transposition of the great arteries.     

Temporospatial study of the migration and distribution of cardiac neural crest in quail-chick chimeras

It has been demonstrated that the septation of the outflow tract of the heart is formed by the cardiac neural crest. Ablation of this region of the neural crest prior to its migration from the neural fold results in anomalies of the outflow and inflow tracts of the heart and the aortic arch arteries. The objective of this study was to examine the migration and distribution of these neural crest cells from the pharyngeal arches into the outflow region of the heart during avian embryonic development. Chimeras were constructed in which each region of the premigratory cardiac neural crest from quail embryos was implanted into the corresponding area in chick embryos. The transplantations were done unilaterally on each side and bilaterally. The quail-chick chimeras were sacrificed between Hamburger-Hamilton stages 18 and 25, and the pharyngeal region and outflow tract were examined in serial paraffin sections to determine the distribution pattern of quail cells at each stage. The neural crest cells derived from the presumptive arch 3 and 4 regions of the neuraxis occupied mainly pharyngeal arches 3 and 4 respectively, although minor populations could be seen in pharyngeal arches 2 and 6. The neural crest cells migrating from the presumptive arch 6 region were seen mainly in pharyngeal arch 6, but they also populated pharyngeal arches 3 and 4. Clusters of quail neural crest cells were found in the distal outflow tract at stage 23.     

Effect of neural crest ablation on development of the heart and arch arteries in the chick

Mesenchymal derivatives of the neural crest contribute to the connective tissues and blood vessels of the pharyngeal arches, and participate in the septation of the outflow tract of the heart. The present study was designed to determine the nature and timing of alterations in the development of the heart and arch arteries subsequent to diminished neural crest contributions. The neural crest contributing to the three caudalmost pharyngeal arches was ablated bilaterally in chick embryos and compared with sham or unoper-ated controls. Heart development was studied by scanning electron microscopy. Arch artery development was studied microscopically after intravascular injection of India ink and clearing of the specimen. Neural crest ablation caused morphological changes in most hearts. Hearts in experimental animals commonly were elongate and were subject to inappropriate development of ventricular and atrial areas. A surgical effect delayed the disappearance of arch arteries one and two, and removal of neural crest produced an additional delay. Neural crest ablation caused failure of arch arteries three, four (right), and six to develop to the proper size in some animals. Survival of those whose sixth arch arteries achieved the proper size caused group measurements to reach normal values again by stage 32. Closure of arch arteries in some animals and maintenance in others produced greater variability in experimental animals than in controls. It is significant that heart morphology was altered before septation of the outflow tract normally occurs. This indicates at the least that another factor, such as altered blood flow, contributes to the abnormal development. Altered flow may result from changes in pharyngeal arch mesenchyme and arch artery endothelium.