小腿动脉为流出道的股-小腿动脉或股-腘-小腿动脉旁路术随访分析

.9%.保肢患者中重症下肢缺血占13.0%,随访时踝肱指数足背动脉0.66±0.26,胫后动脉0.64±0.25,与术前和术后相比差异均有统计学意义.自体静脉和复合血管、股-小腿动脉直接旁路和股-腘-小腿动脉序贯旁路在保肢率和旁路血管通畅率上差异无统计学意义.结论 以小腿动脉为流出道的旁路术对于腔内治疗失败或长段、多节段动脉闭塞濒临截肢者是有效的治疗方法 .加强术后随访和早期干预有助于提高二期通畅率和保肢率.     

Transcutaneous oxygen tension in flaps

Summary Transcutaneous oxygen tension (pTcO₂) in various types of flap is described and compared. Random and arterial flaps showed different pTcO₂ patterns. The value of delay was shown. The results indicated the potential of the pTcO₂ technique for flap research and for clinical monitoring of flap circulation.     

Transcutaneous carbon dioxide tension for the evaluation of limb ischemia

Purpose  Understanding the hemodynamics of critical limb ischemia caused by chronic peripheral arterial occlusive disease is important to evaluate its severity and the efficacy of treatment. We investigated the usefulness of transcutaneous carbon dioxide tension (tcPCO₂) measurement for evaluating ischemic limbs, in conjunction with the measurement of ankle pressure (AP), toe pressure (TP), skin perfusion pressure (SPP), and transcutaneous oxygen tension (tcPO₂). Methods  We measured tcPCO₂ in the dorsum of the foot in 158 patients (304 limbs) with arteriosclerosis obliterans. Results  The tcPCO₂ in normal limbs without any clinical sign or abnormal noninvasive measurement was 43.7 ± 3.7 mmHg; that in noncritical ischemic limbs was 45.5 ± 9.0 mmHg, which was not significantly different from that in the normal limbs; and that in critically ischemic limbs was 87.6 ± 35.5 mmHg, which was significantly different from that in the normal limbs. All limbs with a tcPCO₂ of 100 mmHg or higher, indicative of critical ischemia, had a tcPCO₂ of less than 100 mmHg after revascularization. Conclusion  We found tcPCO₂ to be a useful measurement for diagnosing the severity of limb ischemia, and for evaluating the effect of treatment, especially in patients with critically ischemic limbs.     

无损伤血管检查ABI,Duplex,MRA诊断下肢动脉硬化闭塞症

目的:探讨无损伤性血管检查的准确性以及用无损伤性血管检查代替常规血管造影的可能性.方法:本组病例同时采用3种无损伤性血管检查法,包括踝/肱指数测定、彩色超声扫描、磁共振血管显象,并与手术探查结果相对照,以观察无损伤性血管检查的准确性.结果:在本组14例中,用3种不同的无损伤性血管检查法诊断下肢动脉硬化闭塞症,其结果均相符合,除3例未手术外,余11例经手术探查,结果也完全符合.3种无损伤性血管检查中以MRA最为准确、直观,可显示病变的程度、位置和范围的解剖学图象,提供手术治疗的依据.结论:通过本组观察ABI、Dup-lex、MRA3种无损伤血管检查法的综合检查结果,说明三者的结合可代替常规的下肢动脉造影检查,此是近年血管检查方面的一个突破性进展.     

Predictive Values of Transcutaneous Oxygen Tension for Above-the-ankle Amputation in Diabetic Patients with Critical Limb Ischemia

OBJECTIVE: To assess the values of transcutaneous oxygen tension (TcPO2) capable of predicting above-the-ankle amputation in diabetic patients diagnosed for critical limb ischemia (CLI) according to the criteria of the TransAtlantic Inter-Society Consensus. DESIGN: Retrospective study. METHODS: From January 1999 to December 2003, 564 diabetic patients were consecutively hospitalized for CLI in one limb. Revascularization with angioplasty or bypass graft was performed when possible and, if not possible, prostanoid therapy was used. In patients in whom therapies did not relieve the rest pain or the gangrene was extended above the Chopart joint, an above-the-ankle-amputation was performed. After treatment TcPO2 values were evaluated in all patients at the dorsum of the foot. RESULTS: Fifty-five (9.8%) patients underwent an above-the-ankle amputation: 22 of 420 patients who underwent angioplasty, 17 of 117 patients who underwent bypass (14.5%) and 16 of 27 patients in whom revascularization was not possible. Post-treatment TcPO2, measured by a receiver operating characteristic (ROC) curve, showed a value 34 mmHg as the best threshold for determining the need for revascularization, with an area under the curve of 0.89 (95%CI 0.85-0.94). Using logistic regression analysis the probability of above-the-ankle amputation for this threshold is 9.7% and reduces to 3% for TcPO2 > 40 mmHg. CONCLUSION: TcPO2 levels<34 mmHg indicate the need for revascularization, while for values >or= 34 < 40 mmHg this need appears less pressing, although there remains a considerable probability of amputation. TcPO2 levels greater than 40 mmHg suggest that revascularization is dependent on the severity of tissue loss and possible morbidity caused by the procedure.     

Spinal Cord Stimulation in Diabetic Lower Limb Critical Ischaemia: Transcutaneous Oxygen Measurement as Predictor for Treatment Success

OBJECTIVES: to evaluate whether transcutaneous oxygen tension (TcpO(2)) measurements could be used as a specific prognostic parameter in selecting diabetic patients for permanent device implantation. METHODS: sixty consecutive diabetic patients (28 with autonomic neuropathy), classified as Fontaine stage III or IV, underwent spinal cord stimulation (SCS) for ischaemic pain, after failed conservative or surgical treatment. Pedal TcpO(2)on the dorsum of the foot and ankle-pressure Doppler measurements were performed before, and 2 and 4 weeks after implantation. RESULTS: limb salvage and good pain relief were achieved in 35 patients, while in 12 partial pain relief and limb salvage for at least 6 months were obtained. In 13 patients the method failed and the ischaemic limbs were amputated. Only 3 of the 28 patients with neuropathy had any long-term benefit. Limb salvage was achieved in those patients with a significant increase in TcpO(2)within 2 weeks of stimulation. The stage of the neuropathy was inversely related to the success of SCS therapy. The ankle-brachial pressure index (ABPI) did not change after stimulation. CONCLUSIONS: diabetic patients with significant increase of TcpO(2)and pain relief during a 2-week test period may be successfully treated by long-term SCS unless they have advanced autonomic neuropathy.     

Near-Infrared Spectroscopy with Treadmill Exercise to Assess Lower Limb Ischemia in Patients with Atherosclerotic Occlusive Disease

Purpose We used near-infrared spectroscopy (NIRS) to measure exercise-induced ischemia in patients with intermittent claudication, and compared these results with those obtained by ankle-brachial pressure index (ABPI) analysis.Methods Sixty-two patients with intermittent claudication caused by atherosclerotic occlusive disease exercised on a treadmill until reaching the maximal tolerated walking distance. We measured the ABPI at rest and after exercise until it returned to the baseline value. A NIRS probe was positioned on the patients calf, which allowed the continuous monitoring of oxygen saturation (StO₂), oxygenated hemoglobin (Oxy Hb), and deoxygenated hemoglobin (Deoxy Hb) in the calf muscles before, during, and after exercise. During exercise, the StO₂ and Oxy Hb decreased, and the Deoxy Hb increased. The time taken for each measurement to return to the baseline value was defined as the recovery time. The recovery times obtained by NIRS and ABPI were compared.Results The recovery time for ABPI correlated well with that for StO₂ (_s = 0.73), Oxy Hb (_s = 0.63), and Deoxy Hb (_s = 0.65); however, the recovery times measured by NIRS were shorter than the recovery time for the ABPI.Conclusions Near-infrared spectroscopy is a reliable method for monitoring peripheral circulation during and after exercise, although the data generated provided slightly different information than the results obtained by ABPI.     

无创性动脉硬化检测技术在高血压肾病中的评估价值

目的探讨无创性动脉硬化检测指标[颈动脉内中膜厚度(carotid intima-media thickhess,IMT),踝臂指数(ankle brachial index,ABI)及心脏-脚踝血管指数(cardio-ankle vascular index,CAVD]在高血压肾病中的评估价值。方法选择2010年1月至2014年1月在我院经病理检查确诊为高血压肾病的46例患者作为高血压肾病组,另按数字表法随机选取高血压患者50例及健康人群50名分别为高血压组和健康对照组,比较IMT、ABI和CAVI。尿微量白蛋白/尿肌酐比值(urinary albumin-creatinine ratio,ACR)、尿β微球蛋白(urinary beta 2 microglobulin,β2-MG)、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)的差异。结果高血压肾病组ACR、尿β2-MG、IMT、CAVI均较高血压组、健康对照组增高,差异有统计学意义(P0.01)。高血压组ACR、尿β2-MG、IMT、CAVI均较健康对照组增高,差异有统计学意义(P0.05)。高血压肾病组eGFR及ABI较高血压组及健康对照组下降,差异有统计学意义(P0.01)。高血压组ABI较健康对照组下降,差异有统计学意义(P0.05)。高血压组和健康对照组eGFR差异无统计学意义(P0.05)。随着高血压病情进展及动脉硬化程度加重,IMT、CAVI与肾功能下降呈负相关,ABI与肾功能下降呈正相关,可见动脉硬化程度与肾功能水平密切相关。结论及早应用无创动脉硬化检测技术于高血压患者,并使用此检测手段监测血管硬化情况,并予相关药物干预,或许可延缓高血压病情的进展。     

肢体负压对动脉闭塞犬血浆内皮素和降钙素基因相关肽的影响

目的观察肢体负压(LNP)对肢体动脉闭塞犬血浆内皮素(ET)和降钙素基因相关肽(CGRP)的影响,以探讨肢体负压的作用机理.方法犬15只,分治疗组10只和对照组5只,采用切断左后肢股动脉分支,动脉腔内置入螺旋状金属丝的方法,制作肢体动脉闭塞模型.2周后,治疗组行患肢负压治疗,连续10 d;对照组不做负压治疗.于模型制作前、制作后2周及负压治疗10 d时,用放射免疫分析法检测患肢股静脉血浆ET及CGRP水平.结果治疗组经负压治疗后,血浆ET水平显著低于治疗前(P<0.01),血浆CGRP水平显著高于治疗前(P<0.01),两者呈负相关;而对照组无明显变化(P>0.05).结论肢体负压可显著降低肢体动脉闭塞犬的血浆ET水平,提高CGRP水平.     

控制性缺氧条件下国产脉搏血氧饱和度仪的准确度研究

目的 研究国产脉搏血氧饱和度仪(pulse oximeter,POM)在健康志愿者控制性缺氧条件下的准确度及特点,为临床安全、有效使用提供依据. 方法 通过吸入氧氮混合气体使健康志愿者处于缺氧状态,相同型号的POM采用Masimo和Nellcor两种脉氧探头同时监测脉搏血氧饱和度(pulse oxygen saturation,SpO2),监测SpO2区间为70％～ 100％,在＞95％、92％、85％、78％、70％这5个目标值的区间内记录SpO2数值,并在相应时点抽动脉血行血气分析作对照. 结果 Masimo和Nellcor两种脉氧探头所测的70％～ 100％范围内的SpO2与血气分析所测的动脉血氧饱和度(arterial oxygen saturation,SaO2)相对照,差异都在标准范围内(Arms分别为2.16和2.32),Masimo探头的偏差(SpO2-SaO2)在≥80％和＜80％时分别为0.93％和-1.45％,Nellcor探头则分别为0.16％和-1.91％,且两种探头差异有统计学意义(P＜0.01). 结论 使用Masimo和Nellcor探头的国产POM均能准确反映不同缺氧程度下的血氧饱和度情况,但两者由于原理的不同而存在差异,Nellcor探头读数普遍低于Masimo探头读数;随着SpO2读数下降,偏差朝着负值逐渐增大,即容易低估SaO2,在SpO2＜80％时更加明显.     

血管内皮细胞损害在动脉硬化性闭塞症发病中的意义

目的　探讨脂质过氧化物（ＯＸＬＤＬ）致ＥＣ损害与动脉硬化性闭塞症（ＡＳＯ）发病的关系及循环内皮细胞（ＣＥＣ） 、ＯＸＬＤＬ检测的临床价值。方法　ＡＳＯ 患者２９ 例,间歇性跛行组１５ 例,静息痛组８例,坏疽组６ 例。分别测其ＣＥＣ、ＯＸＬＤＬ及ＡＢＩ值。结果　ＣＥＣ及ＯＸＬＤＬ值患者组显著高于正常对照（Ｐ＜ ０．０１）,且与病情严重程度一致（坏疽组＞ 静息痛组＞ 间歇性跛行组）,ＣＥＣ与ＯＸＬＤＬ呈显著正相关（ｒＯＸＬＤＬ＝０．９６３）。ＡＢＩ值患者组虽明显低于正常对照,但静息痛组与坏疽组差异无显著性（ Ｐ＞ ０．１）。结论　ＯＸＬＤＬ是导致ＥＣ损害引发ＡＳＯ的重要原因。ＣＥＣ、ＯＸＬＤＬ可作为ＡＳＯ早期诊断及临床病情轻重判别的较好参考指标,以弥补无创指标ＡＢＩ的不足。     

The Limits of Percutaneous Intervention in Aortoiliac Occlusive Disease

Aortoiliac occlusive disease (AIOD) is a common manifestation of atherosclerosis that may lead to limb-threatening ischemia. Over the past two decades, considerable advances in the management of patients with AIOD have taken place. Conventional surgical reconstructive procedures, namely aortofemoral and extra-anatomic bypasses, tend to be replaced by newer emerging percutaneous techniques, such as angioplasty and stenting, initially employed to reduce morbidity, complications and cost of treatment. However, irrational application of these percutaneous techniques is not suggested, since these surgical procedures are not devoid of limitations. A careful evaluation of the various restraining parameters should precede the choice of surgical approach, to ensure the selection of the most suitable technique in each individual patient, on the grounds of clinical presentation of the disease and efficiency of the surgical procedure.     

Efficacy of the transfer function index using the pulse volume recording as a parameter to assess intermittent claudication

Purpose  The aim of this study was to elucidate whether the ankle brachial pressure index (ABPI) or transfer function index (TFI) was useful as an alternative parameter to the treadmill-walking test using near-infrared spectroscopy (NIRS) in evaluating muscle ischemia for patients with intermittent claudication (IC). Methods  In 155 claudicants, the treadmill-walking test using NIRS was performed to calculate the recovery ability index (=recovery time/walking time). The ABPI and TFI were measured at the calf (TFI_calf) and ankle (TFI_ankle) using pulse volume recording. The area under the curve (AUC) was calculated from the receiver operating characteristic (ROC) curve and cutoff value was determined using crossing point of the ROC curve with a diagonal line. Results  In the nondiabetics, AUCs were 77.3%, 80.0%, and 76.0% in the ABPI, TFI_calf, and TFI_ankle, respectively, which were not different significantly. In the diabetics, the AUC of TFI_calf was 77.9%, which was different significantly from those of the other indices such as the ABPI or TFI_ankle showing 66.2% or 68.1%. The cutoff value of ABPI indicating moderate or severe IC was 0.75 in the nondiabetics whereas that of TFI_calf was 0.85 in the diabetics. Conclusion  TFI_calf was useful to distinguish moderate or severe IC from mild IC in diabetic patients even if the ABPI was sufficient in nondiabetic patients.     

An assessment of peripheral vascular disease in patients with diabetic foot ulcer

BackgroundPeripheral vascular disease (PVD) is a chronic limb ischaemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus is a risk factor for this disease. The most common symptom of PVD is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and PVD is more likely to present with an ischaemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index (ABI) in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischaemia and limb loss.ObjectiveThe purpose of this study is to evaluate the occurrence of peripheral vascular disease using ankle-brachial index in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcer (DFU).MethodThis prospective study involved all type 2 DM patients with foot ulcer (DFU population) and those without foot ulcers (non-DFU population) seen in our hospital. Their demographic, clinical and laboratory parameters were noted and documented. Measurement of ABI was done using a portable hand held Doppler and ankle pressures < 0.9 is suggestive of PVD.ResultsA total of 74 patients were recruited. Males were 42 (56.8%) and females were 32 (43.2%). The mean age of the patients was 62.89 ± 10.66 years and the duration of diabetes was 7.61 ± 7.57 years. Forty-six (62.2%) presented with foot ulcer while 28 (37.8%) were without foot ulcer. Patients with PVD represented by ABI < 0.9 was DFU 31(76.4%) while in non-DFU it was 10 (13.4%). Multivariant analysis of variables associated with DFU in those with ABI < 0.9 showed correlation with tobacco use r = .235, p = 0.044; duration of diabetes r = ?.427; p = 0.001; and systolic blood pressure r = ?.301; p = 0.009.DiscussionThe occurrence of PVD determined by the absence of >2 pulses by palpation alone and using ABI was 25.7% and 55.4% respectively. This suggests that assessment by palpation is subjective while the use of Doppler is quantitative and more reliable. DFU patients with PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure but not with dyslipidaemia.ConclusionThis study shows that these patients had risk factors for PVD. The use of hand held Doppler will aid early diagnosis of critical limb at risk of loss and help to prevent and reduce the high rate of limb loss in our patients.     

自膨支架在颈动脉分叉狭窄成形术中的临床应用

目的探讨自膨支架在颈动脉分叉狭窄支架置入术（CAS）临床应用。方法回顾性分析实施远端过滤脑保护212例CAS患者的临床资料,其中42例患者植入闭环支架（闭环支架组）,170例患者植入开环支架（开环支架组）。观察两组患者的术后24小时内血流动力学变化、远端过滤脑保护装置回收困难的发生率、住院天数和治疗前后美国国立卫生研究院卒中评分量表（NIHSS）评分、治疗后12个月内狭窄处血管超声收缩期最大峰值速度和舒张末期流速评估狭窄程度以及治疗后死亡、脑卒中或心肌梗死等终点事件。结果两组在住院天数和治疗前后NIHSS评分各层次、12个月颈动脉狭窄程度、治疗后30天内及31天至12月终点事件的累计发生率方面比较,差异无统计学意义( P＞0.05);远端过滤脑保护装置回收困难和术后24小时内血流动力学变化差异有统计学意义（P＜0.05）结论经过充分术前准备且合理选择支架,植入自膨式开环支架除术后24小时内血流动力学变化较大和远端过滤脑保护装置回收困难外,两种类型自膨支架在CAS中的疗效和并发症发生率没有明显差别。     

肢体动脉急慢性闭塞的彩色多普勒超声诊断

目的 研究彩色多普勒超声诊断肢体动脉急慢性闭塞的临床价值.方法 回顾性分析北京安贞医院血管外科2006-2010年收治的129例肢体动脉闭塞患者的临床资料,其中男性85例,女44例,年龄为17～94岁,平均(62±9)岁.分析39条急性闭塞动脉和97条慢性闭塞动脉的二维、彩色多普勒超声结果,对两组闭塞段管腔内回声、管壁结构、闭塞近远段血流动力学参数及侧支动脉进行对比.结果 急慢性动脉闭塞在闭塞段管壁厚度、内径、闭塞近段阻力指数和侧支动脉方面有统计学意义(P＜0.05).急性动脉闭塞段内径大于慢性闭塞段,而管壁厚度、闭塞近段阻力指数和侧支动脉明显小于慢性闭塞段.超声诊断急慢性动脉闭塞的准确率是95.6%.结论 彩色多普勒超声是鉴别肢体动脉急慢性闭塞有价值的检查手段,能够为临床诊断和手术治疗提供客观依据.

Abstract：

Objective To investigate the clinical value of color Doppler ultrasound examination in the diagonosis of acute and chronic artery occlusion of the extremities. Methods A review was made on 129 extremetiy artery occlusion patients at Anzhen Hospital during 2006 -2010. 85 cases were male, and 44 cases were female. Age was from 17 to 94 years (average: 62 ±9 years). We analyzed two-dimensional and color Doppler flow imagings of 39 acute occlusion arteries and 97 chronic occlusion arteries. We compared factors including the echoes of artery lumens, the vessel wall structures, hemodynamic parameters of inlet and outlet at the occlusion, and collaterals between groups. Results The factors of depths of vessel wall,internal diameters of ccclusion arteries, proximal resistant index and collaterals were significantly different between groups ( P ＜ 0. 05 ). The internal diameters of acute occlusion arteries were wider than chronic occlusion arteries. The depths of vessel wall, proximal resistant index and collaterals were thinner, smaller,and less than chronic occlusion arteries. The total accurate rate of differential diagnosis for acute and chronic artery occlusion by color Doppler ultrasound was 95.6％. Conclusions Color Doppler ultrasound is an effective method for the differential diagnosis of acute and chronic artery occlusion of the extremities.