下肢深静脉血栓形成后遗症的外科手术治疗

目的：探讨下肢深静脉血栓形成后遗症外科手术治疗的有效方法。方法：回顾分析1992年以来手术治疗下肢深静脉血栓形成后遗症32例36条下肢的临床资料。结果：血管造影诊断下肢深静脉血栓形成后遗症准确率为100％，本组I型5条，ⅡA型4条，ⅡB型12条，Ⅲ型15条。行人造血管股浅静脉环缩术16条，股浅静脉瓣修复术3条，大隐静脉－Guo静脉原位转流术6条，Guo静脉外肌袢成形术4条；髂总静脉－股浅静脉人造血管移植转流术3条；大隐静脉－股浅静脉交叉转流术4条，治疗后症状完全消失28条（77．8％），部分消失或改善8条（22．2％），结论：血管造影是诊断下肢深静脉血栓形成后遗症的金指标，可根据瓣膜破坏及通畅程度选择不同的手术方法治疗。     

下肢深静脉节段型闭塞症的外科治疗

目的:探讨下肢深静脉节段型闭塞型的外科治疗.方法:采用Palma-Dale手术治疗髂静脉闭塞症24例;Husni手术治疗股浅静脉闭塞症8例,结果:Palma-Dale手术组18例,平均随访56个月,11例患肢肿胀,胀痛明显改善,静脉行跛行消失.5例怕复发,其中2例植皮和游离背阔肌皮瓣移植后溃疡愈合.Husni手术组6例,平均随访70个月,2例转流静脉通畅,临床症状明显好转或基本消失;4例闭塞,肿胀加重但未出现溃疡.结论:手术应在闭塞段远侧深静脉主干瓣和肌肉泵功能尚未被破坏之前施行,若瓣已被破坏,宜同时行瓣膜重建术;Husni手术宜选择病程较短,腓肠肌泵功能尚未严惩衰退的早期病例.     

大隐静脉耻骨上交叉转流术治疗髂股静脉闭塞症的临床分析

目的：探讨大隐静脉耻骨上交叉转流术治疗髂股静脉闭塞症的临床价值。方法：回顾性分析山东省立医院血管外科2006年3月—2010年9月收治的23例髂股静脉闭塞症患者,均行大隐静脉耻骨上交叉转流术。结果：随访18例,随访率78.26%,随访时间2～54个月,平均25个月。15例临床症状缓解3,例临床症状无改善,总有效率83.33%。13例转流大隐静脉通畅,5例转流大隐静脉闭塞。结论：在严格掌握适应证的情况下,大隐静脉耻骨上交叉转流术治疗髂股静脉闭塞症不失为一种有效的治疗方法。     

耻骨上交叉转流治疗髂股静脉闭塞荟萃分析

目的：总结分析耻骨上交叉转流治疗髂股静脉闭塞的可行性及疗效。方法：按预定纳入排除标准,对所有纳入的关于耻骨上交叉转流治疗髂股静脉闭塞中外文文献进行荟萃分析。结果：共纳入21篇文献416例患者,平均随访（3.01±2.10）年,手术有效率为（85.67±15.01）%,建立动静脉瘘的比率为50.72%,术中应用大隐静脉转流的比率为70.19%,应用人工血管转流的比率为29.56%。结论：在严格控制适应证的前提下,耻骨上交叉转流是一种操作简单、安全、实用的治疗髂股静脉闭塞的有效方法。     

大隐静脉转流术治疗髂股静脉栓塞

目的：总结大隐静脉转流术治疗髂股静脉栓塞的临床应用经验。方法：1998年9月至2005年12月，应用大隐静脉转流术治疗6例髂股静脉栓塞，男5例，女1例；年龄36~52岁，平均41岁；均为单侧股和小腿肿胀，伴有疼痛。从对侧切取正常的大隐静脉，经耻骨上隧道转移至患侧，在髂股静脉栓塞段以远与股静脉或大隐静脉近端吻合，将患侧静脉血经大隐静脉引流至对侧股静脉。结果：手术顺利，术后仅1例供区伤口发生表浅感染，经换药处理愈合。随访1—3．5年，平均1．8年，所有患者疼痛消失，水肿明显减轻，但仍有轻度肿胀。结论：大隐静脉转流术是治疗髂股静脉栓塞的有效方法。手术操作相对简单和安全。     

布-加综合征的外科治疗──附502例手术经验总结

作者报告手术治疗布－加综合征５０２例的经验体会。其中Ⅰ型（隔膜型）２７４例，Ⅱ型（肝主静脉闭塞并ＩＶＣ狭窄）１２４例，Ⅲａ型５４例，Ⅲｂ型４８例，Ⅳ型２例。本组中采用隔膜切除术１７２例，脾肺固定术１５８例，球囊导管或手指破膜术４８例，腔－房或腔－腔转流术３４例，肠－房和脾－房转流术２３例，肠－腔分流４４例，腔－脾－房转流术２例，脾静脉－颈静脉转流术１６例，其他手术５例。２４８例（４９．４％）效果良好，１８２例症状改善（３６．３％），有效率８５．７％；１４例死亡（２．８％）。并对临床分型、术式选择、并发症的防治等作了讨论。     

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目的 探讨单侧髂静脉闭塞的外科治疗。方法 1987年8月至1999年12月，采用Palma-Dale手术治疗髂静脉闭塞症23例。结果 17例获得长期随访，平均随访56个月。10例术后患肢肿胀、疼痛明显改善，静脉性跛行消失。5例溃疡复发，其中2例经植皮和游离背阔肌皮瓣移植后溃疡愈合。结论 Palma-Dale手术宜慎重且合理地选择病例。Palma-Dale手术应在患肢闭塞段远侧深静脉主干瓣膜和肌肉泵功能尚未被破坏之前施行；在主干静脉瓣膜已被破坏时，宜考虑同时行瓣膜重建术。     

广泛性下肢动脉闭塞症治疗的选择

目的：探讨广泛性下肢动脉闭塞症治疗方法的选择。方法：自1994年3月至2008年5月对49例51条具有慢性缺血表现的下肢,经多普勒超声和数字减影血管造影（DSA）、CT血管造影（CTA）或磁共振血管造影（MRA）检查,确诊为下肢动脉广泛性闭塞症。根据影像提示的病变部位与程度不同,分别采用3种血管重建方式：①35例（37条下肢）行静脉动脉化手术治疗;②8例（8条下肢）行股深动脉重建;③6例（6条下肢）行血管腔内介入治疗。结果：28例（30条下肢）静脉动脉化术后随访1．5～13．5年,7条截肢;8例（8条下肢）股深动脉重建术后随访1-4年,2条截肢;6例（6条下肢）血管腔内介入治疗术后随访6个月至1．5年,1条截肢。除10条截肢外,其余41条患肢的症状均有不同程度好转,病人基本可正常生活。结论：根据广泛性下肢动脉闭塞症病变部位与程度不同,选择合适的治疗方法是提高其疗效的关键。     

267例主髂动脉闭塞的手术治疗经验

目的 探讨肾动脉开口水平以下腹主动脉闭塞及髂动脉闭塞的手术方式选择及治疗经验。方法 回顾性分析267例主、髂动脉闭塞患者的临床资料。结果 267例患者全部行手术治疗。行腹主动脉－髂（股）动脉人工血管转流术145例,髂动脉－股动脉人工血管转流术40例,股动脉－股动脉人工血管转流术45例,腋动脉－股动脉人工血管转流术37例。总有效率为96．5％,围手术期病死率为3．5％。267例中178例得到随访,平均随访时间5年9个月,人工血管通畅率为82．0％。结论 符合正常血液动力学手术的主要术式是腹主动脉－（双）髂、股动脉人工血管转流术,对于年老、体弱者,特别是全身一般状况较差,伴有冠心病、高血压、脑动脉硬化、脑梗塞等慢性疾病的患者,应采用腋动脉－（双）髂股动脉人工血管转流术或股动脉－股动脉人工血管转流术,可明显减低手术病死率。     

克-特综合征 8例治疗体会

我院自1999～2005年共收治克-特综合征（Klipple Trenaunay syndrome，KTS）8例，男5例，女3例；年龄3～32岁，平均19．6岁。6例于20岁以前出现症状，其中2岁以前出现血管瘤3例，浅静脉曲张2例，其浅静脉曲张较重，肢体明显增粗、增长，其中1例肢体形成溃疡，另1例下肢增长约4cm，出现跛行。发生于单侧下肢7例，上肢1例。本组患者均以皮肤血管痣及不同程度浅静脉曲张拟诊为KTS。术前均进行顺行静脉造影，见腘静脉、股浅静脉畸形各2例；髂静脉、肱静脉畸形各1例；2例深静脉正常者再行逆行静脉造影，示1例正常，1例股浅静脉无瓣膜。手术方法：行单纯浅静脉剥脱、交通静脉结扎1例；腘静脉、股浅静脉及肱静脉周围纤维条索彻底松解各1例；     

The Advantages of the Great Saphenous Vein as a Femoropopliteal Graft: A Report on Its Clinical Use

As a majority of vascular surgeons prefer the autologous saphenous vein as a bypass graft below the inguinal ligament, the need of alternative graft materials or reconstructive techniques is confined to patients with unavailable or unsuitable saphenous veins. The aim of this investigation was to ascertain how often these alternative procedures are necessary. From 1973 to June 1979, the great saphenous vein was used as a femoropopliteal graft without regard to fixed limitations in the diameter and the quality of the vein. During this period, vascular reconstruction was required in 148 limbs due to symptomatic atherosclerotic occlusion of the superficial femoral artery. In 144 of these cases, the ipsilateral (138) or the contralateral (6) great saphenous vein was used for a femoropopliteal bypass reconstruction. Thus, the vein could not be utilized in only 4 of 148 cases (2.7%).

As graft patency rate was not subject to the size and quality of the vein and as cumulative patency rates in the 144 grafts were most satisfactory (97.9, 92.0 and 81.9% at 1 month, 1 year and 5 years, respectively), although all these veins were used regardless of their calibre and quality, we conclude that the great saphenous vein can be used more liberally as a graft for femoropopliteal occlusion In approximately only 3% of patients requiring operation, alternative reconstructive techniques, such as ‘non-vein’ bypass grafts and thrombendarterectomy are needed.     

The effect of anticoagulation therapy and graft selection on the ischemic consequences of femoropopliteal bypass graft occlusion: results from a multicenter randomized clinical trial

OBJECTIVE: A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts. METHODS: Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded. RESULTS: There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0). CONCLUSION: The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy.     

Saphenous vein or PTFE for femoropopliteal bypass. A prospective randomized trial.

To evaluate the patency of PTFE (Gore-tex) as a femoropopliteal bypass, a prospective randomized trial was performed between PTFE and saphenous vein. Forty-nine consecutive patients with intermittent claudication, rest pain, or tissue loss due to an occlusion of the superficial femoral artery entered the study. Randomization between PTFE and saphenous vein was performed at the time of operation after assessment of the quality of the latter. The two groups did not differ significantly regarding stage of peripheral ischemia, outflow tract, or localization of the distal anastomosis. The patency rate 6 weeks after operation was 92% for each group. After a mean follow-up of 54 months, the patency rate for the PTFE group was 37% and 70% for the saphenous vein group (p less than 0.001). In the PTFE group, there were eight major amputations. No amputations were performed in the saphenous vein group. It is concluded from this study that the saphenous vein is by far superior to PTFE as a femoropopliteal bypass.     

Seven-year follow-up of expanded polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts.

Expanded polytetrafluoroethylene (PTFE) grafts have proven to be an acceptable short-term alternative for femoropopliteal reconstruction in those patients without suitable autologous saphenous vein. One hundred and twenty-seven femoropopliteal arterial bypass operations utilizing PTFE grafts were performed in 105 patients. Seven-year follow-up is now available for 20 grafts, 6-year follow-up for 47 grafts, and 5-year follow-up for 62 grafts. Graft occlusion was determined by angiography, Doppler assessment, loss of previously palpable pulses, or return of symptoms. Thirty nonocclusive graft losses were due to death, infection, aneurysm, amputation, or proximal occlusive disease. Overall cumulative patency rate, according to occlusive criteria alone and calculated by the life-table method, was 74% at 6 months, 63% at 1 year, 48% at 3 years, 40% at 5 years, and 35% at 7 years. Excluding early bypass failures (less than 1 year patency), 75% of grafts were patent at 3 years, 63% at 5 years, and 55% patent 7 years following operation. Diabetes mellitus was associated with a significantly lower patency rate. Patency rates were not adversely affected by graft diameter, distal popliteal anastomotic site, number of patent runoff vessels, preoperative symptoms, or prior arterial reconstruction. In patients without suitable autologous saphenous vein, the PTFE graft has proven to be a durable and dependable long-term alternative for femoropopliteal reconstruction.     

A prospective randomized trial comparing vein with polytetrafluoroethylene in above-knee femoropopliteal bypass grafting

OBJECTIVE: Despite many clinical studies, there is still uncertainty as to whether venous material is superior to polytetrafluoroethylene for femoropopliteal reconstruction proximal to the knee joint. Supported by early satisfactory results with thin-walled, stretched polytetrafluoroethylene for suprageniculate bypass grafts, a prospectively randomized clinical trial was designed to evaluate the effectiveness of reversed saphenous vein in comparison with that of polytetrafluoroethylene in above-knee arterial reconstruction. METHODS: In a 3-year period, 151 above-knee femoropopliteal bypass graft operations were performed in 136 patients (77 male, 59 female). The indication for operation was severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. For the bypass graft, a reversed saphenous vein was used in each of 75 cases, and a polytetrafluoroethylene prosthesis was used in each of 76 cases. Preoperative risk factors were diabetes (24%), a history of myocardial infarction (23%), and current status with respect to smoking (74%). There was no hospital mortality; 5% of patients had minor postoperative complications. RESULTS: After 2 years, the primary patency was 83% for saphenous vein and 67% for polytetrafluoroethylene (P =.065); the secondary patency was 83% for saphenous vein and 77% for polytetrafluoroethylene (P =.298). During a follow-up period of 2 years, we found no statistically significant difference in primary and secondary patency between saphenous vein and polytetrafluoroethylene. We found no predictive factor for occlusion of either bypass graft. CONCLUSION: The use of polytetrafluoroethylene above the knee is a reasonable alternative in femoropopliteal bypass grafting that is associated with acceptable short-term patency rates.     

A low flow velocity predicts failure of femoropopliteal and femorotibial bypass grafts

The prognostic value of Doppler-derived blood flow velocity measurements for predicting the patency of femoropopliteal and femorotibial bypass grafts was analyzed. Peak systolic and end-diastolic blood flow velocities were measured in 42 femorotibial, 24 femoropopliteal, and three femoropopliteal (isolated segment) in situ saphenous vein bypasses at operation and serially in the postoperative period. At operation peak systolic flow velocity was greater (p less than 0.01) in femoropopliteal grafts (90 +/- 22 cm/sec) compared with femorotibial grafts (68 +/- 19 cm/sec) and isolated segment femoropopliteal (58 +/- 16 cm/sec) grafts. Diastolic forward flow, indicative of low outflow resistance, was present in all successful grafts at operation and in the immediate postoperative period, but decreased thereafter. Early graft occlusion was associated with a low peak systolic flow velocity (less than 40 cm/sec) and absent diastolic forward flow. Postoperative decrease in peak systolic velocity to less than 45 cm/sec identified grafts with impending failure due to intrinsic graft lesions or progression of atherosclerosis. A low blood flow velocity threatens graft patency and should prompt an angiographic evaluation to identify correctable graft lesions or an outflow tract suitable for sequential grafting for the purpose of augmenting flow velocity.     

Angioscope-assisted occlusion of venous tributaries with prolamine in in situ femoropopliteal bypass: preliminary results of canine experiments

Ten mongrel dogs underwent left lower extremity in situ femoropopliteal bypass with femoral vein. A 20 to 25 cm myocutaneous bridge was left between femoral and popliteal anastomoses. A 2.8 mm angioscope was introduced intraluminally to visualize venous tributaries (VT). A balloon occlusion catheter was placed alongside the angioscope and directed in each VT. Prolamine was injected into each VT to effect occlusion. Seven dogs were followed up for 1 week and three dogs for 1 month. A total of 34 VT (range one to five per dog) were available for attempted occlusion. Twenty-nine of 84 (85%) VT were able to be occluded based on comparison of pre-VT and post-VT occlusion angiograms. Poor visualization of VT or VT too small to admit the 5F catheter were reasons for failure. We conclude that (1) in the canine model studied angioscope-assisted occlusion of femoropopliteal during bypass is technically feasible, (2) this technical detail makes unnecessary medial thigh dissection for exposure of the vein graft, and (3) during short-term observation prolamine appeared to be a suitable occluding substance.     

Revascularization of the leg using polytetrafluoroethylene: Cumulative patency in patients with claudication and limb salvage

Of 196 polytetrafluoroethylene bypass grafts in the leg, 113 were placed in the femoropopliteal and 83 in the femorotibial or femoroperoneal position. Claudication was the indication for 31 percent of the grafts, and 67 percent were done for limb salvage. Cumulative patency rates calculated by the life-table method for the femoropopliteal grafts were 66 percent at 1 year, 53 percent at 2 years, and 49 percent at 3 years. Corresponding patency rates for the femorotibial or peroneal grafts were 48, 44, and 36 percent, respectively. An analysis of factors influencing graft patency indicated that the best results were obtained with femoropopliteal grafts done for claudication in the presence of good distal runoff and grafts placed in limbs without previously failed grafts. Graft occlusion was most likely in distal bypasses for limb salvage and limbs with previously failed grafts. It is concluded that alternatives to PTFE bypass should be considered in those patients at greatest risk for graft occlusion. In patients who lack a satisfactory saphenous vein but who must have a bypass graft, polytetrafluoroethylene is an acceptable arterial substitute; however, thrombectomy or revision will be required to maintain patency in a high proportion of cases.     

Vein versus polytetrafluoroethylene in above-knee femoropopliteal bypass grafting: five-year results of a randomized controlled trial

OBJECTIVE: Controversy still exists whether polytetrafluoroethylene is equivalent to vein as bypass graft material for the above-knee femoropopliteal bypass. Therefore, a prospective randomized trial was performed to compare vein with polytetrafluoroethylene for femoropopliteal bypasses with the distal anastomosis above the knee. METHODS: Between January 1993 and December 1996, 151 above-knee femoropopliteal bypasses were performed. The indications for operation were severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. After randomization, 75 reversed saphenous venous bypasses and 76 polytetrafluoroethylene bypasses were performed. RESULTS: No perioperative mortality was seen, and 5% of the patients had minor infections of the wound, not resulting in loss of the bypass, the limb, or life. After 5 years, 38% of the patients had died and 7% were lost to follow-up. Only once was the saphenous vein necessary for coronary artery bypass grafting. Primary patency rates after 5 years were 75.6% for venous bypass grafts and 51.9% for polytetrafluoroethylene grafts (P =.035). Secondary patency rates were 79.7% for vein and 57.2% for polytetrafluoroethylene bypasses (P =.036). In the venous group, 14 bypasses failed, leading to five new bypasses. In the polytetrafluoroethylene group, 29 bypasses failed, leading to 16 reinterventions. For these 16 new bypasses, in four cases, the ipsilateral preserved saphenous vein was used. In both groups, one above-knee amputation and one below-knee amputation had to be performed. CONCLUSION: We conclude after 5 years of follow-up of this randomized controlled trial that a bypass with saphenous vein has better patency rates at all intervals and needs fewer reoperations. Saphenous vein should be the graft material of choice for above-knee femoropopliteal bypasses and should not be preserved for reinterventions. Polytetrafluoroethylene is an acceptable alternative if the saphenous vein is not available.