原位大隐静脉动脉旁路术治疗下肢动脉硬化性闭塞症

目的提高下肢动脉缺血的救治率。方法作采用原位大隐静脉动脉旁路术治疗下肢动脉硬化性闭塞症．自1991年～1995年，进行7例病人，9条肢体手术。结果所有患术前均经动脉造影证实。术前踝／肱指数为0～0．57(平均0．43)。术后移植物均可扪及搏动，踝／肱指数由术前平均的0．43上升至0．93，严重缺血肢体挽救率为100％。随访1～3年中，血管通畅率分别为78％、56％和20％。结论作认为原位大隐静脉动脉旁路术是治疗下肢动脉硬化性闭塞症的理想方法之一。     

下肢远端动脉旁路移植治疗糖尿病下肢缺血

目的探讨治疗糖尿病下肢缺血动脉旁路移植的方法和疗效。方法从2000年7月至2004年7月，应用下肢远端动脉旁路移植手术治疗了82例2型糖尿病病人的96条下肢。主要方式为股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术31条（32．3％），胭动脉-小腿动脉旁路移植22条（22．9％），髂动脉支架＋股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术12条（12．5％），股动脉-小腿动脉旁路移植10条（10．4％）。结果82例中，3例全麻手术病人（4条下肢）于术后死亡，病死率为3．7％；手术成功率为96．3％，总有效率为93．7％；救肢成功率为98．9％；足部创面愈合率37．3％。76例患者（96．2％）被随访，平均随访时间为13．5个月，移植血管通畅率为92．2％；死亡率为3．9％；总有效率为87．6％；截肢率为4．5％，保肢率为95．5％。93．8％（30／32）下肢创面分别于出院2～10个月（平均6个月）后愈合。结论糖尿病下肢缺血行远端动脉旁路移植手术，可以使大多数患者得到有效治疗，从而挽救肢体或降低截肢平面。     

大隐静脉原位旁路术治疗老年下肢动脉硬化

目的：动脉旁路术是外科治疗下肢股胭动脉硬化闭塞症的主要办法,根据选择动脉移植物材料不同,可分为人造血管动脉旁路术与自体大隐静脉动脉旁路术,自体大隐静脉动脉旁路术又因手术方法不同分为倒置旁路术与原位旁路术。本文回顾性的比较动脉旁路术中分别采用人造血管与自体大隐静脉作为移植物治疗老年性下肢动脉硬化闭塞症的临床治疗效果,探讨人造血管与大隐静脉原位旁路术利弊,为临床选择提供良好的根据。方法：选择我院2008年6月～2009年9月应用动脉旁路术治疗老年性下肢动脉硬化闭塞症的47例患者进行回顾总结,根据旁路血管不同分为两组,人造血管组32例,自体大隐静脉组15例,比较两组病例的症状缓解与旁路血管通畅情况。结果：动脉旁路术可以明显改善动脉硬化闭塞症患者的症状,原位大隐静脉通畅率（93．75％）优于人造血管通畅率（85．71％）。结论：动脉旁路手术是治疗老年性下肢动脉闭塞性疾病的有效手段,选择大隐静脉作为移植物治疗效果优于人造血管。     

周围动脉血管旁路手术

当动脉血管发生闭塞、狭窄造成肢体缺血、经药物治疗无效时,应切除有病变血管行血管重建术,以恢复正常的循环功能。对一些病人可选用周围动脉旁路手术。此手术可在局麻下进行,操作简单,不必暴露胸、腹     

糖尿病性下肢缺血的外科治疗

目的 探讨糖尿病下肢缺血的外科治疗方法。方法 78例2型糖尿病(T2DM)患者合并下肢动脉缺血的95条肢体进行了外科手术治疗，其中动脉旁路移植术76条下肢，占80％。主要方式为股动脉-腘动脉人工血管旁路移植-单支小腿动脉自体血管旁路移植术(23．2％)和腘动脉-小腿动脉旁路移植术(21．0％)；15例患者16条下肢截肢处理，占16．8％；自体骨髓干细胞移植3例3条患肢，占3．1％。结果 75例91条下肢的移植血管在出院时均保持通畅，通畅率为100％；3例(4条下肢)于术后死亡，围手术期病死率为3．8％，手术成功率为96．2％。术后踝肱指数(ABI)为0．86～1．12，平均0．94。自体骨髓干细胞移植的3例患者，均达到避免截肢或降低截肢平面的目的。出院时足部创面愈合率39．2％。结论 糖尿病性下肢缺血可以通过外科治疗，如下肢远端动脉旁路移植、腔内血管成型术、自体骨髓干细胞移植及适当平面的截肢等方法而获得较好的疗效，外科治疗不仅可以挽救肢体或降低截肢平面，而且可为足部创面的愈合提供较好的营养环境，有利于创面的愈合和提高生活质量。     

动脉内膜剥脱自体干细胞移植治疗下肢动脉闭塞症的临床疗效观察

目的探讨患肢动脉内膜剥脱和(或)人工血管旁路术、自体骨髓干细胞动脉腔内及肌内移植对治疗下肢动脉硬化闭塞症的临床价值。方法总结185例下肢动脉闭塞症的临床资料,回顾分析其病因、临床特点、诊断方法、治疗手段及治疗效果。结果 185例经闭塞段动脉内膜剥脱、自体干细胞腔内和肌内移植,术后随访3、6、12、18、24个月,肢体血液循环改善明显,临床症状缓解。结论下肢动脉硬化闭塞症采取闭塞段内膜剥脱和(或)人工血管旁路术,辅以自体骨髓干细胞动脉腔内和肌内移植可获较好疗效。     

膝下动脉闭塞腔内治疗与手术治疗效果的临床分析

目的:评价膝下动脉闭塞球囊扩张成形术和动脉旁路术的治疗效果。方法:回顾性分析2005年12月至2009年5月北京协和医院收治的膝下动脉闭塞重症下肢缺血病例,全部资料都是前瞻性收集并录入数据库,并将治疗结果进行回顾性分析。根据膝下动脉初次处理手段的不同分为2组:球囊扩张成形术(PTA)组、以膝下动脉为流出道行自体静脉旁路移植术(bypass surgery,BPS)组,比较2组手术及随访结果。结果:PTA组54例(61条肢体),男性37例,女性17例,平均年龄66岁;手术前后踝肱指数(ABI)由(0.43±0.27)增加至(0.86±0.21),随访期间一期通畅率63.8%,二期通畅率74.1%,救肢率88.3%。动脉旁路术组17例(17条肢体),男性12例,女性5例,平均年龄67岁,ABI由(0.21±0.19)增加至(0.73±0.38),手术通畅率60%,救肢率87.5%。2组治疗结果差异无统计学意义。结论:膝下动脉腔内成形术的临床治疗效果不次于膝下动脉旁路手术,可以作为膝下动脉闭塞首选的治疗方法。     

TASCⅡA、B型股胭动脉闭塞的外科治疗

下肢动脉硬化闭塞症(ASO)是由于动脉硬化病变引起的慢性动脉闭塞性疾病.股腘动脉一直是ASO的高发部位.ASO患者中,出现静息痛或重症下肢缺血性症状的病例,3个月的截肢发生率可达12.2％;不经系统治疗的重症肢体缺血病例,半年截肢率超过40％,1年期病死率约为20％[1].根据2007年泛大西洋介入学会协议(TASC)更新的周围动脉疾病(PAD)的诊治共识,即TASCⅡ的PAD治疗指南[2],腔内治疗已与血管旁路术和血管内膜剥脱术一样,成为血管外科手术干预具有间歇性跛行与重症下肢缺血症状的股腘动脉疾病的常用手段.本文回顾性分析我科2008年以来,TASCⅡA、B型患者中接受血管腔内治疗及开放手术治疗的患者的临床资料.     

髂动脉支架联合股深动脉成形术治疗下肢动脉硬化闭塞症12例回顾性分析

下肢多平面多节段动脉硬化闭塞是老年人下肢缺血的主要原因，经典的动脉旁路术是有效的治疗手段，但是对于远端流出道不佳或伴有严重心脑肺肾等重要脏器功能不全的老年病人，不适合行创伤较大的动脉旁路手术治疗，部分病人因而丧失治疗机会而被截肢，严重影响了老年人的生活质量。随着血管腔内介入治疗技术的巨大进步，腔内介入治疗与腔外手术相结合已成为新的研究发展方向。我院于2003年7月至2005年11月，应用术中髂动脉球囊扩张和支架植入结合股深动脉成形术治疗高危重症老年人下肢多平面动脉硬化闭塞症12例，现将回顾性分析结果报道如下。     

动脉内溶栓治疗大脑中动脉完全闭塞的临床分析

目的评价动脉内溶栓治疗大脑中动脉闭塞的血管再通率及临床疗效。方法回顾性分析动脉内溶栓治疗大脑中动脉闭塞患者168例。根据溶栓药物分为尿激酶组122例，重组组织型纤溶酶原激活剂（rt-PA）组46例，通过数字减影血管造影（DSA）分析闭塞大脑中动脉再通率，采用Moil分级标准评价血管再通程度，格拉斯哥预后评分（GOS）评价患者预后。结果①尿激酶组：血管完全再通占37．7％（46／122）；部分再通占46．7％（57／122）；未通占15．6％（19／122），溶栓后脑出血占6．6％（8／122）；预后恢复良好为51．6％（63／122），轻度残障22．1％（27／122）重度残障19．7（24／122），植物状态0．8％（1／122），死亡5．7％（7／122）。②rt—PA组：血管完全再通占41％（19／46）；部分再通占52％（24／46）；未通占6％（3／46），出血6％（3／46），恢复良好54％（25／46），轻度残障24％（11／46），重度残障15％（7／46），植物状态2％（1／46），死亡4％（2／46）。两组血管再通率、出血率及其GOS评分比较，差异无统计学意义，P〉0．05。结论动脉内溶栓可有助于再通完全闭塞的大脑中动脉和改善患者预后。尿激酶和rt—PA溶栓效果相近。     

Arterial pressure--self measurement. Recommendations. French Society for Arterial Hypertension--the Measurement Group

Self-measurement of blood pressure has become widespread in recent years. It may be defined as the measurement of arterial pressure by a conscious and free-willed subject. Self-measurement must remain a medical procedure, which means that doctors should be able to advise their patients (a) on the type of apparatus they should purchase and get validated at regular intervals; (b) on the method of using the apparatus in practice, and (c) on the circumstances, conditions and numbers of measurements to be performed. Doctors must remain responsible for the interpretation of the results obtained and for the diagnostic, pronostic an therapeutic applications of the method. Self-measurement of blood pressure naturally has advantages and disadvantages, but it must be noted that it may offer an alternative to hospitalization or to ambulatory arterial pressure measurement, avoid excessive or defective therapies and improve the patient's compliance with his treatment.     

A Case Report of Locked-in Syndrome Due to Bilateral Vertebral Artery Dissection After Cervical Spine Manipulation Treated by Arterial Embolectomy

Cervical spine manipulation (CSM) is a commonly spinal manipulative therapies for the relief of cervical spine-related conditions worldwide, but its use remains controversial. CSM may carry the potential for serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke. Here, we reported a rare case of locked-in syndrome (LIS) due to bilaterial VAD after CSM treated by arterial embolectomy.A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after treating with CSM for neck for half an hour. Gradually, although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnea at 4 hours after admission. He was diagnosed with LIS. Then, the patient was received cervical and brain computed tomography angiography that showed bilateral VAD. Aortocranial digital subtraction angiography showed vertebrobasilar thrombosis, blocking left vertebral artery, and stenosis of right vertebral artery. The patient was treated by using emergency arterial embolectomy and followed by antiplatelet therapy and supportive therapy in the intensive care unit and a general ward. Twenty-seven days later, the patient''s physical function gradually improved and discharged but still left neurological deficit with muscle strength grade 3/5 and hyperreflexia of limbs.Our findings suggested that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to SCM have pre-existing craniocervical artery dissection.     

Peripheral Arterial Disease and Its Relationship to Cardiovascular Risk Factors and Coronary Heart Disease in Newly Diagnosed Non-insulin-dependent Diabetics

ABSTRACT The prevalence of peripheral arterial disease and its relationship to cardiovascular risk factors was investigated in 133 patients aged 45–64 years with newly diagnosed non-insulin-dependent diabetes and in 144 randomly selected non-diabetic subjects of the same age. History of intermittent claudication, absent foot pulses, decreased ankle-arm blood pressure ratio (<0.9) and radiologically detectable arterial calcifications of the lower limbs were used as indicators of the presence of peripheral arterial disease. Peripheral arterial disease tended to be somewhat more common in men with newly diagnosed non-insulin-dependent diabetes than in non-diabetic men, whereas no difference was found in prevalence of peripheral arterial disease between diabetic and non-diabetic women. The association of various indicators of peripheral arterial disease with cardiovascular risk factors and coronary heart disease was low or absent.     

Arterial disobliteration by the laser

In order to determine the optimal conditions for disobliteration of occluded arteries without damaging the arterial wall, the effects of a Nd-YAG laser connected to a 0.2 mm diameter fibre optic system were studied on post-mortem coronary arteries and popliteal and tibial arteries of amputated limbs. Vaporisation of atheromatous plaques was consistently obtained with energies of 300 to 600 joules associated with perfusion of the vessel with dilated blood (3 g/100 ml of haemoglobin) at a flow rate of 20 ml/min. Protection of the arterial wall was ensured by introducing the fibre aortic system through a balloon catheter and by cooling with the perfusion liquid. The reproducibity of these results in the absence of major arterial wall damage, and the facility of manipulation of the fibre optic system due to its flexibility and narrow diameter, encouraged us to use this method clinically. The first three applications on peripheral arteries (femoral and popliteal arteries) confirmed that this method of arterial disobliteration can be used with a certain degree of efficacy with only a slight risk of arterial perforation. Further studies are essential to improve the degree of laser penetration of the arterial obstruction and to increase the diameter of the tunnel of recanalisation.     

Therapeutic Angiogenesis by Transplantation of Autologous Bone Marrow and Peripheral Blood Mononuclear Cells in Patients with Peripheral Arterial Disease

Recently, the effectiveness and safety of therapeutic angiogenesis by transplantation of autologous bone marrow mononuclear cells (BM-MNCs) to ischemic limbs have been reported. We investigated whether transplantation of peripheral blood mononuclear cells (PB-MNCs) would also be as effective as BM-MNC-transplantation in patients with peripheral arterial disease. BM-MNC-transplantation into unilateral ischemic limbs was performed in five patients, and both BM-MNC and PB-MNC-transplantation into bilateral ischemic limbs (BM-MNCs into severe ischemic limbs and the same number of PB-MNCs into contralateral less ischemic limbs) were performed in five patients. The number of CD34⁺ cells in PB-MNCs was ~100-fold less than that in BM-MNCs, while PB-MNCs secreted substantial amounts of vascular endothelial growth factor (VEGF) during a 24-hour incubation. There was no increase in the serum VEGF levels by BM-MNC-transplantation alone, while there was a significant increase in the serum VEGF levels after transplantation of both BM-MNCs and PB-MNCs. Two weeks after transplantation, the ankle-brachial index and transcutaneous oxygen pressure were significantly increased in BM-MNC-transplanted limbs, while there were no significant increases in these parameters in PB-MNC-transplanted limbs. In conclusion, autologous transplantation of BM-MNCs represents a new and promising strategy for clinical application designed to revascularize ischemic tissues, but there were no definite therapeutic effects of transplantation of PB-MNCs.     

Office Management of Peripheral Arterial Disease

Patients with peripheral arterial disease are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped, and hypertension, diabetes mellitus, and dyslipidemia should be treated. Statins reduce the incidence of intermittent claudication and increase exercise duration until the onset of intermittent claudication in patients with peripheral arterial disease and hypercholesterolemia. Antiplatelet drugs, such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins, should be given to all patients with peripheral arterial disease. Beta-blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol improve exercise time until the onset of intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are incapacitating claudication interfering with work or lifestyle in patients; limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, infection, or gangrene; and vasculogenic impotence.     

Arterial complications of thoracic outlet syndrome and pseudarthrosis of the clavicle: three patients

During a 3-year period, three patients developed arterial complications related to congenital or post-traumatic old pseudarthrosis of the clavicle. Arterial complications of pseudarthrosis of the clavicle presenting as a thoracic outlet syndrome are very rare. Symptoms are variable and occur late. Without treatment, the prognosis is poor with spontaneous development of gangrene. Arterial morphology investigations should be undertaken in patients with pseudarthrosis of the clavicle or isolated arterial symptoms involving the upper limb whose radial pulse disappears during postural tests. Duplex Doppler of the subclavian artery is an excellent screening exam but selective arteriography is the gold standard. It shows proximal arterial lesions (embolytic stenosis of the subclavian artery with post-stenotic dilatation), as well as distal embolic complications. Both static and postural tests must be performed to unmask subclavian restriction by the clavicle, proving its causal effect in the arterial complications. There are four clinical varieties: chronic thrombosis of the subclavian artery, distal arterial micro emboli, acute thrombosis of proximal arteries of the upper limb, and subclavian aneurysm. These lesions are thought to be due to chronic constriction and repeated arterial microtrauma. Congenital or post-traumatic pseudarthrosis, hypertrophic callus, arterial restriction by a screw in a clavicular plate, usually explain the arterial lesions. Bone tumors and Paget's disease are potential but exceptional clavicular etiologies. Surgical treatment is always necessary. Clavicular resection is usually needed in case of pseudarthrosis; there is no functional handicap. Plate fixation and autologous grafting, or open reduction and internal fixation are other valid surgical treatments; The embolytic lesions must be treated to prevent recurrence of distal embolization: graft resection and thromboendarteriectomy have been described. Neurological and venous decompression may be associated at the same time. Complementary treatment can be associated: distal bypass, cervicothoracic sympathectomy, in situ thrombolysis or thrombectomy. Endovascular treatment is not indicated. Optimal treatment of clavicular fractures is required to prevent the development of thoracic outlet syndrome.     

Arterial thrombolysis. Review and future prospects

After describing the mechanism of action, results and local and general complications of classical thrombolytic agents (streptokinase and urokinase) administered systemically, locally and peroperatively, then of modern thrombolytic agents (acyl enzyme, tPA and scuPA), the future perspectives of arterial fibrinolysis are discussed. These are based upon: analysis of the comparative efficacy of the different thrombolytic agents in the light of results seen, not only in peripheral arterial pathology but also in other indications, as in coronary pathology; discussion of the methods of administration of the thrombolytic agent in such a way as to obtain an optimal local concentration and at the same time reduced systemic fibrinolysis. better definition of the indications of thrombolysis in acute ischemia of the limbs in comparison with other therapeutic approaches, in particular surgery, taking into account the degree of ischemia, of etiological mechanism and the site of the arterial obstruction.     

Arterial complications of neurofibromatosis

Type 1 neurofibromatosis (NF1) is the most frequently observed phacomatosis, but involvement of arterial trunks is uncommon. Expression depends on the localization and is not easily related to the causal condition. Seven patients with type 1 neurofibromatosis developed vascular manifestations (table I) disclosed by hypertension (n = 2) digestive angina (n = 1), arterial rupture (n = 1) and aneurysm of the subrenal aorta (n = 1). The diagnosis of NF1 was clear in 5 cases; in 2 cases, the diagnosis could only be established on the basis of pathology findings demonstrating dysplasia of the media with voluminous periadventitial hypertrophic nerves (table II). All the large arteries can be involved in NF1. A complete vascular work-up is needed to identify multiple arterial localizations as found in two of our cases. Thoraco-abdominal stenosis was observed in 5 cases leading, in 2 cases, to coarctation with a hemodynamic and functional impact requiring aortic revascularization. The most frequently observed localization involves the renal arteries: 3 of our patient had occlusive lesions of the renal arteries and in 2, aneurysms were observed. Three of our patients (including 2 of the preceding), had major occlusion of digestive arteries. Three other cases revealed an aneurysm of inflammatory subrenal aorta, a rupture of the iliac into the inferior vena cava and a rupture covered by a subclavian aneurysm. The indication for surgery depends on the arterial signs of associated complications (5 of our cases). In one case surgery was indicated to prevent rupture of a splenic artery aneurysm and an aneurysm of the subrenal abdominal aorta. Two cases were treated by exclusion (ilio-cava fistula) or excision (splenic aneurysm); renal or digestive revascularization was performed with arterial or venous autografts in young patients (3 cases). One extensive abdominal coarctation was repaired with a PTFE graft as were the subclavian and subrenal aorta aneurysms. One patient with an ilio-cava fistula died from collapsus. Long-term results of the revascularizations are satisfactory with good control of the hypertension and total regression of the digestive angina. Fibrodysplasia of the renal or digestive media occurring alone or thoraco-abdominal coarctation should suggest NF1 and lead to a complete work-up to identify other arterial localizations. Patients should be followed regularly to prevent complications which in case of rupture can be life-threatening.     

Arterial hypertension associated with hyperlipoproteinemia

Hypertension and serum cholesterol levels are strongly interrelated as cardiovascular risk factors. The Framingham study showed that the risk of both ischaemic heart disease and brain infarction doubles in presence of mild hypertensive status and triplicates in presence of a definitive hypertension. The systolic pressure showed to be the best predictor of both ischaemic heart disease and cerebral infarction particularly in persons aged more than 65 years. In terms of physiopathology we point out several mechanisms by which hypertension could interact with hypercholesterolemia on the arterial wall causing endothelial lesion, enhancing the penetration of arterial wall by lipoproteins, calcium accumulation on smooth subendothelial muscle and suppression of the relaxation factor produced by endothelial cells. In relation to the dietetic treatment, we must restrict more rigorously the ingestion of salt, saturated fatty acids, and total calories. In terms of anti-hypertensive drugs, we should: Avoid thiazide diuretics in case of cholesterol levels of moderate to high risk. Avoid beta blockers in patients with high levels of triglycerides, low HDL and low ratio total cholesterol/HDL. Consider to choose a calcium antagonist, a converting enzyme or an alpha blocker.