56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Dacron femoral-popliteal bypass grafts in good-risk claudicant patients

PURPOSE: To evaluate prosthetic femoral-popliteal (FP) grafts as bypass conduits in favorable patients with refractory calf claudication. SETTING: University-affiliated urban teaching hospital. METHODS: Cohort study of patency of 6-mm Dacron FP grafts used to treat patients with medically refractory calf claudication meeting the following criteria: nonsmoker; above-knee popliteal artery as an appropriate target vessel; > or =2-vessel tibial outflow; and postoperative anticoagulation and antiplatelet therapy. End points included primary and secondary FP graft patency, need for and outcome of subsequent intervention, limb amputation, and survival. RESULTS: From January 1998 through March 2001, 92 patients underwent 100 Dacron bypass grafts for medically refractory claudication. All underwent serial postoperative graft surveillance using duplex ultrasound. Using the Society for Vascular Surgery/International Society of Cardiovascular Surgery criteria life-table, primary patency was 84%, assisted primary patency was 88%, and secondary patency was 90% at 5 years. Two patients (2%) died during a mean follow-up period of 49 months (range 30 to 68). No limbs required amputation. Among 9 limbs in which Dacron FP bypass failed, 8 underwent subsequent successful autogenous bypass to the popliteal artery. CONCLUSION: In highly selected subjects with favorable features known to increase the likelihood of prosthetic graft patency, prosthetic FP grafts function well. Such patients undergo a simpler, more straightforward procedure than when autogenous FP bypass is performed. Subsequent success of autogenous FP repeat bypass suggests that previous prosthetic FP bypass does not threaten lower-extremity arterial outflow.     

ARTERIAL RECONSTRUCTION FOR LOWER LIMB ISCHAEMIA IN HONG KONG CHINESE

Background : Lower limb ischaemia due to peripheral arterial disease is uncommon in Chinese people, and few arterial bypass operations have been performed. The management of a consecutive series of patients who were admitted to our department with severe lower limb ischaemis between March 1990 and October 1996 is reported here. Methods : A total of 91 primary arterial bypass operations were performed for 83 patients (eight patients had bilateral, or two procedures). Of these, 84 operations were for foot salvage and seven operations were for debilitating claudication. There were 80 infra-inguinal bypasses, 10 of which required additional femoro-femoral crossover grafts to improve in-flow. The remaining 11 bypass procedures were performed for aorto-iliac occlusion, which included aortobifemoral bypass (5), axillobifemoral bypass (3) and cross-femoral bypass (3) grafts. There were 46 male and 37 female patients, with a median age of 70 years (36–94). Results : Six patients died (6.6%) postoperatively, all of whom were in the foot salvage group. The overall cumulative foot salvage rate and graft patency was 84 and 56%, respectively, at 5 years. Conclusions : These results justified the use of the same aggressive approach that was adopted in Western countries for the treatment of peripheral arterial disease, which seemed to be an emerging problem in Hong Kong.     

血栓闭塞性脉管炎合并动脉硬化闭塞导致下肢缺血的手术治疗

目的 探讨下肢血栓闭塞性脉管炎(thmmboangiitis obliterans,TAO)合并动脉硬化闭塞症(arteriosclerosis obliterans,ASO)手术治疗效果.方法 回顾性分析2007年治疗的TAO合并ASO 6例患者的资料.2例行腹主动脉切开取栓+内膜剥脱+腹主动脉-股深动脉人工血管旁路移植-胭动脉人工血管-小腿动脉自体大隐静脉旁路移植术,1例行腹主动脉切开取栓+内膜剥脱+腹主动脉-右股深动脉人工血管旁路移植-膝下胭动脉人工血管旁路移植术;1例行左髂总动脉-左股深动脉人工血管旁路移植一胫前动脉自体大隐静脉原位移植术,1例行左侧人工血管切开取栓+左股深动脉成形-膝下腘动脉人工血管旁路移植术,1例行右股总动脉-左股总动脉人工血管旁路移植-胫后动脉自体大隐静脉旁路移植术.结果 5例患者术后恢复顺利,1例于术后当天出现股动脉-腘动脉人工血管和远段的大隐静脉桥血栓形成,立即再次手术行人工血管和大隐静脉切开取栓术,并同时行胫后动静脉吻合.6例患者均痊愈出院,无死亡病例.5例患者的下肢远端静息痛完全缓解,1例部分缓解.足部溃疡的2例创面明显缩小,无感染发生.所有患者得到随访,平均随访为6.5个月,3例足部溃疡愈合.1例术后3个月出现左股部切口感染,最终行膝上截肢处理,残端一期愈合.其他5例患者的移植血管通畅,症状缓解.结论 对TAO合并ASO患者如果手术治疗方式恰当,可以取得比较好的疗效.     

The multiple sequential distal bypass graft: seven-year follow-up

Thirty-nine infrainguinal bypass grafts with multiple sequential distal anastomoses were performed on 35 patients ranging in age from 32 to 79 years (mean 65.8 years) with severe femoropopliteal occlusive disease. Thirty-eight procedures were performed for limb salvage indications. Distal anastomoses were performed to the popliteal-anterior tibial arteries in seven procedures, the popliteal-posterior tibial arteries in six, the popliteal-peroneal arteries in six, the anterior tibial-peroneal arteries in eight, the posterior tibial-peroneal arteries in 10, and the posterior tibial-anterior tibial arteries in two. Saphenous vein was the graft material in 31 procedures (in situ in two), polytetrafluoroethylene (PTFE) in four, and saphenous vein-PTFE composite in four. The mean Doppler ankle-arm index was 0.38 +/- 0.14 preoperatively and 0.89 +/- 0.13 postoperatively. The early (30-day) graft patency rate was 93%. With life-table analysis, the long-term primary patency rate was 70% at 1 year, 61% at 3 years, and 52% at 7 years for saphenous vein grafts; the secondary patency rate was 65% at 7 years for saphenous vein grafts. The secondary patency rate for PTFE and PTFE-vein composite grafts was 75% at 1 year, 50% at 3 years, and 17% at 5 years. Cumulative life-table limb salvage rates were 91% at 1 year, 85% at 5 years, and 61% at 7 years. The multiple sequential distal bypass graft is durable and highly efficacious in achieving limb salvage.     

Triple sequential grafts using the internal mammary artery. An angiographic and short-term follow-up study.

Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4% of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6%, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality.     

Are peroneal artery bypass grafts hemodynamically inferior to other tibial artery bypass grafts?

Purpose: Many authors have reported excellent long-term patency rates of peroneal artery bypasses. It has been suggested, however, that the hemodynamic result of the peroneal bypass is inferior to that of other infrapopliteal artery bypasses, making it suboptimal in patients with forefoot ischemic tissue loss. A retrospective review of 118 recent infrainguinal vein grafts (36 peroneal, 27 anterior tibial, 35 posterior tibial, 20 popliteal) was undertaken to assess and compare the hemodynamic results for each group.Methods: We reviewed the hemodynamic results of 36 peroneal bypass grafts assessed by preoperative and postoperative ankle-brachial index and transmetatarsal pulse volume recording, duplex scan-derived distal graft peak systolic flow velocity, and intraoperatively measured outflow resistance. These results were compared with a concurrent series of anterior tibial, posterior tibial, and popliteal artery bypass grafts. All but one of the infrapopliteal bypass grafts were performed for limb salvage, and 65% of patients had ischemic ulcerations or gangrene.Results: There was no difference in postoperative ankle-brachial index, postoperative transmetatarsal pulse volume recording, peak systolic flow velocity, or measured outflow resistance among the four different outflow groups. All patients with peroneal bypass grafts had healed wounds within a mean follow-up period of 17 months. There were no hemodynamic failures.Conclusion: Peroneal artery bypass grafts achieved hemodynamic results equivalent to anterior tibial, posterior tibial, and popliteal artery bypass grafts. (J VASC SURG 1994;19:964–9.)     

Staged infrainguinal revascularization: initial prosthetic above-knee bypass followed by a distal vein bypass for recurrent ischemia. A valid concept for extending limb salvage?

Optimal infrainguinal revascularization should provide limb salvage for the longest duration of time. It is not known whether limb salvage is longer with an initial below-knee popliteal or tibial in situ saphenous vein graft or with staged bypasses; that is, an initial above-knee popliteal prosthetic bypass if feasible, followed by a more distal vein graft should the above-knee prosthetic graft fail. A retrospective review of 197 lower extremity vascular reconstructions performed since 1976 utilizing polytetrafluoroethylene (PTFE), umbilical vein, or in situ saphenous vein was completed. The data were analyzed for differences in limb salvage and prevention of limb threatening ischemia among three subgroups: above-knee prosthetic bypass, below-knee or tibial in situ saphenous vein bypass, and staged reconstructions (above-knee prosthetic bypass with subsequent in situ bypass). The groups were similar with respect to severity of limb threatening ischemia as indicated by mean preoperative ankle-brachial indices. Cumulative secondary limb salvage at 36 months was 73 percent for prosthetic grafts in the above-knee position, 78 percent for in situ saphenous vein grafts in the below-knee or tibial position, and 87 percent for staged reconstruction with an initial prosthetic graft to the above-knee position followed by a distal in situ vein bypass when the prosthetic graft fails.     

Early experience with the Palmaz expandable intraluminal stent in iliac artery stenosis

Since 1987, we have used the Palmaz expandable intraluminal stent in 22 selected cases of iliac artery stenosis in 14 men and six women with a mean age of 63 years for claudication (9), graft salvage (5), rest pain (4), and tissue loss (2). Morphologic criteria included severe percutaneous balloon angioplasty-induced dissection (6), long or multiple stenoses or occlusions (5), post-percutaneous balloon angioplasty elastic recoil (4), location of stenosis (4), and restenosis following percutaneous balloon angioplasty (3). Twenty-two limbs were treated with 61 stents. The mean pressure gradient across the lesion fell from 31±15 to 1.1±2.4 mmHg after stenting. The mean ankle/brachial systolic pressure index improved from 0.59±0.31 to 0.83±0.25 after stenting. The mean follow-up is 11.4 months, with a mean ankle/brachial index at their most recent follow-up of 0.88±0.19. Symptomatically, 11 extremities are normal and five limbs are improved. Three patients have died and two have required bypass grafts for iliac occlusive disease. In this early experience, the Palmaz intraluminal stent appears to be valuable for the management of post-percutaneous balloon angioplasty restenosis, elastic recoil, and percutaneous balloon angioplasty-induced dissection, although it is not without complications.Presented at the Fifteenth Annual Meeting of Peripheral Vascular Surgical Society, June 2, 1990, Los Angeles, California.     

Long-term Outcome of Femoral Above-knee Popliteal Artery Bypass Using Autologous Saphenous Vein Versus Expanded Polytetrafluoroethylene Grafts

Despite a recent flurry of publications on preferred techniques for femoral above-knee popliteal artery bypass, controversy persists over the use of autologous saphenous vein and expanded polytetrafluoroethylene (ePTFE) grafts. The purpose of this study was to compare our long-term results using these two bypass materials. In a series of 474 infrainguinal bypasses performed between January 1993 and December 1998, we performed a total of 75 femoral above-knee popliteal artery bypass using an autologous saphenous vein graft in 48 cases (64%) and an ePTFE graft in 27 cases (36%). Prosthetic grafts were used by choice in 17 cases and by necessity due to the absence of useable vein in 10 cases. There were 55 men and 18 women with a mean age of 70 years. The indication for bypass was lower extremity arterial occlusive disease at stage II in 17 cases (22.7%), stage III in 9 cases (12%), and stage IV in 36 cases (48%); subacute ischemia in 8 cases (10.7%); and femoropopliteal aneurysm in 5 cases (6.7%). Preoperative arteriography demonstrated three patent leg arteries in 15.5% of cases, two patent leg arteries in 43.5%, and one patent leg artery in 41%. There was no significance difference between the vein graft and ePTFE graft groups with regard to indications and arteriographic findings. No patient died during the immediate postoperative period. The mean duration of follow-up was 25.5 months (range, 3 to 108 months). The primary patency rate at 4 years was 82.2 ± 8% for venous bypass vs. 80.6 ± 11.8% for ePTFE bypass (p = 0.42). The secondary patency rate at 4 years was 84.7 ± 7.4% for vein bypasses and 79.5 ± 12% for ePTFE bypasses (p = 0.26). In our experience, there was no statistically significant difference in long-term outcome of femoral above-knee popliteal artery bypass using autologous vein grafts or prosthetic ePTFE grafts. Presented at the Seventeenth Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 29-31, 2002, Liege, Belgium.     

Diabetic gangrene in peripheral vascular occlusion. Saving the extremity by popliteo-pedal venous bypass]

23 patients with diabetic gangrene and complete occlusion of all 3 tibial arteries were treated by 26 popliteopedal vein bypass grafts. All 6 early graft failures resulted in major amputations. The cumulative graft patency rate was 76% after 6 years. One patient needed lower-leg amputation despite a functioning graft. All other limbs were saved (mean follow-up period: 24.8 months). It is concluded that despite a palpable popliteal pulse an angiographic examination should be performed, when the infectious lesion cannot be controlled by local treatment and pedal pulses are absent.     

Idiopathic arterial calcification in 9-year-old boy: a successful reconstruction for ilio-femoral occlusion

We treated a 9-year-old boy suffering from underdevelopment of the length as well as circumference of the left lower extremity due to idiopathic arterial calcification of the left ilio-femoral artery. There was no deposition of calcium on the other arteries and tissues of the body. He had undergone aorto-internal iliac bypass graft with resection of the calcific iliac and superficial femoral arteries in the National Fukuoka Central Hospital when he was 4 years old, but the graft became occluded. He was admitted to the University of the Ryukyus Hospital. The common femoral artery was completely occluded with severe deposition of calcium on the wall and with gritty contents. The profunda femoris artery and the proximal part of the superficial femoral artery were also completely occluded with organized thrombi. Re-establishment of blood flow to the ischemic left lower extremity was performed with an ilio-femoral cross-over synthetic bypass and femoro-popliteal saphenous vein bypass graft,in situ. The patient has been well with adequate pulses of the pedal and posterior tibial artery 8 months after surgery.     

Prospective randomized study of concomitant lumbar sympathectomy with aortoiliac reconstruction

Ninety-three consecutive patients for aortofemoral bypass grafting were studied to determine the effect of sympathectomy on early and late patency, the need for subsequent distal procedures, amputation rate, and ankle-brachial Doppler systolic pressure indexes. Sixty-seven patients completed the study. Fifty-three limbs were randomized to receive sympathectomy and 81 no sympathectomy. The mean length of follow-up postoperatively was 11 ± 2.53 months (maximum 24).Five grafts occluded, two early and three late. Both early occlusions occurred in the nonsympathectomy group and all three late occlusions ensued in the sympathectomy group. Subsequent distal procedures were necessary early (within 30 days) in five limbs, all in the nonsympathectomy group. Nine limbs required distal procedures late, four (5 percent) in the nonsympathectomy group and five (9.5 percent) in the sympathectomy group (p > 0.05). Altogether, distal bypass was required in 11 percent of the patients in the nonsympathectomy group versus 9.4 percent in the sympathectomy group (p > 0.05). Five limbs were amputated 4 to 14 months after aortofemoral bypass, four (5 percent) in the nonsympathectomy and one (2 percent) in the sympathectomy group (p > 0.05). The ankle-brachial pressure index increased significantly after aortofemoral bypass in both groups (p < 0.05). The mean increase after aortofemoral bypass was more marked in the sympathectomy group (p > 0.05).Thus, at a mean follow-up time of 11 months after aortofemoral bypass, there was no significant difference in graft patency, need for subsequent distal bypass, or amputation rate between the sympathectomy and nonsympathectomy groups.     

Distal polytetrafluoroethylene bypasses in patients older than 75 years

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.     

Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease

OBJECTIVE: This randomized prospective study was designed to compare the effectiveness of treating superficial femoral artery occlusive disease percutaneously with expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent grafts vs surgical femoral-to-above knee (AK) popliteal artery bypass with synthetic graft material. METHODS: From March 2004 to May 2005, 100 limbs in 86 patients with femoral-popliteal arterial occlusive disease were identified. Patients had symptoms ranging from claudication to rest pain, with or without tissue loss, and were prospectively randomized for treatment into one of two groups. The limbs were treated percutaneously with angioplasty and one or more self-expanding stent grafts (n = 50) or surgically with femoral-to-AK popliteal artery bypass using synthetic Dacron or ePTFE grafts (n = 50). The mean +/- SD total length of artery stented was 25.6 +/- 15 cm. Follow-up evaluation with ankle-brachial indices and color flow duplex sonography imaging were performed at 3, 6, 9, and 12 months after treatment. RESULTS: Patients were monitored for a median of 18 months. No statistical difference was found in the primary patency (P = .895) or secondary patency (P = .861) between the two treatment groups. Primary patency at 3, 6, 9, and 12 months of follow-up was 84%, 82%, 75.6%, and 73.5% for the stent graft group and 90%, 81.8%, 79.7%, and 74.2% for the femoral-popliteal surgical group. Thirteen patients in the stent graft group had 14 reinterventions, and 12 reinterventions occurred in the surgical group. This resulted in secondary patency rates of 83.9% for the stent graft group and 83.7% for the surgical group at the 12-month follow-up. CONCLUSIONS: Management of femoral-popliteal arterial occlusive disease using percutaneous treatment with a stent graft is comparable with surgical revascularization with conventional femoral-to-AK popliteal artery bypass using synthetic material up to 12 months. Longer-term follow-up would be helpful in determining ongoing efficacy.     

Pedal Bypass for Limb Salvage

Background: Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. It involves arterial reconstruction with distal anastomosis to one of the pedal arteries.

Material and Methods: Between January 2000 and June 2004, 54 pedal bypasses were performed in 53 patients with chronic critical lower limb ischemia. Forty-seven (87%) patients had gangrene or ischemic ulcer, 36 (68%) had diabetes. In some of the patients (16.7%), previous percutaneous transluminal angioplasty (PTA) of the crural arteries had failed. Preoperative angiographic findings were unsatisfactory in the majority of the patients; the plantar arch was not visualized in 36 (66.7%) limbs.

Results: In the period investigated (54 months) 11 grafts (20.4%) failed. Early thrombectomy resulting in long-term graft patency salvaged five limbs. One limb with graft occlusion occurring after foot ulcer healing was also salvaged. However, one amputation had to be performed despite a patent graft. The perioperative mortality rate was 3.8%. Cumulative primary and secondary graft patency rates and limb-salvage rates at 54 months were 76%, 78% and 81%, respectively.

Conclusion: Pedal bypass grafting is a safe method with very good long-term outcomes. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere “angiographic” absence.     

Changes in angiographic features and the ankle/brachial pressure index of femorodistal arterial bypass grafts during knee flexion

Systolic ankle pressure was measured in limbs in the extended and 90°-flexed positions in three groups of patients who had undergone below-knee femorodistal arterial bypass. Group 1 consisted of eight limbs in seven patients who had received an autologous saphenous vein (ASV) graft; group 2 consisted of seven limbs in seven patients who had received a ringed expanded polytetrafluoroethylene (ePTFE) graft; and group 3 consisted of five limbs in five patients who had received a reinforced biosynthetic borine collagen vascular (Omniflow) graft. Intravenous digital subtraction angiography was performed within 3 months of implantation. The ankle/brachial index (ABI) was significantly lower when the knee was flexed than when it was extended in groups 1 and 3, but not in group 2. The ABI in flexion in group 1 was similar to that in group 2. Morphologic changes such as kinking were demonstrated angiographically in groups 1 and 3. Given that the ABIs in groups 1 and 2 were similar with the knee flexed, despite the morphologic changes in group 1, we concluded that saphenous vein and ringed ePTFE grafts are more durable when subjected to acute knee flexion than Omniflow grafts. Thus, as graft failure is unlikely to result from kinking as a result of knee flexion alone, further clinical studies are required to elucidate the precise causes of graft failure.     

Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb-threatening ischemia

Purpose: Although axillobifemoral bypass procedures have a lower mortality rate than aortobifemoral bypass procedures, they are limited by decreased patency, moderate hemodynamic improvement, and the need for general anesthesia. This report describes an alternative approach to bilateral aortoiliac occlusive disease using unilateral endovascular aortofemoral bypass procedures in combination with standard femorofemoral reconstructions.Methods: Seven patients who had bilateral critical ischemia and tissue necrosis in association with severe comorbid medical illnesses underwent implantation of unilateral aortofemoral endovascular grafts, which were inserted into predilated, recanalized iliac arteries. The proximal end of the endovascular graft was fixed to the distal aorta or common iliac artery with a Palmaz stent. The distal end of the graft was suture-anastomosed to the ipsilateral patent outflow vessel, and a femorofemoral bypass procedure was then performed.Results: All endovascular grafts were successfully inserted through five occluded and two diffusely stenotic iliac arteries under either local (1), epidural (5), or general anesthesia (1). The mean thigh pulse volume recording amplitudes increased from 9 ± 3 mm to 30 ± 7 mm and from 6 ± 2 mm to 26 ± 4 mm ipsilateral and contralateral to the aortofemoral graft insertion, respectively. In all cases the symptoms completely resolved. Procedural complications were limited to one local wound hematoma. No graft thromboses occurred during follow-up to 28 months (mean, 17 months).Conclusions: Endovascular iliac grafts in combination with standard femorofemoral bypass grafts may be an effective alternative to axillobifemoral bypass in high-risk patients who have diffuse aortoiliac occlusive disease, particularly when bilateral axillary-subclavian disease is present. (J Vasc Surg 1996;24;984-97.)     

个体化血管重建术治疗下肢多平面动脉硬化闭塞症

目的 观察序贯立交搭桥或结合腔内技术治疗下肢多平面动脉硬化闭塞症的临床效果。方法 2004年4月～2005年7月，对11例14条下肢多平面动脉硬化闭塞症患者，采用序贯立交搭桥或动脉内膜剥脱术或腔内外结合手术治疗。其中男10例，女1例；年龄62～79岁，平均70．5岁。表现为间歇性跛行8例（FontaineⅡ期），静息痛3例（Fontaine Ⅲ期），足趾溃疡、坏疽1例（FontaineⅣ期）。彩色多普勒检查示14条下肢均为多平面动脉硬化闭塞，踝肱指数（ankle brachialindex，ABI）为0．36±0．11。下肢数字减影血管造影（digital subtraction angiography，DSA）显示双侧髂总动脉闭塞2em、髂外动脉闭塞、双侧股浅动脉闭塞3例，右侧髂总动脉狭窄、髂外动脉闭塞、双侧股浅动脉闭塞1例，单侧髂外动脉狭窄、股浅动脉闭塞7例。术后行DSA、彩色多普勒检查及ABI测定，观察血管通畅情况。结果 术后无死亡。患者均获随访3～26个月，平均14．5个月。间歇性跛行、静息痛等症状均消失，ABI术后为0．89±0．13，与术前比较差异有统计学意义（P〈0．01）。肢体获救率100％。术后3～280d行下肢DSA显示转流血管通畅率为92．86％（13／14）。结论 序贯立交搭桥或腔内外手术结合，是治疗严重下肢多平面动脉硬化闭塞症的一种可靠、安全、相对微创的治疗方法。     

Failure of arteriovenous fistulas at distal tibial bypass anastomotic sites

Arteriovenous fistula formation has been advocated to increase the outflow for tibial and peroneal distal bypass grafts. Between January, 1981 and September, 1981, twenty-seven patients underwent thirty femoral to distal tibial or peroneal artery bypass procedures with creation of an arteriovenous fistula at the site of the distal anastomosis. Limb salvage was the primary indication for surgery in 97% of this severely ischemic group, with a mean ankle pressure index of 0.32. Despite high flow rates averaging 260 cc/minute and an initial patency rate of 97%, there were only two fistulas patent in intact limbs at the conclusion of the initial eight month follow-up period with one additional occlusion at 16 months. Limb salvage to the present (July 1983) was achieved in only six cases. In the patients with limb salvage, three bypass grafts remain patent despite fistula occlusion, two patients have occlusion of both graft and fistula but no rest pain, and a single patient has maintained both graft and fistula patency for 23 months. Creation of an arteriovenous fistula at the distal anastomotic site of tibial bypass procedures augments graft flow in the immediate post-op period; but, has very low long term patency rates and is not beneficial to graft patency or effectiveness.