血管内支架治疗外周动脉狭窄或阻塞性疾病

目的 探讨血管内支架治疗外周动脉狭窄或阻塞性疾病的疗效和预后。方法 应用PTA加血管内支架技术,治疗13例外周动脉狭窄性疾病的患者。结果 13例动脉造影显示4例颈动脉、4例锁骨下动脉、4例肾动脉及1例腹主动脉有不同程度狭窄。12例应用导丝顺利完成PTA治疗后,置放自扩展式Wall stent、记忆合金式Symphony及Angiomed支架12支,患者治疗后临床症状消失或缓解。术后造影显示血管及支架通畅,近期效果满意。结论 应用PTA加血管内支架是治疗外周血管狭窄或闭塞性疾病的理想方法。     

移植肾动脉狭窄的介入治疗

目的：探讨移植肾动脉狭窄介入治疗的方法和疗效。方法：9例移植肾动脉狭窄的病人，经股动脉入路行狭窄段的导管球囊扩张和内支架植入术。结果：9例移植肾动脉的患者均成功完成球囊扩张术，其中3例行内支架植入术，治疗后一周7例血压基本恢复正常，2例靠药物维持，所有患者的肌酐术后均明显下降。结论：导管球囊扩张和内支架植入术对治疗移植肾动脉狭窄有较高的临床应用价值。     

多层螺旋CT图像后处理诊断移植肾动脉狭窄

背景:对肾移植后并发移植肾动脉狭窄患者的诊断及随访是否可采用一种无创伤、特异性高、安全的检查方法。目的:评估多层螺旋CT图像后处理技术对移植肾动脉狭窄的诊断价值。方法:对11例临床怀疑为移植肾动脉狭窄的患者进行移植肾动脉期的增强扫描,扫描后所得到的数据经容积重建、最大密度投影、曲面重建、多平面重建处理成像。结果与结论:11例患者均诊断为移植肾动脉狭窄,10例多层螺旋CT图像后处理技术显示移植肾动脉狭窄程度54%～75%,1例移植肾动脉狭窄程度<50%。吻合口狭窄10例,其中合并移植肾动脉主干狭窄2例;移植肾动脉分支狭窄1例。经数字减影血管造影检查9例,狭窄程度75%～95%,8例置入支架,1例球囊扩张;1例给予药物治疗随访,于2年后出现肾功能进一步恶化及难治性高血压,置入支架。1例无临床症状,经多层螺旋CT移植肾动脉狭窄程度<50%,随访4年肾功能、血压正常。支架置入治疗的患者中1例行球囊扩张者2年后彩色多普勒提示移植肾吻合口狭窄,行多层螺旋CT检查移植肾动脉狭窄程度<50%,随访4年3个月,肾功能、血压正常。提示多层螺旋CT后成像技术可作为移植肾动脉狭窄的诊断依据,对区分临床疑似病例,制定支架置入治疗方案,以及术后随访观察有一定的临床参考价值。     

肝移植术后管腔重建相关并发症的介入治疗

目的：探讨介入技术治疗肝移植术后血管和胆管管腔重建相关性并发症的可行性。方法：肝移植术后共有16例相关并发症患者接受介入治疗,其中肝动脉狭窄4例,肝动脉血栓形成2例,门静脉狭窄并血栓形成1例,胆管吻合口狭窄9例。肝动脉狭窄行球囊扩张（PTA）或内支架治疗,肝动脉血栓形成行导管接触性溶栓治疗,门静脉狭窄并血栓形成行溶栓、支架置入及分流道栓塞治疗,胆管吻合口狭窄行PTA或支架置入治疗。结果：16例患者均获技术成功,治疗均有效,有效率为100%。4例肝动脉狭窄1例单纯PTA有效,3例行支架置入术后有效,血流恢复。2例肝动脉血栓形成术后血栓消失,血流恢复通畅。1例门静脉并发症治疗后血流恢复,灌注增加。9例胆管吻合口狭窄2例行PTA有效,7例置入支架后有效。随访0.5～17个月无复发,5例死于原发病进展或系统并发症,与该并发症或介入治疗无关。结论：介入技术成功率高、并发症少,是治疗肝移植管腔重建相关并发症的有效方法。     

肾血管性高血压的介入治疗

目的：研究经皮腔内血管成形术＋内支架植入术治疗肾动脉狭窄所致肾血管性高血压的临床效果。方法：选用Palmaz支架，对10例大动脉炎，3例动脉粥样硬化，2例纤维肌性发育不良所致肾动脉病变先行PTRA术，然后放置支架，术后病人均行常规抗凝治疗。结果：15例患者PTRA＋支架植入技术成功率100％，近期随访3－28个月未见复发。结论：PTRA＋支架植入术治疗肾血管性高血压效果满意，创伤小，病人痛苦少，为肾动脉狭窄所致肾血管性高血压较理想的治疗方法。     

多层螺旋CT扫描在移植肾动脉狭窄中的应用

目的探讨CT血管造影(MSCTA)在移植肾动脉狭窄(TRAS)中的监测评价作用。方法 15例TRAS实施了MSCTA,后处理方法为MPR、CPR、VR、MPVR、MIP及VP。对所有后处理方法进行分析,观察移植肾动脉的情况,比较各自优缺点。结果 TRAS的CT征象表现为狭窄局部血管明显变细,肾实质强化减低。CT后处理方法:①MPR仅有1例可以将移植肾的肾动脉显示于同一层面中;②CPR的13例可在冠、矢状面上显示移植肾动脉全程情况;③VR的15例均可通过旋转体位清晰观察迂曲的移植肾动脉走行状态和血管狭窄外观;④MPVR的15例可同时显示出移植肾动脉及TRAS情况;⑤MIP中9例可以同一平面上显示TRAS的部位;⑥VP的15例可以较好地显示移植肾动脉管腔内部情况,狭窄程度显示清晰。15例TRAS中吻合口狭窄者8例,吻合口远处狭窄者4例,吻合口和远处均有狭窄者2例,全程狭窄者1例。结论 MSCTA作为术后监测TRAS的影像学检查技术,能够直接清晰的显示移植肾动脉狭窄部位、形态,而且可以指导PTA及观测血管内支架植入疗效,将在临床上发挥越来越重要的应用价值。     

同种异体肾移植术后早期肾动脉狭窄诊疗的回顾性研究

目的通过单中心移植肾动脉狭窄(TRAS)诊疗的回顾性研究,探讨早期诊断及治疗移植肾动脉狭窄的方法。方法统计本中心同种异体肾移植术后287例患者的临床表现、检验数据及影像学资料,比较TRAS患者与非TRAS患者移植肾超声参数,建立筛查TRAS的超声诊断阈值。比较有症状TRAS患者和无症状TRAS患者介入治疗前后肌酐、血压的变化。结果287例患者中共出现13例TRAS患者。移植肾动脉收缩期峰值流速(PSV)250 cm/s、叶间动脉动脉阻力指数(RI)0.51、移植肾动脉与叶间动脉PSV比值10可以作为筛查TRAS的超声阈值。有症状TRAS患者与无症状TRAS患者经血管腔内血管成形术(PTA)治疗后肌酐、平均动脉压均显著下降(P0.05)。结论在肾移植术后定期随访中监测肾移植血流量和临床表现有助于早期诊断TRAS。移植肾动脉PSV250 cm/s、叶间动脉RI0.51、移植肾动脉与叶间动脉PSV比值10可以作为筛查TRAS的超声阈值。     

血管内支架植入治疗动脉和静脉狭窄性疾病的疗效比较

目的比较血管内支架植入术治疗动脉和静脉血管狭窄性疾病的近、远期疗效。方法动、静脉狭窄性疾病分别以肾动脉狭窄(RAS)和布-加综合征(BCS)为例,回顾性分析22例RAS和46例BCS的血管内支架植入治疗的疗效,并比较其治疗3个月后发生再狭窄的情况。结果22例RAS和46例BCS接受血管内支架植入治疗后症状均有不同程度减轻,术后重复造影显示狭窄部位均消失,术后随访3年分别发生再狭窄6例和8例。结论动脉和静脉血管狭窄性疾病行血管内支架植入术的近期疗效(3个月内)均良好,远期疗效(3个月~3年)略差。     

介入治疗16例肾移植术后肾动脉狭窄患者的护理

报告了16例经动脉内血管成形及支架治疗移植肾动脉狭窄患者的护理.术前做好健康教育及心理护理,讲解介入治疗的目的、方法以及术中如何配合,消除疑虑.术后密切观察血压变化,监测尿量及肾功能,对可能出现的出血、感染、肾动脉血栓等并发症予以严密观察.本组中14例术后血压及肾功能逐渐恢复,2例术后肾功能恢复不良,移植肾被切除.介入治疗前后采取有效而完善的护理措施是介入成功治疗肾移植术后肾动脉狭窄的重要保证.     

髂静脉压迫综合征致急性髂-股静脉血栓形成的介入治疗

目的　探讨髂静脉压迫综合征所致急性髂 股静脉血栓形成的介入治疗的临床价值。方法　在下腔静脉置入滤器后 ,应用经颈静脉髂 股静脉血栓清除术、PTA和 /或经皮血管内支架置入术等血管介入技术进行综合性介入治疗。结果　 6例患者经上述综合性介入治疗后血栓全部清除 ,5例患者的 7处髂静脉狭窄经PTA治疗后效果满意 ,另 1例患者的2处髂静脉狭窄PTA后效果不佳 ,经置入 1枚Wallstent(14mm× 80mm )和 1枚国产Z型 (16mm× 5 6mm )静脉内支架后狭窄解除。术后随访 5～ 3 3 .5个月 ,平均 19.4个月 ,临床无复发。结论　经颈静脉髂 股静脉血栓清除术、PTA及经皮血管内支架置入术等介入技术的综合应用是治疗髂静脉压迫综合征所致急性髂 股静脉血栓形成的一种安全、有效、微创的治疗手段。治疗后近、中期疗效显著 ,但其长期疗效尚需做大样本的进一步观察     

血管内支架置放术治疗锁骨下动脉盗血综合征15例报告

目的　总结血管内支架置放术治疗15例锁骨下动脉盗血综合征患者的疗效。方法　15例锁骨下动脉盗血综合征患者,血管造影示锁骨下动脉平均狭窄78.6%,双上肢动脉收缩压差平均为45.6mmHg。经股动脉途径血管内支架置放术13例,经股动脉和肱动脉联合入路双向造影打通狭窄或闭塞并支架置放2例。结果　15例患者的血管内治疗获得成功,术后即刻桡动脉搏动获得改善,双上肢动脉收缩压差平均为16mmHg。无任何病例发生严重并发症。15例患者术后随访6个月,无神经症状复发。结论　采用血管内技术对锁骨下动脉盗血综合征的患者支架置放后其效果可靠,操作相对简单、安全,术后复发率低。     

球囊扩张成形术治疗胸主动脉狭窄的实验研究

目的：探讨胸主动脉狭窄时高血压形成的机理,寻找有效的治疗方法。材料和方法：健康杂种家犬10只,全麻下,手术暴露胸主动脉,结扎胸主动脉制成动物模型,股动脉穿刺插管造影,观察狭窄前后主动脉直径,测量狭窄前后主动脉压力,并抽取主动脉血做肾素活性测定。于狭窄后4周,再次插管行球囊扩张成形术,于扩张前后测量动脉压并抽取主动脉血测血浆肾素活性。扩张后2周再次插管测主动脉压并测血浆紧张素活性。结果：10只犬,动脉模型制作成功,狭窄处直径均为原直径25％以下,狭窄后即刻血压升高（P＜0．01）,狭窄后4周血压进一步升高（P＜0．01）,扩张后即刻血压有下降（P＞0．01）,2周后恢复正常。血浆肾素活性,狭窄后4周升高（P＜0．01）,扩张后2周左右恢复正常。结论：胸主动脉狭窄时,血压升高是由于狭窄上方血管容量增加及血浆肾素活性增高共同引起,球囊扩张成形术是治疗胸主动脉狭窄的一种简便,安全,有效的方法。     

小肠血管发育不良出血的DSA应用价值

目的 探讨DSA对小肠血管发育不良的应用价值。提高对小肠不明原因出血诊断的准确性。方法 肠系膜上动脉选择性插管DSA检查,结合手术病理所见,对9例小肠血管发育不良出血者的DSA表现进行分析研究。结果 确诊为出血性毛细血管扩张病5例,表现为节段性肠管小血管增多密集、浓染,伴造影剂外溢。动静脉畸形4例,表现为粗大的供血动脉和连接扭曲成团的畸形血管巢,以及粗大的引流静脉。结论 DSA检查对小肠不明原因出血的诊断有着不可替代的作用。尤其对血管性病变,更是主要的检查手段。     

移植肾动脉狭窄10例

背景：移植肾动脉狭窄的外科治疗包括摘取栓塞或切除狭窄段后重新吻合血管,或者利用自身静脉进行肾动脉与髂动脉的搭桥手术,虽然手术技术逐渐改进,但仍有部分病例发生移植肾的丧失。目的：分析移植肾动脉狭窄的病因、分类、诊治方案的选择及效果。方法：对2002/2010收治的10例移植肾动脉狭窄患者临床资料进行回顾性分析。其中男8例,女2例;年龄36.9（22～55）岁。发病时间移植后5d～7年半,其中8例患者为移植后半年内发病。常规超声筛查,数字减影血管造影检查确诊。结果与结论：除1例患者拒绝数字减影血管造影检查以及1例开放手术患者,最终有8例接受介入治疗,8例数字减影血管造影检测均确诊移植肾动脉狭窄,狭窄程度为60.3%（40%～80%）。4例经皮腔内血管成形,4例支架置入,其中7例均取得显著的效果,5例肌酐降至正常,2例肌酐降至发病前水平,所有患者移植后早期即尿量显著增加、血压降至正常。在之后的长期随访中,也未发现再次狭窄或者血栓形成等并发症。但其中1例经皮腔内血管成形术中出现动脉出血,最终导致移植肾切除。提示对于移植肾动脉狭窄患者,应结合发病时间、发病原因以及狭窄程度等因素综合分析,选择合适的治疗方案,以取得最佳的疗效,并将风险降到最小。     

Combination treatment using percutaneous transluminal angioplasty and low‐density lipoprotein apheresis in a patient with peripheral arterial disease and a history of chronic hemodialysis

Peripheral arterial disease (PAD) is very common in dialysis patients, who tend to have diffuse calcification and severe peripheral arterial stenosis that make it difficult to treat limbs using only surgical or endovascular interventions. Better ways to treat this condition are therefore required and also follow‐up studies to evaluate the effects of these treatments on the microcirculation. A 59‐year‐old man who had a cadaveric kidney transplant five years previously after 25 years of regular hemodialysis complained of pain at rest in his right lower limb and subsequently developed an intractable decubitus ulcer on his right fifth toe (Fontaine IV). Digital subtraction angiography revealed a severe obstruction of the right femoral artery and diffuse stenosis of the right superficial femoral artery. The patient underwent percutaneous transluminal angioplasty (PTA) and six sessions of low‐density lipoprotein apheresis (LDL apheresis). At the end of these sessions his complaints were almost completely alleviated. The mean elevation in skin temperature after each session was (1.58 ± 0.99)°C [mean ± SD] over the right dorsalis pedis artery and (1.52 ± 0.88)°C at the tip of the right fifth toe. Ultrasound‐measured blood flow rates in the right dorsalis pedis artery were 9.2 cm/s before PTA and 20.2 cm/s one month after PTA. Hemodialysis was resumed 3 days after the PTA due to contrast‐induced nephropathy. The combination of PTA and LDL apheresis is useful for treating PAD in hemodialysis patients, with the changes in peripheral artery patency are able to be evaluated effectively by measuring skin temperature. J. Clin. Apheresis 28:330–334, 2013. © 2013 Wiley Periodicals, Inc.     

二次肾移植术后左侧髂外动脉血栓栓塞1例

49岁男性患者,因慢性肾功能衰竭、尿毒症行肾移植术,第一次肾移植术后因移植肾破裂行移植肾切除术,第二次肾移植术后,移植肾供血的左侧髂外动脉吻合口近心段因血栓而闭塞,虽然通过血管介入治疗恢复了左侧髂外动脉和移植肾的血供,但由于移植肾缺血时间较长,最终肾功能并没有恢复正常。通过本病例的探讨,提醒我们：对于血栓高危的移植肾患者,需要警惕供血的髂动脉血栓形成的可能性,从而指导早期诊断与治疗,提高患者预后。     

Percutaneous transluminal renal artery angioplasty: who benefits most?

We set out to assess the long-term benefits of renal percutaneous transluminal angioplasty (PTA) in 107 consecutive hypertensive patients with atheromatous renal artery stenosis. During 12-month follow-up, blood pressure fell to normal levels in 10 (8.8%) patients and improved in 76 (67.3%); renal function improved or remained stable in 74% of patients. In patients with atheromatous disease, renal angioplasty was most successful in those with stenosis in a single functioning kidney, and in nine patients who presented with symptoms and signs of heart failure, in the absence of overt ischaemic or valvular heart disease. In the latter group, renal PTA resulted in a large loss of sodium and water, resolution of the 'apparent' heart failure, and a marked improvement in blood pressure and renal function. It is suggested that all hypertensive patients with haemodynamically significant renal artery stenosis (and/or mild to moderate impairment in renal function), should be considered for renal PTA. Patients with atheromatous stenosis in a single functioning kidney, and those who present with signs of sodium and water retention, are likely to benefit most.     

Pancreas Transplant Alone: A procedure coming of age

The goal of this review is to highlight the significant improvements, over the past four decades, in outcomes after a pancreas transplant alone (PTA) in patients with brittle diabetes and recurrent episodes of hypoglycemia and/or hypoglycemic unawareness. A successful PTA—in contrast to intensive insulin regimens and insulin pumps—restores normoglycemia without the risk of hypoglycemia and prevents, halts, or reverses the development or progression of secondary diabetes complications. In this International Pancreas Transplant Registry (IPTR) analysis, we reviewed the records of 1,929 PTA recipients from December 1966 to December 2011. We computed graft survival rates according to the Kaplan-Meier method and used uni- and multivariate analyses. In the most recent era (January 2007–December 2011), patient survival rates were >95% at 1 year posttransplant and >90% at 5 years. Graft survival rates with tacrolimus-based maintenance therapy were 86% at 1 year and 69% at 3 years and with sirolimus, 94 and 84%. Graft survival rates have significantly improved owing to marked decreases in technical and immunologic graft failure rates (P < 0.05). As a result, the need for a subsequent kidney transplant has significantly decreased, over time, to only 6% at 5 years. With patient survival rates of almost 100% and graft survival rates of up to 94% at 1 year, a PTA is now a highly successful long-term option. It should be considered in nonuremic patients with brittle diabetes in order to achieve normoglycemia, to avoid hypoglycemia, and to prevent the development or progression of secondary diabetes complications.The Diabetes Control and Complications Trial (DCCT) demonstrated, in patients with type 1 diabetes mellitus (T1DM), that intensive insulin therapy may slow the rate of secondary complications of diabetes at the expense of causing (life-threatening) iatrogenic hypoglycemia (1,2). The definitive treatment for these patients, a successful pancreas transplant, restores normal glucose homeostasis without exposing recipients to the risks of severe hypoglycemia and prevents, halts, or reverses the development or progression of secondary diabetes complications (3–5).Pancreas transplants are performed in patients who require insulin administration because of T1DM, T2DM, or total pancreatectomy. Since the first pancreas transplant in December 1966, performed by Drs. William Kelly and Richard Lillehei, the majority (almost 80%) of pancreas transplants have been performed simultaneously with a kidney (SPK) in diabetic and uremic patients (6,7). An additional 15% of pancreas transplants have been performed after a kidney transplant (PAK) in diabetic and posturemic patients. Only ~8% of all pancreas transplants have been a pancreas transplant alone (PTA), performed in nonuremic patients with brittle (or labile) diabetes (including recurrent episodes of hypoglycemia and/or hypoglycemic unawareness).The reason that SPK transplants are most common is that SPK recipients are already obligated to immunosuppressive therapy by the kidney graft, so they incur only the added surgical risk of the pancreas transplant. A PTA is less commonly performed because only a relatively small percentage of insulin-dependent patients truly have brittle diabetes that cannot be controlled despite their own best efforts and the help of diabetologists, endocrinologists, and other health professionals. In general, PTA candidates have not yet developed advanced secondary complications of diabetes; yet, halting the development or progression of such complications significantly improves both quality of life and life expectancy (more so for PTA recipients than for SPK or PAK recipients).PTA recipients, in addition to the surgical risk of the pancreas transplant procedure itself, also incur the risk of immunosuppressive therapy (in the absence of a transplanted kidney graft). Immunosuppression in PTA recipients is required to prevent rejection (in order to establish insulin independence), to avoid hypoglycemic episodes, and to prevent the progression of secondary diabetes complications. Because of the required immunosuppressive therapy and its side effects—in the absence of advanced diabetic nephropathy—the PTA option has not been widely accepted. Moreover, in the first two decades after the first PTA was performed in 1968, its surgical risk was high, with considerable technical morbidity and poor outcomes (7). Only after the introduction of calcineurin inhibitors (and, specifically, tacrolimus) did the immunologic graft failure rates significantly decrease in PTA recipients. Despite improvements in exogenous insulin therapy, including the use of devices such as insulin pumps, the risk of hypoglycemic episodes (and their detrimental side effects) remains substantial in patients with brittle diabetes (8).We present herein the significantly improved PTA results as reported to the International Pancreas Transplant Registry (IPTR) over a 43-year period.