下肢动脉硬化闭塞症外科治疗的评估

下肢动脉硬化闭塞症（ａｒｔｅｒｉｏｓｃｌｅｒｏｓｉｓ　ｏｂｌｉｔｅｒａｎｓ,ＡＳＯ）是老年人慢性下肢缺血最常见原因,治疗不及时或不妥当可致截肢。外科手术治疗的目的是改善肢体缺血症状及挽救肢体,主要术式为动脉内膜剥脱术、血管旁路移植术、血管腔内治疗和复合式手术４类,每种术式都有其适应证和优缺点。动脉内膜剥脱术　　动脉内膜剥脱术（ｅｎｄａｒｔｅｒｅｃｔｏｍｙ）是充分解剖病变血管后,以内膜剥离子在内膜下方全周游离整个病变段,完整切除内膜,同时将远端内膜固定以防夹层形成及管腔堵塞。此术式在动脉代用品问…     

复合动脉重建术治疗下肢动脉缺血症：附21例报告

目的：探讨下肢动脉缺血症复合动脉重建术的治疗经验。方法：全组２１例通过多普勒血流仪检测和动脉造影，确定动脉病变范围。复合近远端动脉重建１９例，股－胫后动脉旁路转流２例。结果：术后病死率４８％，截肢率９５％。术后１个月，病人静息痛缓解，肢端溃疡愈合，踝臂指数平均值０９５。平均随访２４４个月，近端动脉重建通畅率１００％，远端动脉重建通畅率８２４％，平均踝臂指数值０８５。结论：复合动脉重建术治疗下肢动脉缺血闭塞症是安全而有效的。手术成功的关键在于重建动脉流入及流出道的通畅     

内膜下血管成形术治疗外周动脉闭塞性疾病13例

目的评价内膜下血管成形术在治疗外周动脉闭塞性疾病中的应用价值。方法总结2004年5月至2006年5月北京协和医院血管外科对13例髂动脉和锁骨下动脉完全闭塞患者行内膜下介入治疗,同时行球囊扩张和支架植入术的临床资料。结果13例患者中,闭塞段动脉介入治疗均获得成功,闭塞动脉平均长度4．9 cm（2-8 cm）,主要症状均得到改善,无并发症。髂动脉闭塞的术前、术后平均踝-肱比（ABI）,分别为：0．39（0-0．83）,0．94（0．73～1．3）,P=0．004,差异有统计学意义。锁骨下动脉闭塞的病例术后双上肢血压均恢复一致,平均随访时间11个月（3～18个月）,随访率76．9％,支架1年通畅率100％（12／12枚）。结论内膜下血管成形术在外周动脉闭塞性疾病中有很好的应用价值,方法可靠,安全,近期通畅率较好,远期通畅率尚需要进一步随访。     

杂交技术在治疗TASC D型周围动脉闭塞性疾病中的应用

目的：总结杂交技术在治疗TASC D型周围动脉闭塞性疾病的治疗经验。 方法：回顾性分析2009年10月—2013年12月间采用杂交技术治疗的22例TASC D型周围动脉闭塞性疾病患者（24条肢体）的临床资料,其中采用髂动脉支架植入术+股总动脉内膜剥脱术（含股深动脉内膜剥脱术）+股深动脉成形术+股腘动脉人工血管旁路术治疗患者12例,采用股总动脉内膜剥脱术（含股深动脉内膜剥脱术）+股腘动脉人工血管旁路术+胫前动脉、胫后动脉球囊扩张术治疗患者4例,采用Fogarty导管取栓术+髂动脉支架植入术+股总动脉内膜剥脱术（含股深动脉内膜剥脱术）治疗患者6例。 结果：所有的患者均获得技术上的成功,围手术期无患者死亡,术后患肢疼痛改善,皮温升高,平均踝肱指数从术前的0.38升至术后的0.75。18例患者获随访3~28个月,2例患者术后发生人工血管旁路血栓形成,1例患者术后发生支架内再狭窄,其余患者未发生人工血管或支架相关并发症。 结论：杂交技术微创、安全、有效,是处理TASC D型周围动脉闭塞性疾病的合理选择,尤其适用于无法进行单纯腔内治疗的高危患者。     

下肢动脉搭桥术后移植物闭塞的外科治疗体会

目的探讨下肢动脉搭桥术后再缺血的治疗策略。方法选择2002年7月～2006年2月我院收治下肢动脉搭桥术后移植物闭塞患者21例，男17例，女4例，平均68．2岁；21例患者共行手术35例次：再次下肢动脉搭桥术16例次（45．7％），单纯人工血管取栓手术10例次（28．6％），人工血管取栓同时行股或胭动脉内膜剥脱术6例次（17．1％），3例患者行截肢术（8．6％）。结果35例次手术探查发现移植物闭塞原因以远侧流出道病变（62．9％）和远侧吻合口内膜增生（25．7％）为主。其中13例次术后再次闭塞行手术治疗，但人工血管搭桥术平均再发闭塞时间明显长于其他术式。2例患者围手术期死亡。17例患者末次行血运重建手术，术后随访6—44个月，平均17个月，未见缺血症状复发。结论下肢动脉搭桥术后移植物闭塞原因以远侧流出道病变为主，再次搭桥手术可作为首选术式，术后缺血反复发作导致截肢。     

下肢动脉人工血管旁路术后再闭塞的治疗经验

目的总结治疗下肢动脉人工血管旁路术后再闭塞的治疗经验,探索合理的治疗策略。方法回顾性总结19例下肢动脉人工血管旁路术后再闭塞的病例,分析再闭塞的原因,并根据原因选择再次手术的方式。其中4例行人工血管取栓术,5例行人工血管取栓＋远端吻合口成形术,3例行人工血管取栓＋股深动脉扩大成形术,2例行新的人工血管旁路术,1例行髂外动脉内膜剥脱术,2例行骨髓干细胞移植,2例由于肢体广泛坏死,行1期截肢术。在术后进行规律的随访以明确手术的效果。结果19例患者术后1年中定期随访。除2例截肢外,14例围手术期获得了1期成功,成功率82．4％,3例（17．6％）手术失败,术后1年内死亡2例,病死率10．5％。术后1年随访时,人工血管通畅6例,血管通畅率35．3％,保肢率76．4％（13例）。结论人工血管旁路术后再闭塞的治疗比较棘手,术前有效地评估闭塞原因、选择正确的手术方式和良好的随访计划是保持患者肢体功能和生存质量的重要因素。     

半闭式小切口切取大隐静脉移植物作股Guo动脉搭桥术

为探讨缩小股Ｇｕｏ动脉搭桥术的手术切口，采用自制顶端带孔的大隐静脉圈套器，半闭式小切口取得大隐静脉后，作股Ｇｕｏ动脉搭桥术治疗下肢股Ｇｕｏ动脉硬化闭闭塞症，共１８例，术后切口的均获一期愈合，经６月～４年随访（平均２６月）１５例术后间歇性跛行消失或明显减轻，３例因远端输出道血管不佳，间歇性跛行仍同术前，术前患者肢踝／肱指数平均为０．４６，术后０．７６，平均提高０．３０，证实下肢动脉血流明显改善，疗效     

动脉自膨式支架置入治疗下肢缺血

目的探讨下肢各个部位动脉腔内自膨式支架置入治疗下肢缺血的疗效。方法对2002年1月-2006年3月支架治疗65例71条患肢的临床资料进行临床回顾性研究，其中52．3％（38／71）肢体为糖尿病下肢动脉硬化，47、7％（33／71）肢体为非糖尿病下肢动脉硬化。支架部位包括腹主动脉支架2例2条患肢2枚支架，腹主动脉及髂动脉闭塞行腹主动脉和单侧髂动脉支架置入1例3枚支架，髂动脉支架33例35条患肢38枚支架，髂动脉和股浅动脉同时支架置入6例6条息肢12枚支架，股浅动脉支架置入16例19条肢体23枚支架，股浅动脉和近端胭动脉病变同时支架置入5例6条患肢10枚支架，远端胭动脉支架2例2条患肢。结果65例随访2—50个月，平均16．1月，2例腹主动脉支架、1例腹主动脉与髂动脉支架同时置入全部通畅；髂动脉支架闭塞4例4条患肢，通畅率88．6％（31／35）；股浅动脉支架闭塞4例4条患肢，通畅率为78．9％（15／19）；股浅动脉与近端胭动脉支架闭塞1例，通畅率83．3％（5／6）；远端胭动脉支架2例全部闭塞；3例小腿动脉流出道主干动脉全部闭塞的支架术后平均5．6月仍然保持通畅。结论下肢动脉腔内支架置入可作为治疗主髂动脉病变的首选方法；对于股动脉和近段胭动脉病变也可根据情况适当选用，尤其是年老体弱，无法耐受动脉旁路移植手术的患者，也可以作为首选方法；对于膝下小动脉病变应慎重使用支架。     

半闭式小切口切取大隐静脉移植物作股动脉搭桥术

为探讨缩小股动脉搭桥术的手术切口。采用自制顶端带孔的大隐静脉圈套器，半闭式小切口取得大隐静脉后，作股动脉搭桥术治疗下肢股动脉硬化闭塞症，共１８例。术后切口均获一期愈合。经６月～４年随访（平均２６月），１５例术后间歇性跛行消失或明显减轻，３例因远端输出道血管不佳，间歇性跛行仍同术前。术前患肢踝／肱指数平均为０４６，术后为０７６，平均提高０３０，证实下肢动脉血流明显改善，疗效满意。结果表明，在作股动脉自体大隐静脉搭桥术时，使用顶端带孔的大隐静脉圈套器可使手术切口缩小，改善手术疗效。     

近肾腹主动脉完全闭塞11例的诊治体会

目的探讨近肾腹主动脉完全闭塞的手术治疗方法。方法回顾2004年7月至2006年9月期间诊治的11例近肾腹主动脉完全闭塞患者的临床资料,其中6例伴肾动脉狭窄。采用腹正中切口,充分游离腹主动脉近肾段,清除病灶,术中结合动脉造影,行腹主动脉-双股动脉人工血管搭桥术。结果本组无死亡病例,未出现严重并发症。患者术后下肢缺血症状均得到改善,其中7例间歇性跛行症状消失,2例无跛行距离较术前明显增加,2例下肢静息痛症状消失。所有患者均获6～27个月随访,平均随访18个月,吻合口通畅率为100%。结论近肾腹主动脉完全闭塞的病例采用肾动脉下切口清除病灶,术中结合动脉造影,并行腹主动脉-双股动脉人工血管搭桥术,疗效满意。     

Chronic upper extremity arterial insufficiency. Etiology, manifestations, and operative management.

Forty-eight arterial reconstructions were performed for chronic upper extremity ischemia in 43 patients, aged 31 to 81 years. Diagnostic arterial catheterization was the most frequent cause of symptomatic occlusion, followed by proximal arteriosclerotic lesions and noniatrogenic trauma. Doppler ultrasound evaluation provided important diagnostic and prognostic data that complemented information derived from arteriography. Indications for operation included disabling claudication (39 cases) or digital gangrene (four cases). Restoration of normal extremity function can be anticipated except in instances where poor forearm runoff exists. Autogenous saphenous and basilic interposition vein grafts have proved excellent for axillary-brachial revascularizations. Axillary-axillary bypass procedures for innominate-subclavian artery occlusions appear hemodynamically sound and technically simple. Follow-up, averaging 48 months, extended to 144 months. Late vein graft failure or progressive distal occlusive disease was not encountered.     

Upper extremity arterial bypass distal to the wrist.

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold.(ABSTRACT TRUNCATED AT 250 WORDS)     

下肢多平面动脉闭塞症的动脉重建术

探讨下肢多平面动脉闭塞症近远端动脉重建的治疗经验。方法:全组18例,男15,女3,平均67.4岁。通过测定踝/臂指数和经皮动脉穿刺插管造影,确定动脉病变范围。一期实施近、远端动脉重建16例,股-胫后动脉旁路转流2例。结果:全组术前平均踝/臂指数0.4,主、髂、股动脉病变33.3％,股、腘、小腿动脉病变55.6％,髂-小腿全下肢动脉病变11.1％。术后病死率5.6％,截肢率11.1％。术后1月,静息痛症状均得到改善,肢端溃疡愈合,踝/臂指数平均值0.94。平均随访22.5月,近端动脉重建畅通率100％,远端动脉重建畅通率80％,踝/臂指数平均0.85。结论:下肢多平面动脉闭塞症同时行近远端动脉重建安全、有效。手术成功关键在于动脉重建流人、流出道的畅通。     

Prolonged endarterectomy in distal forms of arterial diseases of the lower extremities

Six-year experience of surgical treatment of patients with critical lower limb ischemia due to a distal form of arterial lesion is presented. Surgical treatment was performed in extended occlusive lesion from inguinal fold to arteries of the calf and foot, and inadequate "ways of outflow". The king of arterial lesion did not permit the surgeon to perform typical bypass surgery or arterialisation of venous system with a traditional scheme. All the patients were candidates for amputation. For salvage of extremity 36 patients underwent prolonged semi-closed endarterectomy using special instrument which was supplemented with temporary arterio-venous fistula or popliteal-distal auto-venous bypass. In short-term period after surgery critical ischemia was eliminated in 25 (69%) patients. The rest of the patients underwent amputations. 5 years later cumulative safety of the extremities was 95% among patients with good short-term results. These variants of revascularizing surgery may be regarded as alternative to amputations in patients with critical limb ischemia due to distal lesions of lower limbs arteries.     

Method of surgical treatment of critical ischemia of lower extremities in patients with occlusive injuries of shin arteries

The work describes a new method of restoration of blood circulation in patients with critical ischemia of the lower extremities of atherosclerotic genesis with a distal type of damage of the arterial bed. In 52 patients with the saved lumen of the distal part of the shin and little capacity of the distal bed reconstructive operations were performed by the developed technique. Reconstructive operations were fulfilled on 45 (86.5%) patients with the saved patency of the distal third of the posterior tibial artery, in 7 (13.5%) patients--of the anterior tibial artery. Thrombosis of the arterial bed occurred in 2 patients with saved patency of the vein in 3 weeks after operation. No recurrence of the critical ischemia of the extremity was observed. Thrombosis of the distal segment of the foot vein was found in 3 patients with the saved patency of the arterial bed in the period from 3 days to 4 weeks. Thrombosis of the venous shunt due to embolism of the cut off cusps of the venous valve was observed in 2 patients on the first day after operation. Thromboectomy from the shunt was fulfilled in these patients followed by recovery of blood circulation. Long-term results were followed up to 24 months. The shunt patency was 68%, the extremity was saved in 87% of the cases.     

Trends in the care of the diabetic foot. Expanded role of arterial reconstruction.

In recent years, our operative approach to ulceration and gangrene in the diabetic foot has changed markedly. We now investigate all such patients for ischemia, even in the presence of neuropathy and localized infection. This strategy is based on a rejection of the concept of a microvascular occlusive lesion, an improved understanding of the pattern of atherosclerotic occlusion, an emphasis on arteriographic delineation of the foot arteries, and increasing success with extreme distal arterial reconstruction, especially vein bypass grafts to the dorsalis pedis artery. From 1984 through 1990, 2883 procedures were performed at our institution on patients with diabetes mellitus. There was a statistically significant decrease in every category of amputation, which correlated precisely with the increasing rate of dorsalis pedis artery bypass. Our indications for surgery, in-hospital mortality, and the bypass-associated amputation rate did not change.     

Distal arterial reconstruction using Esmarch's bandage technique to salvage upper extremity function in thoracic outlet syndrome caused by cervical ribs: A report of two cases

We present herein the cases of two patients with thoracic outlet syndrome (TOS) who required arterial reconstruction due to gangrene of the fingers and/or hand. In both patients, the cervical ribs had produced intimal injury of the subclavian arteries, and the successive distal arterial embolism brought about severe ischemia of the affected upper extremity. To treat the TOS, the cervical ribs were resected through a supraclavicular incision. In the first patient, arterial reconstruction was performed from the subclavian artery to the radial collateral artery, a branch of the deep brachial artery, which resulted in minimizing amputation of the gangrenous hand. In the second patient, resection and direct anastomosis of the injured subclavian artery were performed, and bypass surgery from a brachial artery to an interosseous artery was carried out, preserving finger function. Reversed saphenous vein grafts were utilized and Esmarch's bandage technique was applied as a substitute for a vascular clamp in both patients. Following these case reports, we discuss the technique of performing distal bypass in the upper extremities and comment on the usefulness of Esmarch's bandage technique for preserving upper extremity function.     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

剖解外腋—股,股—股动脉旁路移植术治疗主髂动脉闭塞症

目的 探讨剖解外腋－股、股－股动脉旁路移植术治疗主髂动脉闭塞症的疗效。方法 采用解剖外旁路移植术治疗主骼动脉闭塞症患者３２例。１８例腹主动脉或两侧髂动脉闭塞者采用腋－股动脉旁路术,其中２例为腋－两股动脉旁路术;１４例单侧髂动脉闭塞者采用股－对侧股动脉旁路术。采用腋－肌动脉旁路的患者,术中８例用真丝人造血管移植,１０例四氟乙烯（Ｇｏｒｅ－Ｔｅｘ）人造血管;股－股动脉旁路术中６例用真丝人造血管移植,１     

Angioscopy as an adjunct to arterial reconstructive surgery: a preliminary report

To date our use of angioscopy as an adjunct to in situ vein grafting, arterial embolectomy, femoropopliteal bypass surgery, and laser recanalization has been studied in 11 patients. Three angioscopes have been used: a 1.7 mm optiscope, a 2.8 mm laser optiscope, and a 3.2 mm bronchoscope. Scopes were introduced through an arteriotomy and a clear field maintained by continuous saline infusion. Twenty-four angioscopic evaluations were performed in the 14 patients studied. Adequate visualization was achieved with all three scopes. Angioscopy showed total atherosclerotic occlusion of six superficial femoral and popliteal arteries, intimal flaps in two arteries, thrombus in two arteries and one graft, adequate valvulotomy in three saphenous veins used for in situ bypass grafting, and removal of thrombus after embolectomy in one artery. With the 2.8 mm laser optiscope, the optical fiber used for laser recanalization could be positioned at the site of arterial occlusion before lasing and recanalization were done under direct vision. The 1.7 mm scope could be passed through the recanalized artery to inspect the channel and confirm communication with the artery distal to the occlusion. Thus, angioscopy appears to be potentially useful as a diagnostic device in arterial occlusive disease and as an adjunct in in situ saphenous vein grafting or laser recanalization of occluded arterial segments.