再论静脉动脉化治疗下肢严重缺血的临床价值

下肢动脉闭塞性疾病是血管外科最常见的临床问题,以血栓闭塞性脉管炎（TAO）和动脉硬化闭塞症（ASO）为最多见,部分病例晚期可出现下肢严重缺血（criticallimbs ischemia,CLI）。CLI是指客观证明存在动脉闭塞诱发的慢性缺血性静息痛、溃疡或坏疽,此类病人治疗困难、致残率高,是世界性的研究课题。按动脉影像学检查,CLI可分为节段性闭塞和广泛性闭塞。     

Pedal branch artery bypass: a viable limb salvage option

PURPOSE: We reviewed our experience with pedal branch artery (PBA) bypass to confirm the role of these target arteries for limb salvage and to identify patient and technical factors that may be associated with graft patency and limb salvage. METHODS: In this retrospective study we analyzed 24 vein grafts to PBAs performed from 1988 to 1998 for limb salvage in 23 patients who had no suitable tibial, peroneal, or dorsal pedal target arteries. These PBA grafts were compared with 133 perimalleolar posterior tibial, defined at or below the ankle, or dorsalis pedis bypass grafts performed contemporaneously; the Kaplan-Meier life table was used in the analysis of graft patency and limb salvage. Life table analyses and logistic regression analysis of prognostic patient variables were also performed. RESULTS: The PBA bypass represented 3% of infrainguinal revascularizations for chronic critical limb ischemia at our institution over the study period. Patients who received PBA bypasses were more likely to be male (92% vs. 69%, P =.02) with lower incidences of overt coronary artery disease (33% vs. 50%, P =.12) and stroke (0% vs 15%, P =.04), and a higher incidence of end-stage renal disease (21% vs 8%, P =.06) than those undergoing perimalleolar bypass. Seventeen percent of PBA bypasses were performed with the anterior lateral malleolar artery, a vessel not previously described as a common bypass target. Two-year primary patency and limb salvage for PBA versus perimalleolar bypass was 70% versus 80% (P =.16) and 78% versus 91% (P = .28), respectively. Patency and limb salvage rates were no different in bypasses with above-knee or below-knee inflow arteries. CONCLUSION: An autogenous vein bypass to the PBA, though rarely required, provides acceptable primary patency and limb salvage when compared with perimalleolar tibial artery bypass when no suitable, more proximal target arteries are available. The PBA bypass should be considered before major amputation is undertaken.     

Early individual experience with distal venous arterialization as a lower limb salvage procedure

This prospective randomized study reported early results of the treatment of 36 unreconstructable patients with critical lower limb ischemia. The patients were divided into two groups: 12 were treated with distal venous arterialization (DVA) and 24 were conservatively (CT) using antiplatelet drugs. There were seven men and five women with an average age 64.3 ± 9.9 in DVA and 13 men and 11 women with a average age 67.1 ± 10.8 in CT groups of patients. The aim of this study was to estimate the validity of DVA as the limb salvage procedure. During the period of monitoring, morbidity and mortality rates were 50 and 0 per cent at DVA versus a mortality rate in the CT group of 33.3 per cent (P < 0.05). The mean follow-up period for DVA was 4.8 ± 3.9 months (range, 1 to 14 months) versus 4.9 ± 2.4 months (range, 1 to 9 months) for the CT group (P > 0.05). Graft patency was 83.3 per cent with two early graft thromboses. There were significant differences between the two groups in limb salvage (91.7% DVA vs 12.5% CT, P < 0.001), pain relief (75% DVA vs 8.3% CT, P < 0.001), and wound healing rates (77.8% DVA vs 0% CT, P < 0.001). Lactate level in the blood of deep venous system after repeated measuring was significantly decreased after the multivariate analysis of variance method was applied (F = 7.691, P < 0.01). Hemodynamic parameters such as systolic digital pressure and digitobrachial systolic pressure index were increased after revascularization using Student's t test (P < 0.001). The DVA may improve the outcome of the treatment of the patients for whom the conventional bypass procedure mainly was not possible.     

Infrainguinal bypass for critical limb ischemia: tips and tricks

A thoughtful but aggressive approach to care of patients with critical limb ischemia (CLI) is required to alleviate lower-extremity pain/tissue injury and achieve durable limb salvage. Specific subsets of CLI patients have been identified to clearly benefit from open surgical revascularization based on presenting signs (extensive tissue loss), multi-level, long-segment arterial occlusive disease, healthy saphenous conduit, and nondiseased tibial artery target vessel with continuous patency to the pedal arch. When other clinical scenarios exist, the treatment strategy requires consideration of patient’s medical and surgical risk factors, anatomic distribution of atherosclerotic disease, and the clinical status of the limb affected by CLI. Infrainguinal saphenous vein bypass is the most durable technique for limb salvage and when properly performed is associated with excellent wound healing rates and improvement in quality of life. In this review, we detail our approach to infrainguinal arterial vein bypass in patients with CLI, including patient selection criteria, surgical planning based on arterial imaging studies, and operative technical requirements required for successful open lower-extremity bypass procedures.     

Prediction of critical lower limb ischemia at the patients with lower limb arteries atherosclerosis

Arterial inflow, venous outflow and microcirculation were studied with ultrasound Doppler, photopletismography and oxygen partial pressure detection at 115 patients with lower limb arteries atherosclerosis and different stages of limb ischemia. Four-level algorithm of critical limb ischemia prediction has been created. First level is the study of arterial inflow. Gradient of regional systolic blood pressure >or=2.0 is the critical parameter. Second level is the study of venous outflow. Critical parameter - gradient of postocclusive venous pressure >or=3.0. Third level is the ratio of arterial and venous blood flow. Venous-arterial index >or=40% demonstrates critical disturbances of macrohemodynamics. Fourth level is the study of microcirculation. If the capillary gradient 相似文献   

Platelet activation in bypass surgery for critical limb ischemia

Platelet activation contributes to graft occlusion after bypass surgery. This study investigated platelet activation status before, during, and after bypass. Blood was taken preoperatively from patients undergoing femoro-popliteal bypass and at incision, after dissection, after ischemia, after reperfusion, 24 hours after surgery, and almost 2 years after bypass (and given aspirin or warfarin). Platelet aggregation was measured using a turbidimetric method and platelet activation with flow cytometry. Statistical analysis was performed using Mann-Whitney U and Wilcoxon's tests. Resting platelet activation was similar between controls and patients undergoing bypass. Platelet activation decreased at incision but remained highly reactive. Platelet aggregation increased after dissection and the ischemic phase but significantly decreased after reperfusion. Platelet aggregation and activation were increased at 24 hours and subsequently after bypass. Platelets in critical limb ischemia exist in the primed state and become activated by minimum stimuli. Increased platelet activation occurs after bypass grafting for critical limb ischemia despite adjunctive therapy.     

Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia

Transluminal balloon angioplasty of the iliac artery was combined with a distal bypass graft procedure in 25 patients with critical ischaemia of the lower limb. Eleven patients had angioplasty in the operating theatre before a vascular graft and the remaining 14 patients had percutaneous transluminal angioplasty performed in the X-ray department before bypass surgery. The distal bypass grafts were 20 femoropopliteal and five femorofemoral grafts. Two patients died in the immediate postoperative period. Follow-up of patients ranged from 2 to 26 months with a graft patency of 63% at 12 months and 50% at 24 months but successful limb salvage rate of 75% at 12 and 24 months. Six patients required major amputations for failure of limb salvage. Transluminal iliac angioplasty is a valuable adjunct to distal bypass surgery by improving arterial inflow without the requirement for major aorto iliac surgery.     

Recent trends in bypass surgery performed in patients with critical limb ischemia

Recently, many candidates for infrainguinal bypass surgery have been patients with diabetes and tended to have ischemic tissue loss or gangrene. In the management of these patients, many technical strategies are required to obtain a good outcome after bypass surgery. The predisposing region of diabetic atherosclerosis is typically the tibial artery trunk and crural arteries. Inframalleolar bypass is ideal to supply the maximum blood flow to the foot. For this purpose, in situ bypass surgery has been the first choice since the advent of the LeMaitre valve cutter. Combined inflow percutaneous transluminal angioplasty and distal bypass are indicated for patients with a TASC A lesion in the iliac artery or superficial femoral artery. This procedure is advantageous especially for patients with end-stage renal disease (ESRD) to decrease the surgical invasiveness and to preserve the autogenous vein. Patients with ESRD usually have severe calcification of the intrinsic foot artery and sometimes a dual bypass to the pedal arteries are useful to expedite healing. Meticulous topical debridement after bypass surgery is also essential for accelerating the healing process. In this situation, negative-pressure wound drainage is currently used worldwide. Free tissue transfer, which is often combined with bypass, is another armament to salvage a severely gangrenous foot.     

Medical treatment and therapeutic angiogenesis of critical limb ischemia

The incidence of arteriosclerotic disease is increasing in Japan due to the aging of the population and the westernization of the diet. Peripheral arterial disease (PAD) presents with various clinical conditions. In particular, the management of patients with critical limb ischemia (CLI) such as pain at rest, ischemic ulcer, or gangrene in the lower extremities has been problematic and the treatment of these patients varies widely among countries. A surgical approach such as distal bypass using an autogenous saphenous vein is still the "gold standard" for the treatment of CLI. In addition, due to recent advances in endovascular technologies, catheter-based intervention has become a viable option, and percutaneous treatment is becoming more widely used. However, the surgical approach is not indicated for some patients with PAD. Recently, therapeutic neovascularization has been suggested as new strategy for patients with CLI. This strategy is mainly classified into two types of therapy, gene therapy and cell therapy, both of which aim to promote the development of collateral vessels in the ischemic lesions. In the present report, we discuss the current status of the medical treatment of CLI, including therapeutic angiogenesis.     

A review of percutaneous deep vein arterialization for the treatment of nonreconstructable chronic limb threatening ischemia

Peripheral arterial disease is estimated to affect more than 200 million people worldwide with some patients progressing to chronic limb threatening ischemia (CLTI). Patients with CLTI have extremely high rates of amputation and associated increases in morbidity and mortality. There is a subset of patients with CLTI that have no available options for revascularization due to factors such as the absence of distal target vessels or adequate conduit for surgical revascularization. Percutaneous deep vein arterialization can be used in patients with nonreconstructable CLTI. In this review article, we discuss patient selection, methods, and techniques of deep vein arterialization. In addition, results from studies evaluating the use of percutaneous deep vein arterialization, such as the Alkmaar (The Netherlands), Leipzig (Germany), Paris (France), and Singapore (ALPS) multicenter center study and the prospective, multicenter, single-arm, early feasibility (PROMISE I) trial, are highlighted. These results have been encouraging with improved rates of limb salvage and wound healing reported, suggesting percutaneous deep vein arterialization may be beneficial in treating patients with CLTI.     

Reconstructive surgeries on deep femoral artery in chronic critical limb ischemia

Possibilities of revascularisation of the lower extremity through the deep femoral artery in elderly and aged patients with chronic critical limb ischemia were evaluated. Forty-nine patients with high surgical risk were studied. Safety of the extremity, decrease of ischemia degree and level of amputation were the main problems in surgical treatment. Deep-femoral-popliteal index was very important. If this index was less 0.3 surgeries on deep femoral artery were effective. If index was 0.3-0.5 results of surgery were questionable. Index more than 0.5 is the factor of unsuccessful revascularisation through the deep femoral artery.     

Prevention of limb loss in critical ischaemia by arterialization of the superficial venous system: an experimental study in dogs

The possibility of ischaemic limb salvage by arterializing the superficial venous system was examined in a canine study. The experiment was carried out on four healthy dogs in three stages. In the first stage, collateral circulation to the hind limb was abolished. In the second stage, all branches of the common femoral artery were ligated, which created a model of ischaemia incompatible with limb survival. Revascularization was achieved by anastomosing the valvulotomized long saphenous vein to the common femoral artery, proximal to its ligation. The dogs were monitored for 2 weeks. All limbs maintained tissue oxygenation similar to that of the control contralateral limb. In the third stage, the artery was ligated proximal to the femoro-saphenous anastomosis and the limb monitored for 7 hours. Acute loss of motor function of the limb resulted. In the present study, arterialization of the valvulotomized long saphenous vein prevented limb loss in critical ischaemia.     

Pedal arterial bypass for limb salvage in patients with diabetes mellitus.

OBJECTIVE: to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD: from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS: one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION: Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.     

Percutaneous transluminal angioplasty of the femoropopliteal arteries in limbs with chronic critical lower limb ischemia.

PURPOSE: The aim of the study was to evaluate the results of percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries in patients with subcritical or critical lower limb ischemia.Materials and Methods: Ninety-two patients underwent 121 PTA procedures, 68 were of the superficial femoral artery (SFA), 13 of the popliteal and 40 of both arteries. Fifty-seven procedures were performed for treatment of occlusions. Eighty-four patients (94 procedures) were monitored with duplex scanning. RESULTS: Technical success rate was 88%. Primary success rates at 12 and 60 months in the whole series were 40% and 27%, respectively. The primary success rate in limbs with SFA occlusion of longer than 5 cm was only 12% after 5 years compared with 32% if the occlusion was 相似文献   

PTA及药物洗脱支架在老年人腘动脉以下临界缺血性病变的临床应用

目的研究探讨血管腔内治疗技术在老年人腘动脉以下临界缺血性病变应用的可行性及效果。方法回顾性总结2004年8月至2006年4月间中国人民解放军总医院应用球囊扩张成形术(PTA)治疗腘动脉以下病变15例(18条肢体)的效果,其中合并应用药物洗脱支架治疗4条肢体。病人年龄65~89岁,平均76岁。结果PTA技术成功率89%(16/18),治疗病变部位21处;选择性地对4条肢体有复发的局限性短段狭窄闭塞的5处病变应用了5枚药物洗脱支架置入治疗。术中造影即可见病变血管恢复通畅,术后均有不同程度的症状改善。无围手术期死亡及严重并发症发生。44%(8/18)术后6个月有复发,在多数复发病人中能够成功地再次进行PTA。结论PTA及药物洗脱支架在腘动脉以下病变应用的技术上可行并可重复治疗;近期临床意义主要表现在改善症状、保趾、保足或促进溃疡愈合方面。