干细胞治疗糖尿病下肢动脉病变

一、糖尿病下肢动脉病变的危害 下肢动脉病变(peripheral arterial disease,PAD)是周围动脉病变的一个组成部分,是全身动脉粥样硬化的局部临床表现.动脉内膜粥样斑块形成后可逐渐向血管腔内发展,使管腔变窄甚至闭塞,也可因为斑块内出血或局部血栓形成导致血流中断[1].与非糖尿病患者比较,糖尿病患者PAD更易累及股深动脉及胫前动脉等中小动脉[2].PAD在普通人群中的患病率为3%～10%,且随着年龄的增长而增加.据报道,超过15%的60岁以上老年人罹患PAD[3].同时,由于导致PAD的相关危险因素(如人口老龄化、糖尿病、肥胖和高血压等)在持续增加,预计PAD患病率在将来会进一步增加.     

彩色多普勒超声对2型糖尿病患者下肢动脉病变的诊断价值

目的探讨彩色多普勒超声对2型糖尿病患者下肢动脉病变的诊断价值。方法选择62例2型糖尿病患者作为观察组,75例非糖尿病患者作为对照组,用彩色多普勒超声技术探查并比较两组双下肢股总动脉、股浅动脉、股深动脉、腘动脉、胫前动脉、胫后动脉、足背动脉斑块、狭窄、闭塞的检出情况。结果观察组下肢动脉管腔硬化斑块、狭窄闭塞的发生率明显高于对照组,膝关节以下动脉的狭窄、闭塞检出率也明显高于对照组,两组比较差异具有统计学意义(P0.01)。结论糖尿病对下肢动脉尤其膝关节以下动脉病变有非常明显的影响,彩色多普勒超声作为无创、简单有效的检查方法,对早期诊断、病程观察、预防下肢坏疽在临床中起到非常重要的作用。     

Bilateral lower extremity arterial thromboembolism mimicking conversion disorder

Thromboembolic causes of acute limb ischemia are not frequent; however, an immediate true therapy is needed to save the extremity. Here we presented a case with bilateral lower extremity arterial thromboembolism mimicking conversion disorder. Conversion disorder and acute arterial embolism can be confronted in different patterns. This case proved us that anamnesis can be misleading and manipulating to evaluate patients. Furthermore, our report may potentially highlight the inadequacies in the guidelines for diagnosis.     

无症状下肢动脉病变老人的踝臂指数的检测及下肢动脉病变相关因素的分析

目的：检测无症状下肢动脉病变（LEAD）老人的踝臂指数（ABI）,分析LEAD的相关因素。方法：随机选择206例老年患者,以ABI≤0.9作为LEAD的诊断标准,所有对象被分为无症状下肢动脉病变组（LEAD组,48例）和无下肢动脉病变组（无LEAD对照组,158例）,比较两组心血管病危险因素的分布,分析与LEAD相关的因素。结果：LEAD组的年龄、动脉收缩压（SBP）、脉压（PP）、脂蛋白（a）[Lp（a）]、血尿酸（UA）、C反应蛋白（CRP）、糖化血红蛋白（HbA1c）,以及臂踝脉搏波传导速度（baPWV）均明显高于无LEAD对照组（P〈0.05,或P〈0.01）;而舒张压（DBP）显著低于无LEAD对照组（P〈0.05）。Pearson相关分析显示,ABI与年龄（r=-0.347,P=0.025）,PP（r=-0.246,P=0.034）,Lp（a）（r=-0.321,P=0.002）,UA（r=-0.215,P=0.046）,CRP（r=-0.335,P=0.031）,HbA1c（r=-0.272,P=0.017）,baPWV（r=-0.278,P=0.017）均呈负相关。Logistic多元回归提示,年龄、SBP、PP以及Lp（a）与LEAD独立相关。结论：年龄、收缩压、脉压以及脂蛋白（a）是LEAD独立危险因素,其积极矫正有助于无症状下肢动脉病变的防治,减少心、脑血管事件的发生。     

Doppler ultrasound parameters for peripheral arterial vascular diagnosis

In order to control the valency of Doppler-sonographic parameters for the arterial vascular diagnostics, in patients with arterial obstructive disease apart from the measurement of the blood pressure characteristics of Doppler speed curves were analysed. Proximal obstacles of the vascular system of haemodynamic relevance led to the systolic decrease of pressure in the area of the extremities and to the monophasic configuration of curves with increased diastolic flow velocity and loss of the reflux component. Relations to the degree of severity of the ischaemia were found. The Doppler-sonographic comprehension of a changed local behavior of resistance and blood supply was valuable also for the differential diagnosis.     

The significance of lower extremity peripheral arterial disease.

The role of the cardiologist is expanding and involves the management of patients with lower extremity atherosclerotic occlusive arterial disease. Peripheral arterial disease (PAD) remains an underdiagnosed and undertreated disease. The purpose of this review is to educate the clinician on the significance of lower extremity atherosclerotic occlusive arterial disease. Pathophysiology and anatomy are briefly reviewed. The definition of PAD is based upon both anatomic and functional considerations. Risk factors for PAD include traditional atherosclerotic risk factors. There is a considerable overlap between coronary and cerebrovascular diseases and PAD. Diagnosis is made mainly by history and physical examination. Noninvasive and invasive tests help diagnosis and localize disease. Expanded therapies to improve outcomes include lifestyle changes, medical treatment, interventional cardiovascular procedures, or surgical intervention.     

Assessment of captopril and nicardipine effects on chronic occlusive arterial disease of the lower extremity using Doppler ultrasound

The effects of two potent vasodilating drugs, captopril (C) (25 mg tid), nicardipine (N) (20 mg tid), and placebo (P) were evaluated and compared, in 10 men (mean age of sixty-five years) with intermittent claudication from moderate to severe multilevel chronic occlusive arterial disease (COAD) of the lower extremity, by use of the Doppler ultrasonic method, at rest and after Carter's exercise test. All the examined subjects were normotensive, without diabetes or cardiopathy; all have been smokers. The eight-week total protocol consisted of an initial two-week placebo run-in period followed by two active drug phases and a two-week placebo phase, according to a double-blind, randomized, crossover design. At the end of each two-week period, ankle-arm index (AAI) and, following exercise, onset of lower extremity discomfort time (ODT), duration of exercise (ET), decrease of ankle systolic pressure after test (APD), and recovery time (RT) were determined. Moreover, at rest, just after exercise, and after recovery, simultaneous common femoral artery velocity waves were recorded and analyzed by a quantitative approach to detect the peripheral vasomotor adjustments. None of the patients required the withdrawal of the active treatments. Compared with P, C significantly reduced APD and RT, and N reduced RT and AAI; furthermore N caused a significant decrease in ODT, whereas C showed a trend, although not statistically significant, to increase ODT. Neither active therapy modified ET. These results suggest that C and N have different short-term effects on peripheral circulation in COAD. During exercise, C induces hemodynamic improvement in the ischemic lower extremity probably by inhibition of the sympathetic system and consequent reduction in collateral vessel vasoconstriction.     

Ocelot catheter for the recanalization of lower extremity arterial chronic total occlusion

Peripheral arterial disease (PAD) is a growing clinical condition affecting more than 10 million patients in the United States and it is responsible for more than 120,000 amputations annually. The presence of chronic total occlusions (CTO) increases the complexity of endovascular procedures and open surgery may often be the preferred approach. Despite the optimization of the CTO devices and technique, percutaneous CTO revascularization remains a challenging procedure even for experienced operators with important complication rates. The Ocelot^TM system is a novel CTO device to use real-time optical coherence tomography (OCT) imaging guidance for the recanalization of peripheral CTOs. We review the mechanism of the Ocelot system, the initial results from the multi-center Connect-II trial and two cases of Ocelot-assisted CTO recanalization.     

Comparison of Doppler and oscillometric ankle blood pressure measurement in patients with angiographically documented lower extremity arterial occlusive disease

To assess the reliability of the oscillometric method in patients with peripheral vascular disease, ankle blood pressure measurement by Doppler and oscillometry was compared. This study represents a prospective, non-blinded examination of pressure measurements in 168 patients. Twenty-two patients were included who had abdominal aortic aneurysms (AAA) and 146 had peripheral arterial occlusive disease (PAOD). Patients with PAOD were divided into 2 groups according to angiography results: a crural artery occlusion group (CAO, n = 32), and a no crural artery occlusion group (NCAO, n = 114). All subjects underwent pressure measurement by both Doppler and oscillometry. The correlation coefficient was 0.928 in AAA patients and 0.922 in PAOD patients. In CAO patients, there were significantly fewer patients whose oscillometric pressure was equivalent to the Doppler pressure (DP), as compared to NCAO patients, because the oscillometric pressure (OP) was 10% higher than DP in 44% of CAO patients. A high correlation exists between Doppler and oscillometric ankle pressure measurements irrespective of the type of vascular disease. However, the oscillometric method could not be substituted for the Doppler method completely, because there were several patients whose OP was greater than DP especially in those with crural artery occlusive disease.     

Carotid and lower extremity arterial disease in acute myocardial infarction

The authors present the results of noninvasive ultrasound examinations of the carotid and the arteries of the lower extremities in 111 patients with acute myocardial infarction. Carotid arterial disease was detected in 45 (41%). In 85% it was asymptomatic, haemodynamically significant lesions of the internal carotid artery were asymptomatic in more than half of the patients. Peripheral arterial disease was found in 43 patients (39%); it was bilateral in three fourths of them. Asymptomatic findings were present in 42%. Associated atherosclerotic lesions in both vascular locations were demonstrated in 16 patients (14%). On the average, patients with vascular changes had 3 risk factors and more. The most frequent risk factor was hypercholesterolaemia (79%) which was, at the same time, the most pronounced risk factor in patients with as well as without vascular changes. On the whole, peripheral vascular changes were found in 71 patients (64%) with acute myocardial infarction.     

Doppler diagnosis in peripheral arterial occlusive disease

PHYSICAL AND TECHNICAL FUNDAMENTALS OF DOPPLER ULTRASONOGRAPHIC METHODS: In addition to units recording both velocity and direction of blood flow, mostly using two ultrasonic frequencies and phase-out technique, there are small non-directional units available which provide useful diagnostic information from the acoustic Doppler signal derived. Doppler ultrasonic techniques utilize two physical phenomena: a) High-frequency ultrasonic energy penetrates biologic tissue and is partially reflected at borders between tissues of differing density. b) If the border area is in motion, due to the Doppler effect, there is a change in the reflected ultrasonic frequency with respect to the frequency emitted. In blood vessels the ultrasonic beam is primarily reflected from the flowing red blood cells where the change in frequency is a function of the velocity of flow (Doppler effect). From the Doppler transducer, the continuously-emitted ultrasonic beam is also received after being reflected. The frequency of the reflected beam is directly proportional to the velocity of the flowing blood. If flow is directed toward the transducer, the frequency of the reflected beam increases and if the flow is away from the transducer, the converse is true. The best Doppler signals can be received when the angle beta of the transducer to the studied vessel is about 45 degrees. The unprocessed Doppler signal represents a frequency spectrum corresponding to the various velocities of the individual lamina of the blood stream from which the prevailing velocity is integrated and registered. The penetration depth is dependent on the frequency emitted. Doppler units are preferred with working frequencies of 8 to 10 MHz and 3 to 5 MHz. With 8 MHz, the maximal depth of penetration is 3.5 cm, with 4 MHz, 8 cm. The lowest detectable velocity is also dependent on the frequency emitted: with 8 MHz, minimum is 3 cm/s. Since flow toward the transducer results in a positive Doppler shift and flow away in a negative shift, with the Doppler signal, the direction of flow can also be determined. The recorded Doppler curves enable a qualitative and, to some degree, quantitative assessment. Phase-out and frequency analysis systems enable differentiation of forward and backward flow components. From separate forward and backward flow curves, the instantaneous summation curve (integrated instantaneous hemotachygram) as well as a trend curve over 5 to 7 seconds can be constructed and the mean flow velocity displayed.     

Associations between lower extremity ischemia, upper and lower extremity strength, and functional impairment with peripheral arterial disease

OBJECTIVES: To identify associations between lower extremity ischemia and leg strength, leg power, and hand grip in persons with and without lower extremity peripheral arterial disease (PAD). To determine whether poorer strength may mediate poorer lower extremity performance in persons with lower arterial brachial index (ABI) levels.
DESIGN: Cross-sectional.
SETTING: Academic medical centers.
PARTICIPANTS: Four hundred twenty-four persons with PAD and 271 without PAD.
MEASUREMENTS: Isometric knee extension and plantarflexion strength and handgrip strength were measured using a computer-linked strength chair. Knee extension power was measured using the Nottingham leg rig. ABI, 6-minute walk, and usual and fastest 4-m walking velocity were measured. Results were adjusted for potential confounders.
RESULTS: Lower ABI values were associated with lower plantarflexion strength ( P trend=.04) and lower knee extension power ( P trend <.001). There were no significant associations between ABI and handgrip or knee extension isometric strength. Significant associations between ABI and measures of lower extremity performance were attenuated after additional adjustment for measures of strength.
CONCLUSION: These results are consistent with the hypothesis that lower extremity ischemia impairs strength specifically in distal lower extremity muscles. Associations between lower extremity ischemia and impaired lower extremity strength may mediate associations between lower ABI values and greater functional impairment.     

彩色多普勒超声在下肢静脉曲张交通静脉检测中的应用

目的 探讨彩色多普勒超声(color Doppler ultrasound,CDU)在下肢静脉曲张中交通静脉功能不全的检查技巧和诊断方法 .方法 应用Logiq 700彩色多普勒超声仪对33例下肢静脉曲张患者进行术前下肢静脉CDU常规检查,探测交通静脉的发生部位、范围、内径及瓣膜功能情况,标记其在体表的部位,并与手术结果 比较.结果 33例下肢静脉曲张患者中共发现151条交通静脉功能不全,主要发生部位位于小腿浅静脉区域(82%)和大腿部位(18%).CDU所见的交通静脉均得到手术证实,与手术结果 相比,CDU显示率为83%.结论 CDU能显示大部分下肢静脉曲张中的交通静脉,是一种能准确诊断下肢交通静脉功能不全简单易行的无创性检查技术.     

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。