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中华血管外科杂志
中华血管外科杂志

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中华血管外科杂志/Journal Chinese Journal of Vascular Surgery
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    主髂动脉闭塞症的治疗现状和进展

    舒畅黎明王丽萍
    1-5页
    查看更多>>摘要：主髂动脉闭塞症（AIOD）是周围动脉疾病的一种，主要表现为腹主动脉远端和/或髂总动脉、髂内动脉、髂外动脉的慢性狭窄或闭塞性改变。由于很多无症状患者，其人群发病率很难统计，据报道为4%~14%。70岁以上人群发病率为14%~20%，80岁以上发病率约为23%。AIOD的临床表现可从间歇性跛行、静息痛至组织坏死，合并髂内动脉闭塞者还可同时伴有阳痿。流出道通畅的单纯性主髂动脉病变的症状更多为间歇性跛行。据统计，约有1/4间歇性跛行患者症状可自行好转，另外1/4间歇性跛行患者症状将加重。开放治疗是过去治疗的金标准，而随着腔内技术的进步，微创介入治疗目前已占主导地位。本文将对目前各种治疗方法进行了综合评述。 Aorto-iliac occlusive disease(AIOD) is a type of peripheral arterial disease(PAD) characterized with chronic stenosis/occlusion of distal abdominal aorta, common iliac arteries, external iliac arteries or the combination of the above. It's prevalence, although is reported 4%-14%, is hard to calculate in general population because a great amount of patients are asymptomatic. Symptoms range from intermittent claudication(IC), rest pain to tissue loss. If internal iliac artery is involved, patients can develop ED. Symptoms can aggravate in 1/4 of IC patients and can alleviate in another 1/4 of IC patients. Open surgery used to be the "gold standard" for treatment, yet endovascular approach have taken the place and become the first line treatment for AIOD.

    主髂动脉闭塞症开放手术腔内治疗

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    主髂动脉闭塞症开放手术治疗策略

    张建彬叶志东王丽萍
    6-8页
    查看更多>>摘要：主髂动脉闭塞症的治疗逐渐从开放手术向腔内治疗转变，部分复杂病变应用腔内治疗也可以取得良好的效果，但是开放手术仍然有通畅率高和避免使用造影剂的优势，而且对于腔内治疗失败或者出现主髂动脉破裂等严重并发症时，开放手术是重要的保障。本文对主髂动脉闭塞症的开放手术治疗进行阐述。 At present, the treatment of aortoiliac artery occlusion is gradually changing from open surgery to endovascular treatment. Endovascular treatment can also achieve good results for some complex lesions. However, open surgery still has the advantages of a high patency rate and the avoidance of using contrast agents. Moreover, open surgery is an important guarantee against the failure of endovascular treatment or serious complications such as ruptured aortoiliac arteries. This article introduces the open surgical treatment of aortoiliac artery occlusion.

    主髂动脉闭塞症开放手术腔内治疗

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    主髂动脉闭塞症腔内治疗策略与技术

    包俊敏刘广钦陈章颖
    9-12页
    查看更多>>摘要：腔内治疗因其微创、易耐受、中远期通畅率满意等特点已成为主髂动脉闭塞症首选的治疗方法，但要提高腔内手术的成功率和疗效，必须重视入路选择和病变开通、血管准备方式、动脉重建方式、重要分支保护、严重并发症的预防等治疗策略和技术细节的把握，对此，笔者结合最新技术进展和个人经验进行较为全面的阐述，以期对广大同道能有所借鉴和裨益。 Endovascular therapy has become the first choice for the treatment of aortoiliac occlusive disease due to its characteristics of minimally invasive, easy to tolerate, and satisfactory medium- and long-term patency rates. However, to improve the technical success rate and efficacy of endovascular surgery, attention must be paid to treatment strategies and technical details such as the approach selection, the recanalization of lesions, the vessel preparation, the reconstruction of the arteries, the protection of important branches, and the prevention of serious complications. The author has made a relatively comprehensive exposition based on the latest technological progress and personal experience, in order to provide reference and benefit to my young colleagues.

    主髂动脉闭塞腔内治疗主动脉分叉支架植入覆膜支架

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    覆膜支架和裸支架在主髂动脉闭塞症腔内治疗中的循证与经验

    卫任郭伟王丽萍
    13-16页
    查看更多>>摘要：支架植入已成为主髂动脉闭塞病变腔内治疗的常规性操作，而覆膜支架（CS）与裸支架（BMS）孰优孰劣尚无定论。本文以重建腹主动脉分叉与否，对已发表的对比性研究证据分节阐述，发现不同设计的研究得出的结果不尽相同。大宗病例的回顾性研究得出CS与BMS的中期结果相仿，而仅有的一项前瞻性随机对照研究凸显CS的优势。临床决策中，除了参考循证学的证据外，还需有多方面因素的考量，以保证手术的安全、有效和经济。 Stent implantation has become a routine procedure for the endovascular treatment of aortoiliac occlusive disease, while the superiority of covered stent (CS) or bare-metal stent (BMS) has not been concluded. In this paper, the published comparative studies were described in sections according to whether the abdominal aortic bifurcation was reconstructed. It was found that the results of different studies were not the same. Retrospective studies in large samples showed that CS and BMS had similar mid-term results, while the only prospective randomized controlled trial highlighted the advantages of CS. In clinical decision-making, many factors should be taken into consideration besides the evidence, ensuring that the procedure is safe, effective and economical.

    主髂动脉闭塞覆膜支架裸支架腔内治疗对吻技术

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    对吻式支架技术和主髂动脉分叉部覆膜支架重建技术在主髂动脉闭塞症中的使用策略

    王睿涵司逸符伟国王丽萍...
    17-21页
    查看更多>>摘要：主髂动脉闭塞的主要病理变化为动脉粥样硬化导致的腹主动脉远端以及主髂动脉分叉处血管狭窄或闭塞，继而引发盆腔和下肢缺血。伴随血管腔内技术的迅速发展，腔内治疗已逐渐成为治疗此类疾病的主要手段。其中，对吻式支架技术和主髂动脉分叉部覆膜支架重建（CERAB）技术是两项应用于复杂主髂动脉闭塞的技术探索，大大地改变了对于主髂动脉闭塞症的治疗理念。本文结合体外几何流体力学基础研究以及国际临床研究现状，旨在探讨对吻支架技术和CERAB技术治疗主髂动脉闭塞疾病的技术特点、技术优势以及临床经验。 The main pathological changes of aortoiliac occlusive disease are the stenosis or occlusion of the distal abdominal aorta and aortoiliac bifurcation caused by atherosclerosis, which potentially leads to symptoms such as pelvic ischemia and lower limb ischemia. Progress is being made in endovascular treatment, which has gradually become the main means to treat the disease. Kissing-stent technique and covered endovascular reconstruction of aortic bifurcation (CERAB) technique were established as significant procedures for complex aortoiliac occlusive diseases. Based on the studies of in vitro geometry, hemodynamics, and clinical applications, this article aims to discuss the technical characteristics, technical advantages, and clinical experiences of kissing-stent and CERAB techniques in the treatment of aortoiliac occlusive disease.

    主髂动脉闭塞症腔内治疗对吻支架技术主髂动脉分叉部覆膜支架重建

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    主髂动脉分叉部覆膜支架重建术治疗主髂动脉闭塞症的疗效评估

    袁丁祁渝涵翁诚馨赵纪春...
    22-25页
    查看更多>>摘要：主髂动脉分叉部覆膜支架重建术（CERAB）在治疗复杂主髂动脉闭塞性疾病中逐渐受到关注。本文将通过关于CERAB技术的文献报道以及临床应用体会进行综合分析，从该技术的治疗要点、技术特点优势、中远期疗效和围术期并发症发生率四个方面解析，从而证实CERAB技术在治疗复杂主髂动脉闭塞性疾病的安全性和有效性；进一步，抛出该技术值得思考的问题为后续CERAB研究提供方向。 The covered endovascular reconstruction of aortic bifurcation (CERAB) technique has attracted much attention in the treatment of complex aortoiliac occlusive disease (AIOD). Through the literature and clinical application experience of CERAB technology, the safety and effectiveness of this technique in the treatment of AIOD are comprehensively analyzed and confirmed from four aspects, including the technical key points, advantages characteristics, medium-and long-term effects and incidence of perioperative complications. Furthermore, some problems with this technology are induced for subsequent CERAB research.

    主髂动脉闭塞性病变腔内治疗主髂动脉分叉部覆膜支架重建术球扩覆膜支架疗效

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    TASC-D型主髂动脉硬化闭塞症腔内治疗的疗效分析

    何昊李全明黎明李鑫...
    26-31页
    查看更多>>摘要：目的 探讨TASC-D型主髂动脉硬化闭塞症（AIOD）腔内治疗的疗效及预后。 方法 回顾性分析2016年1月至2021年12月中南大学湘雅二医院血管外科115例行腔内治疗的TASC-D型AIOD患者的临床资料。术前根据Rutherford临床分级及相应的影像学检查拟定治疗方案。术后随访，观察临床症状、踝肱指数（ABI）、并发症发生率和通畅率情况。 结果 115例患者（148条靶血管）均实施了腔内治疗，总体技术成功率为98.3%（113/115），靶血管开通率为98.6%（146/148）。术后Rutherford分级较术前提高4级4例，3级58例，2级24例，1级1例，无改善28例。术后1周ABI较术前提高，差异有统计学意义［0.9（0.8，1.1）比 0.2（0，0.4），Z=-14.233，P<0.001］。30 d手术相关并发症发生率为4.3%（5/115）。113例患者（144条靶血管）获得随访，中位随访时间为37（21，57）个月。术后1、3和5年累积生存率分别为97.2%、95.6%和89.7%。术后1、3和5年累积主髂动脉免于再次手术干预率分别为90.4%、86.1%和83.5%。术后1、3和5年累积一期通畅率分别为90.4%、85.2%和82.5%，1和3年累积二期通畅率分别为92.9%和85.1%。 结论 腔内技术治疗TASC-D型AIOD是一种安全、有效的治疗方法，中远期临床效果令人满意。 Objective To investigate the clinical efficacy and prognosis of endovascular treatment of Trans-Atlantic Inter-Society Consensus D (TASC-D) aortoiliac occlusive disease (AIOD). Methods A retrospective analysis was made of the clinical data of 115 patients with TASC-D AIOD in the Department of Vascular Surgery of the Second Xiangya Hospital of the Central University from January 2016 to December 2021. Before the operation, a therapeutic protocol was instituted according to Rutherford classification and corresponding imaging examination. All patients underwent endovascular interventions and were followed up regularly. Their clinical symptoms, ankle-brachial index (ABI), complication rate, and patency rate were observed annually. Results All 115 patients with 148 target vessels underwent endovascular treatment. The overall success rate of endovascular therapy was 98.3% (113/115), and the patency rate of target vessels was 98.6% (146/148). Postoperative Rutherford classification was improved by 4 grades in 4 patients, 3 grades in 58 patients, 2 grades in 24 patients, 1 grade in 1 patient, and no improvement in 28 patients. ABI at one week after the operation was significantly higher than that before the operation [0.9(0.8, 1.1) vs 0.2(0, 0.4), Z=-14.233, P<0.001]. Postoperative complications occurred in 5(4.3%) patients in 30 days. Moreover, 113 patients (144 target vessels ) were followed up with a median follow-up time of 37(21,57) months. The 1-, 3- and 5-year cumulative survival rates were 97.2%, 95.6% and 89.7%, respectively. The 1, 3 and 5 years cumulative freedom from reintervention rates were 90.4%, 86.1% and 83.5%, respectively. The cumulative primary patency rates were 90.4%, 85.2% and 82.5% at 1, 3 and 5 years, respectively. The cumulative secondary patency rates were 92.9% and 85.1% at 1 and 3 years, respectively. Conclusion Endovascular therapy is safe and effective for TASC-D AIOD with satisfactory mid- and long-term clinical results.

    主髂动脉闭塞性疾病腔内血管成形术血管支架

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    主髂动脉闭塞症开放手术与腔内治疗中远期疗效比较

    王鼎贾龙元赵成东王雷...
    32-36页
    查看更多>>摘要：目的 分析主髂动脉闭塞症（AIOD）开放手术与腔内治疗的中远期疗效。 方法 回顾性分析中国医科大学附属第一医院2010年1月至2020年1月收治的92例TASC Ⅱ C/D型AIOD患者的临床资料，根据手术方式分为开放手术组（38例）和腔内治疗组（54例），比较两组的围术期和随访期结果。采用Kaplan-Meier法和log-rank检验比较两组术后通畅率和累积生存率。 结果 90例患者取得技术成功，技术成功率为97.8%，85例（92.4%）患者症状得到改善。8例（8.7%）出现围术期并发症，开放手术组并发症发生率高于腔内治疗组（15.8% 比 3.7%，χ 2=4.103，P=0.043）。89例（96.7%）患者获得随访，随访时间为（92.67±21.74）个月（范围：6.4~120.0个月）。开放手术组5和10年的一期通畅率高于同期腔内治疗组（5年：91.5% 比 85.2%；10年：78.4% 比 77.9%），差异具有统计学意义（log-rank χ 2=5.126，P=0.040），而二期通畅率两组差异无统计学意义（P=0.102）。两组术后复发率、再狭窄率、保肢率及生存率方面，差异无统计学意义（均P>0.05）。 结论 腔内治疗组并发症发生率较手术治疗组低，手术治疗组的一期通畅率较腔内治疗组高，而二期通畅率两组差异无统计学意义。 Objective To analyze the medium- and long-term results of open surgery and endovascular therapy for aortoiliac occlusive disease (AIOD). Methods The clinical data of 92 patients with TASC Ⅱ C/D AIOD admitted to the First Affiliated Hospital of China Medical University from January 2010 to January 2020 were analyzed retrospectively. They were divided into open surgery group (38 cases) and endovascular therapy group (54 cases) according to the surgical methods. The perioperative results and medium- and long-term efficacy of the two groups were compared. The Kaplan-Meier method and log-rank test were used to compare the patency rates and the cumulative survival rates of patients between the two groups. Results 90 patients achieved technical success, with a technical success rate of 97.8%, and 85 patients (92.4%) had improved symptoms. 8 patients (8.7%) had the perioperative complications, and the complication rate in the open surgery group was higher than that in the endovascular therapy group (15.8% vs 3.7%, χ 2=4.103, P=0.043). 89 patients (96.7%) were followed up with an average follow-up time of (92.67 ± 21.74) months. The primary patency rate in the open surgery group at 5 and 10 years was higher than that in the endovascular therapy group at the same period (5 years: 91.5% vs 85.2% 10 years: 78.4% vs 77.9%), with a statistically significant difference (P=0.040), while the secondary patency rate in the two groups had no statistically significant difference (P=0.102). There were no significant differences in postoperative recurrence rate, restenosis rate, limb salvage rate, and survival rate between the two groups (all P>0.05). Conclusion The incidence of complications in the endovascular therapy group is lower than that in the open surgery group. The primary patency rate in the open surgery group is higher than that in the endovascular therapy group, while there is no difference in the secondary patency rate between the two groups.

    主髂动脉闭塞症开放手术腔内治疗中远期疗效

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    主髂动脉闭塞症外科治疗的单中心回顾性研究

    吕俊兵招扬贺海朋林任...
    37-41页
    查看更多>>摘要：目的 探讨主髂动脉闭塞症（AIOD）外科治疗方式的选择。 方法 回顾性分析2020年4月至2022年10月中山大学附属第三医院血管外科收治并行外科治疗的21例AIOD患者的临床资料。其中Rutherford 3期3例，4期8例，5~6期10例。采取开放手术（腹主动脉-双髂/股动脉人工血管旁路移植术）、腔内手术（腹主动脉-双髂动脉球囊扩张+对吻支架植入术）及杂交手术（双侧股动脉切开取栓+支架植入术）治疗并随访观察患者临床改善及血管通畅情况。 结果 21例患者中，13例患者行开放手术，4例行腔内手术，4例行杂交手术，闭塞血管均完全开通，手术成功率100.0%。1例开放手术患者术后出现肾功能不全，短期透析后肾功能恢复正常。1例腔内治疗患者于术后12 d因急性心功能衰竭死亡。20例患者获得随访，中位随访时间为23.0（15.5，27.8）个月。随访期内，1例开放手术患者出现人工血管内血栓形成，行支架植入后重新开通，余患者未出现明显并发症。 结论 综合考虑AIOD患者的病变累及范围、病变性质、一般情况等多方面因素并加以个体化选择手术方式，均可取得安全、有效的临床效果。 Objective To investigate the choice of surgical treatment for the aortoiliac occlusive disease(AIOD). Methods The clinical data of 21 patients (19 male and 2 female) with AIOD who received surgical treatment in the Department of Vascular Surgery of the Third Affiliated Hospital of Sun Yat-sen University from April 2020 to October 2022 were analyzed retrospectively. According to the Rutherford classification, there were 3 cases of grade 3, 8 cases of grade 4, and 10 cases of grade 5-6. Open surgery (abdominal aorta-bilateral iliac/femoral artery bypass grafting), endovascular surgery (abdominal aorta-bilateral iliac artery balloon dilation and kissing-stent implantation), and hybrid surgery (bilateral femoral artery thrombectomy and stent implantation) were performed. The clinical improvement and vascular patency of patients were followed up and observed. Results Among the 21 patients, 13 patients underwent open surgery, 4 underwent endovascular surgery and 4 underwent hybrid surgery. The operation success rate was 100.0% and all occlusive vessels were completely opened. Renal insufficiency occurred in 1 patient after open surgery and recovered after short-term dialysis. A total of 20 patients were followed up for 23.0 (15.5, 27.8) months. During the follow-up, in the open surgery group, thrombosis in the artificial vessels developed in 1 case and recanalized after stent implantation. No significant complications in the remaining patients. Conclusion A safe and effective clinical result can be achieved by comprehensively considering the lesion involvement, lesion characteristics, and general condition of patients with AIOD, and offering individualized treatment.

    主髂动脉闭塞症开放手术腔内手术杂交手术

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    高位结扎剥脱术与射频消融术治疗下肢静脉曲张的疗效对比

    王世材阎军田琴琴闫盛...
    42-47页
    查看更多>>摘要：目的 比较不保留膝下大隐静脉的高位结扎剥脱术（HLS）和保留膝下大隐静脉的腔内射频消融术（RFA）治疗下肢静脉曲张的疗效及其对患者生活质量的影响。 方法 回顾性分析2018年5月至2020年4月山西医科大学第二医院和太原市中心医院收治的177例（217条患肢）下肢静脉曲张患者的临床资料，根据手术方式不同分为HLS组（n=90，112条患肢）和RFA组（n=87，105条患肢）。采用t检验和χ 2检验比较两组术后两年内复发率、术后并发症、静脉临床严重程度评分（VCSS）以及慢性静脉功能不全问卷评分（CIVIQ-14）等情况。 结果 RFA组的住院时间［（4.67±1.11）d 比（9.34±2.24）d，t=17.523，P<0.001］、手术时间［（57.74±8.36）min 比（121.46±40.55）min，t=14.361，P<0.001］及术中出血量［（11.90±3.07）ml 比（85.06±21.21）ml，t=32.378，P<0.001］均优于HLS组，差异具有统计学意义。在术后并发症方面，RFA组的肢体疼痛（8 比 18，χ2=4.121，P=0.042）和麻木（6 比 16，χ2=4.812，P=0.028）发生率低于HLS组，差异具有统计学意义；但深静脉血栓形成、血栓性静脉炎、皮下血肿、感染、皮肤硬结等发生率，两组差异无统计学意义（均P>0.05）。177 例患者均完成2年的随访。随访期间，HLS组复发2例，RFA组未见复发。两组患者术后3个月、1年及2年的VCSS评分［HLS组：（5.30±1.07）分、（1.97±1.29）分、（1.87±1.31）分；RFA组：（1.44±0.50）分、（1.11±0.69）分、（1.09±0.68）分］及 CIVIQ-14评分［HLS组：（57.32±5.79）分、（61.50±5.17）分、（62.78±4.61）分；RFA组：（65.15±2.69）分、（65.43±2.51）分、（65.72±2.33）分］均较术前［HLS组：（9.20±0.96）分；RFA组：（9.11±0.87）分］表现出持续改善，差异具有统计学意义［（1）VCSS评分：HLS组：t=49.313，48.239，47.867，均P<0.001；RFA组：t=77.739，72.145，71.596，均P<0.001；（2）CIVIQ-14评分：HLS组：t=-12.700，-17.599，-18.922，均P<0.001；RFA组：t=-26.412，-26.814，-27.974，均P<0.001］。相较于HLS组，RFA组患者术后3个月、1年及2年的VCSS评分更低（t=31.073，5.469，4.924，均P<0.001），CIVIQ-14 评分更高（t=11.594，-6.464，-5.394，均P<0.001），差异具有统计学意义。 结论 保留膝下大隐静脉主干的RFA和不保留膝下大隐静脉的HLS均有良好的治疗效果。与传统的HLS比较，RFA手术时间更短，术后恢复更快，并发症较低和随访期生活质量改善较高，患者满意度较高。 Objective To compare the efficacy and quality of life of patients with lower extremity varicose veins treated by high ligation and stripping (HLS) without preservation of the great saphenous vein and endovascular radiofrequency ablation (RFA) with preservation of the below-knee great saphenous vein. Methods The clinical data of 177 patients (217 affected limbs) with lower extremity varicose veins admitted to the Second Hospital of Shanxi Medical University and Taiyuan Central Hospital from May 2018 to April 2020 were retrospectively collected and analyzed. Among them, 90 patients (112 affected limbs) received HLS and 87 patients (105 affected limbs) received RFA. The recurrence rate within 2 years after surgery, postoperative complications, venous clinical severity score (VCSS) and Chronic Venous Insufficiency Questionnaire (CIVIQ-14) were compared between two groups using t and χ2 tests. Results The length of hospital stay, operation time and intraoperative blood loss in RFA group were significantly less than those in HLS group [(4.67±1.11) d vs (9.34±2.24) d, t=17.523, P<0.001 (57.74±8.36) minvs (121.46±40.55) min, t=14.361, P<0.001 (11.90±3.07) mlvs (85.06±21.21) ml, t=32.378, P<0.001]. In terms of postoperative complications, limb pain and numbness were less common in the RFA group than that in the HLS group, and the differences were startistically significant (8vs 18,χ2=4.121, P=0.042 6 vs 16, χ2=4.812, P=0.028). However, there was no significant difference in the incidence of deep vein thrombosis, thrombophlebitis, subcutaneous hematoma, infection, skin induration, and other complications between the two groups. A total of 177 patients completed the 2-year follow-up, of which 2 patients had recurrence in HLS group and no recurrence in the RFA group. The scores of VCSS (HLS group: 5.30±1.07, 1.97±1.29, 1.87±1.31, 9.20±0.96 RFA group: 1.44±0.50, 1.11±0.69, 1.09±0.68, 9.11±0.87) and CIVIQ-14 scores (HLS group: 57.32±5.79, 61.50±5.17, 62.78±4.61, 49.43±5.42 RFA group: 65.15±2.69, 65.43±2.51, 65.72±2.33, 48.82±4.87) in the two groups at 3 months, 1 year and 2 years after operation were significantly improved compared with those before operation [(1) VCSS: HLS group: t=49.313, 48.239, 47.867, all P<0.001 RFA group: t=77.739, 72.145, 71.596, allP<0.001 (2) CIVIQ-14: HLS group:t=-12.700, -17.599, -18.922, all P<0.001 RFA group:t=-26.412, -26.814, -27.974, all P<0.001]. Compared with HLS group, the VCSS score was lower (t=31.073, 5.469, 4.924, all P<0.001) and CIVIQ-14 score was higher (t=11.594, -6.464, -5.394, all P<0.001) in RFA group at 3 months, 1 year and 2 years after operation, and the differences were startistically significant. Conclusion RFA with the preservation of the below-knee great saphenous vein and HLS without the preservation of the below-knee great saphenous vein show good therapeutic effect. Compared with HLS, RFA has shorter operation time, faster postoperative recovery, fewer complications, and improved quality of life during the follow-up period, with higher patient satisfaction.

    大隐静脉曲张射频消融术高位结扎剥脱术并发症生活质量

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