超声在狭窄颈部动脉支架植入术后随访中的应用

目的评价超声在颈部动脉(颈动脉、锁骨下动脉及椎动脉)狭窄血管支架成形术后随访中的应用价值。方法应用超声随访观察47例患者的15枚颈内动脉(ICA)支架、9枚锁骨下动脉(SCA)支架及26枚椎动脉(VA)支架术后1～12个月,观察狭窄血管处支架位置、支架内及远端的收缩期峰值流速(PSV)、支架内有无血栓及再狭窄等情况,判断其疗效。结果支架置入术后超声示狭窄ICA、VA及SCA内径较术前明显增宽,内径分别由术前(2．90±0．76)mm、(2．0±0．38)mm及(4．00±1．46)mm增宽至术后的(4．20±1．78)mm、(3．4±0．51)mm、(6．15±0．98)mm;PSV分别由术前(115±15)cm/s、(181．4±32．5)cm/s、(257．67±66．41)cm/s减低至术后的(75±24)cm/s、(47．15±12．44)cm/s及(98．87±48．63)cm/s。随访中发现2例患者颈内动脉支架狭窄,1例颈内动脉支架闭塞。结论超声是评价颈部动脉狭窄血管支架成形术后疗效的无创、安全可靠的影像学检查方法。     

Percutaneous Endovascular Treatment for Stenoses and Occlusions of Infrarenal Aorta and Aortoiliac Bifurcation: Midterm Results

OBJECTIVE: evaluation and comparison of the endovascular treatment of isolated aortic and aortoiliac atherosclerotic lesions (stenoses and occlusions). METHODS: a percutaneous endovascular procedure was performed in 52 patients (38 men and 14 women) with a mean age of 52 years (range, 25-85 years). The baseline angiogram showed 35 aortic lesions (31 stenoses, 4 occlusions) and 17 aortoiliac lesions (14 stenoses, 3 occlusions). Percutaneous techniques used in this series included variable combinations of transluminal angioplasty and stenting. All stents placements were performed over-the-wire using the transfemoral route (most often bilateral approach). Clinical examination and Duplex-scan were performed at discharge, 1 month, 6 months, 12 months, and then yearly. RESULTS: technical success was 100% for aortic and aortoiliac lesions. Angiographic success rates were comparable for aortic (91%) and aortoiliac (94%) lesions. No death occurred during or early after the endovascular intervention. Duplex-scan confirmed 100% patency rate at discharge. There was no significant difference between the aortic (94%) and aortoiliac (96%) groups regarding immediate clinical improvement. Mean follow-up was 34+/-31 months (range, 0-130 months). The cumulative primary patency rate at 36 months was 85% in the aortic group and 86% in the aortoiliac group. Clinical success, defined as a symptom-free status at the end of follow-up, was also similar in both groups. CONCLUSION: endovascular treatment of isolated aortic lesions of the infra-renal aorta has favorable outcomes comparable to those of aortoiliac lesions.     

化学镀法制备32P放射性支架预防血管成形术后再狭窄的实验研究

目的：评价^32P放射性支架对兔髂动脉狭窄的预防作用。方法：以化学镀法制备^32P放射支架，与普通支架配对后，随机植入兔双侧髂动脉，于术前、术后即刻及术后30d血管造影观察动脉狭窄程度，病理组织学观察内膜面积及管腔内径的变化。结果：术后30d，两种支架植入后的动脉最小腔径（MLD）均较术后即刻显著减小，放射性支架组的MLD显著大于对照组（P＜0．01），而其后期丢失、丢失指数、狭窄程度3项指标则显著小于对照组（P＜0．01）。两种支架植入均使血管内膜增生；放射性支架侧血管管腔面积显著大于对照侧（P＜0．05），而其新生内膜面积显著小于对照侧（P＜0．01）。两种支架植入后对支架边缘部位均无影响。结论：化学镀法制备的新型32P放射性支架安全有效，较低的放射活度即可有效防止支架内狭窄；短球囊扩张支架可能会避免边缘部位狭窄的发生。     

血管内支架成形术治疗症状性椎动脉起始部狭窄的疗效分析

目的研究血管内支架成形术治疗症状性椎动脉起始部狭窄的安全性及有效性。方法对16例症状性椎动脉起始部狭窄的患者行支架成形术治疗。16例患者均成功植入球囊扩张支架。结果术后11例患者恢复正常管径;5例患者狭窄程度明显改善,残余狭窄均小于20%。无1例发生严重并发症。在6个月的临床随访中,16例患者均无脑缺血发作及再狭窄发生。结论血管内支架成形术是治疗症状性椎动脉起始部狭窄的安全、有效方法,其长期疗效还需进一步随访研究。     

生物可降解性尿道内支架修复战伤性尿道狭窄的研究

目的建立战伤性尿道狭窄动物模型,探讨生物可降解性尿道内支架对其进行重建修复的可行性。方法将新西兰雄兔28只分为两组,实验组(n=20):以定位爆炸法建立尿道狭窄模型。一月后行逆行尿道造影、尿道镜检查,并切除狭窄段尿道,行病理组织学观察证实。后置入人工合成生物可降解尿道内支架,置入术后2、4、8、12周分别行逆行尿道造影、尿道镜检查以及尿流动力学检测。并在以上各时间点处死5只动物,取狭窄处尿道组织,观察组织学修复重建情况。对照组(n=8):于实验组爆炸处理后4周和支架置入12周,分别取对照组4只动物与实验组对比观察。结果实验组所有动物爆炸后4周在尿道球部狭窄形成稳定狭窄模型(狭窄段长5～10 mm,尿道腔缩窄50%以上)。尿道内支架置入后2周,组织学观察见黏膜上皮新生迹象,并有炎性细胞浸润;4周时上皮新生明显,炎性细胞消失;8周时出现尿道平滑肌细胞再生,12周时见损伤后尿道组织结构完全修复,与正常尿道组织比较差异无统计学意义(P>0.05)。。同时间点尿道镜检查证实尿道腔隙、黏膜形态结构无异于正常对照组。尿流动力学检测显示两组间差异无统计学意义(P>0.05)。。结论应用成功建立的战伤性尿道狭窄动物模型,证实生物可降解性尿道内支架能作为修复战伤性尿道狭窄的理想材料,具有损伤小,易操作,功能恢复快的特点。     

血管内超声显像在冠心病支架植入术中的应用

目的探讨血管内超声在冠心病支架植入中的作用。方法50例患者的52处病变在支架植入前后分别用血管内超声进行定量和定性分析,并根据血管内超声标准决定支架的直径以及植入的终点,分析CAG和IVUS对支架植入终点判断的差异和最终获得的管腔面积大小的差别以及支架后管腔面积增大的机制。结果IVUS比CAG判断的平均支架直径大[(3.48±0.29)mmvs(3.36±0.33)mm,P=0.011],支架囊的最终峰值压力明显增大[(17.7±2.9)atmvs(12.8±2.4)atm,P<0.001],QCA测得的支架面积狭窄百分比减小(13.2%±6.6%vs16.6%±9.1%,P=0.044);首次高压扩张后支架满意率CAG达96.2%,而IVUS只有37.7%。IVUS指导后最终的球囊压力更高[(16.13±1.87)atmvs(12.62±2.61)atm,P<0.001],获得的管腔直径更大[(3.64±0.53)mmvs(3.31±0.57)mm,P<0.001],管腔面积也更大[(9.90±2.05)mm2vs(8.84±1.67)mm2,P<0.001],面积狭窄百分比更小(49.15%±9.03%vs54.24%±10.05%,P<0.001];所有患者支架的近段和远段CAG均未发现明显的狭窄。而IVUS却发现支架近段血管有39例(75.0%),远段血管有23(44.2%)例存在动脉粥样硬化斑块;支架植入后非脂质斑块较脂质斑块获得的管腔面积更大[(4.50±1.67)mm2vs(3.68±0.97)mm2,P<0.001],其中脂质斑块血管面积增大较非脂质斑块小1.30mm2,斑块压缩程度却增加0.48mm2。结论IVUS较CAG能更好地判断病变的性质,指导支架更好地选择,可获得更大的管腔面积,更小的面积狭窄百分比。     

Treatment of a malignant esophageal fistula with a Gore-Tex-covered flexible nitinol stent

In order to treat fistulated esophageal cancer using a flexible stent, a covered flexible stent was constructed by wrapping a nitinol stent with a thin sheet of Gore-Tex, preserving the stents original advantages of flexibility and a low-profile introducer system. This stent was used to perform standard radiotherapy in a case of fistulated esophageal cancer.     

Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: Technical and clinical aspects after 3 1/2 years’ experience

Purpose To evaluate prospectively our experience with transjugular intrahepatic portosystemic shunt (TIPS) using four different metallic stents. Methods Between November 1991 and April 1995, 57 patients (41 men and 16 women; age 35–72 years, mean 54 years) underwent the TIPS procedure. Techniques for portal vein localization before and during TIPS were fluoroscopy, computed tomography (CT) studies, wedged hepatic venography, arterial portography, and ultrasound. After predilation we deployed balloon-expandable (n=48) and self-expanding (n=45) metallic stents. Fifteen patients underwent variceal embolization. Initial follow-up angiograms (mean 6.9 months, range 3–24 months) were obtained in 39 of these patients. Results Fifty-three patients (93%) had successful TIPS placement. The mean decrease in portal pressure was 42.7%. Besides fluoroscopy, the most helpful techniques for portal vein localization were venography and CT. Residual stenosis (n=1) and late shortening (n=4) of Wallstents resulted in shunt dysfunction. The technical problems encountered with the Palmaz stent resulted from its lack of flexibility. We combined balloon-expandable and self-expanding stents in 12 patients. The 30-day and late follow-up (mean 11.9 months) percutaneous reintervention rates were 11.3% and 64.2%, respectively. There were no clinically significant complications related to the TIPS insertions. Conclusion An ideal stent does not exist for TIPS, and the authors recommend combining a Palmaz stent with a flexible self-expanding stent.     

血管内支架模型及离体血管经腔内超声三维重建的实验研究

我们自制了16个不同形状和大小的金属支架模型，置入人造血管腔中，并采用高体正常血管8条（犬腹主动脉4条，人冠状动脉4条）进行经血管腔内超声显像（IVUS）的体元模型三维重建（3DR）研究。结果显示，该技术能真实地再现支架在管腔内的形态、支架与管壁之间的间隙及离体正常血管的管腔及管壁形态，经提取后重建的支架模型与实物非常相似。经3DR测得的支架及血管腔内径与实测值均高度相关（r分别为0.96和0.99，p＜0．001）。支架与管壁之间空隙的3DR测值与实测值也高度相关（r=0.97，p＜r.0.01）。     

Use of suture-mediated vascular closure devices for the management of femoral vein access after transcatheter procedures.

Groin complications remain the most common complication of cardiac catheterization procedures. While the use of closure devices is increasing for arterial sheaths, venous sheaths tend to be removed and hemostasis achieved with manual compression. We report our experience using Perclose suture-mediated vascular closure device to achieve hemostasis and early mobility in patients who have had venous access as part of their procedure. There were a total of 42 patients (21 males; average age, 63.5 years) studied. The majority of the patients had 7 Fr sheaths (24), with access sites of sheaths up to 14 Fr being closed with this technique. Two patients developed complications at the access site: one patient requiring rehospitalization for intravenous antibiotics because of late access site infection, and one patient with deep venous thrombosis and pulmonary emboli. We conclude that the use of the Perclose suture-mediated closure device for closure of femoral venous access sites is feasible and should be considered especially in patients with larger venous sheaths and those at increased risk of groin complications.