长段胫腓动脉闭塞的腔内成型技术与结果.ppt

长段胫腓动脉闭塞的腔内成型：技术与结果,虞冠锋 血管外科 温州医学院附属第一医院 ,膝下动脉疾病,多见于高龄病人 糖尿病病人多发 钙化性疾病多发 常合并足部症状，但伴随有小腿症状 常合并其它部位的病变,CLI 病理生理： 动脉狭窄或闭塞 肢体供血下降达到某一阈值 血流不足以满足组织静息时代谢需要 组织分解、坏死 丧失肢体或生命,静息,重度肢体缺血（Critical Iimb Ischemia ） 腹股沟下动脉阻塞 膝下动脉阻塞(包括长段BTK) 弥漫多节段病变,CLI动脉病变分布,Rueda CA, Nehler MR, Perry DJ, et al. Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: Implications for clinical trial design. J. Vasc. Surg. 2008; 47:995-1000.,膝下动脉病变长度,BTK 67例70肢体 病变平均长度6CM 胫腓干4CM 胫前动脉21CM(最长) 胫后动脉10CM（次长） 腓动脉5CM,H Ingle, etal J Endovasc Ther, August 1, 2002; 9(4): 411-6.,CLI死亡率高 高龄 心脑血管疾病 糖尿病 手术并发症,腔内治疗比例上升,无远端流出道 无合适旁路材料 高危开放手术 高死亡率 高并发症 移植物闭塞 腔内治疗重朔病变管腔 潜在流出道开通 低创伤性 可重复性,CLI腔内治疗的目标,取得到达足部的搏动性血流 到达足动脉弓的直线血流，促进创口愈合,膝下动脉解剖,膝下动脉影像,病例1,男性，78岁 间歇性跛行1年 左小腿足部疼痛2天 PE:左足皮温低、足背、胫后动脉搏动（-） 踝部ABI：左0.38 右0.80,诊断：左下肢动脉硬化性闭塞症 腘动脉以下血栓形成,Angiodynamic 4F-20cm,例1,溶栓48小时后 造影,腓动脉远端,更换cook90CM长鞘,300cm PT-2导丝进入腓动脉远端,腓动脉中远端,4mm P3球囊扩张,扩张后DSA,Deep 球囊 2.5*120mm,球囊扩张后造影 腘-腓动脉2处狭窄,腓动脉远端显影,已完成导管溶栓+PTA,效果？,膝下自膨支架,腓动脉近段 Xpert支架3*40,腘动脉5*40mm支架,术后造影结果,例1治疗结果： 体会：溶栓的重要性 选择性应用膝下支架可解决SuboptimalPTA,左足疼痛消失 左下肢ABI 0.38-0.65,病例2,女性，72岁 左小腿间歇性跛行2年 左砪趾溃疡2月 PE：左足皮色紫红，砪趾溃疡2*1cm 双侧足背、胫后动脉搏动（-），右腘动脉（-） ABI：左0.34、右0.56,例2,CTA示左BTK病变,全下肢动脉造影,PT-2 300mm 导丝入腓动脉,Pacific xtrem 2.5*120mm 球囊,球扩后造影,PT-2 导丝+Deep 2*120球囊通过侧枝 逆行进入胫前动脉远端,V-18导丝进入胫前、与逆行PT-2会回,顺行球囊扩张 胫前动脉,例2,最后造影,例2结果：术后左足ABI上升至0.89 左砪趾溃疡3周后愈合 体会： 1.导丝通过病变段血管是手术成功关键 2.逆行途径可选择应用，引导顺行PTA,保护侧枝和主要间接供血动脉,甲病人-腓动脉供血,乙病人-腓动脉供血,远端通过低阻力的交通支供血,先解决主要供血动脉病变,PTA技术发展,主髂动脉病变A-Iiac 股腘动脉病变Fem-Pop 膝下动脉病变BTK 踝下动脉病变BTA,PTA/stent(self/ballon/kissing) 溶栓/SIA/重回真腔 长球囊/途径变化（顺行、逆行）/远端穿刺 Pedal-Plantar loop Angiosome选择开通,BTK动脉腔内成形技术,1、穿刺入路 顺行减少造影剂量、小口径鞘、缩短时间 2、行进途径 逆行经侧枝扩张相邻膝下动脉、导丝捕获 3、导管溶栓（前） 4、支架植入（后）,投影角度 发现常规位未发现的病变 图像放大 有利于精确的操作 路径技术 引导导丝方向，球扩和支架定位 延时造影 有力远端流出道显影,放射学手段,腔内技术,途径,顺行途径 Antegrade Approach - 4F Berenstein catheter (J&J) - 0.014” wire (PT2 Boston Scientific) 逆行途径 Retrograde trans-metatarsal approach Amphirion Deep 2.0 x 40 mm (Invatec) 0.014” wire (PT2, Boston Scientific),材料改进,小口径、高推力、高循迹球囊容易通过病变 在小侧枝里柔顺性好 长球囊(8-21 cm)可减少操作时间和夹层发生 耐高压(13-20 atm) 长时间扩张 (3-5 min.),Endovascular Therapy as the Primary Approach for Limb Salvage in Patients with Critical Limb Ischemia: Experience with 443 Infrapopliteal Procedures,Marc Bosiers, MD*; Joseph P. Hart, MD*; Koen Deloose, MD*; Jurgen Verbist, MD; Patrick Peeters, MD *.Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium Endovascular strategies for the treatment of critical infrageniculate peripheral arterial occlusive disease exist and are becoming the primary methodology for such lesions at many centers. Although technically feasible for experienced operators, the evidence to support this strategy for below the knee (BTK) interventions is still evolving. We studied the 6-month and 1-year outcomes of percutaneous transluminal angioplasty (PTA) alone, PTA with stenting, and excimer laser recanalization for BTK lesions in patients with critical limb ischemia. Between September 2002 and June 2005, 443 patients (355 Rutherford category 4, 82 category 5, 6 category 6) underwent intervention for 681 BTK lesions. Follow-up was performed at 6-month intervals after index intervention: limb salvage data were recorded and duplex ultrasonography was performed to measure the patency of treated areas. The primary patency and limb salvage rates of the entire population were 85.2% and 97.0% and 74.2% and 96.6% at 6 months and 1 year, respectively. Stratified for the treatment strategy (PTA alone in 79, PTA with stenting in 300 patients, and excimer laser in 64), 1-year primary patency rates were 68.6%, 75.5%, and 75.4%, whereas the limb salvage rates were 96.7%, 98.6%, and 87.9% for each modality, respectively. Endovascular intervention will become the primary treatment for BTK lesions in patients with critical limb ischemia, with 1-year primary patency and limb salvage rates that compare favorably with published surgical data. Prospective, randomized, multicenter trials will be needed to further establish the role of endovascular intervention in this challenging patient group. Key,Vascular, Vol. 14, No. 2, pp. 6369, 2006.,我科2007、62011、8资料 膝下PTA61例、63条患肢，即时开通53条患肢，技术成功84% 其中膝下支架12例（DES6/BMS6）,12例即时通畅。,BTK-PTA治疗策略,短段病变,弥漫病变,PTA,准备小支架以备PTA效果不佳者使用,钙化严重/开口病变,弥漫性病变,球扩支架,自膨式支架,膝下裸支架长期效果,Bosiers M, Lioupis C, Deloose K, et al. Two-year outcome after Xpert stent implantation for treating below the knee lesions in critical limb ischemia. Vascular 2009; 17:1-8. The Xpert device is cleared by the U.S. Food its efficacy in the vascular system has not been established.,膝下 DES 临床研究,Siablis D, Kraniotis P, Karnabatidis D, et al. Sirolimus-eluting versus bare stents for bailout after suboptimal infrapopliteal angioplasty for critical limb ischemia. J. Endovasc. Ther. 2005;12:685-695. Siablis D, Karnabatidis K, Katsanos K, et al. Sirolimus-eluting versus bare stents after suboptimal infrapopliteal angioplasty for critical limb ischemia: Enduring 1-year angiographic and clinical benefit. J. Endovasc. Ther. 2007;14:241-250. Commeau P, Barragan P, Roquebert PO. Sirolimus for below the knee lesions: Mid-term results of the SiroBTK study. Cath. Cardiovasc. Interv. 2006;68:793-796. Scheinert D, Ulrich M, Scheinert S, et al. Comparison of sirolimus-eluting vs. bare-metal stents for the treatment of infrapopliteal obstructions. EuroInterv. 2006;2:169-174. Siablis D, Karnabatidis D, Katsanos K, et al. Infrapopliteal application of paclitaxel-eluting stents for critica