腹股溝下動(dòng)脈硬化閉塞癥的治療revised

1、腹股溝下動(dòng)脈硬化閉塞癥的治療revisedWhat Is Peripheral Arterial Disease (PAD)?A Series of DefinitionsStructural: Any arterial structural abnormality spanning:Increased intimal-medial thicknessAny focal arterial stenoses or aneurysmal disease“Non-coronary”: Arterial disease of any etiology in any non-coronary circu

2、lationLower Extremity: Atherosclerotic disease of the aorta and arteries to the lower extremities, impaired the movement, induced the insufficiency of limbs blood supply, ulcer, gangrene or limb loss.Lower Extremity Arterial Occlusive DiseaseTreatment of vascular diseaseis a growth industry!Prevalen

3、ce of PAD in Asia and ChinaIn general population (He Y, JVS, 2006)15.3% (Men: 11.7%; Women: 17.7%)over 60In Diabetes (Rhee SY, Guan H, Diabetes Res Clin Pract. 2006) ChinaAsia19.47%17.7%Type 2, over 50Current population of China (http:/)Total: 1307 millions 2005-11-1Aging peoples: over 60, 144 milli

4、ons, 11.03%ABI 測(cè)定多普勒超聲正常異常間歇性跛行運(yùn)動(dòng)試驗(yàn)正常：非血管源性疾病查找其他病因運(yùn)動(dòng)后ABI值下降下肢動(dòng)脈閉塞癥可疑下肢動(dòng)脈閉塞癥：間歇性跛行、肢體疼痛、運(yùn)動(dòng)能力降低下肢動(dòng)脈體檢異常發(fā)現(xiàn)年齡50-60歲，有吸煙或糖尿病史年齡70歲心血管危險(xiǎn)因素患者Stage of Patients FontaineRutherfordStageClinicalGradeCategoryClinicalIAsymptomatic00AsymptomaticIIaMild claudicationI1Mild claudicationIIbModerate-severe claudicati

5、onII23Moderate claudicationsevere claudicationIIIIschemic rest painII4Ischemic rest painIVUlceration or gangreneIII IV56Minor tissue lossUlceration or gangreneClassic claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with r

6、estCritical limb ischemia: Ischemic rest pain, non-healing wound, or gangrene (always consider as chronic ischemia for more than 2 months)Natural History of Atherosclerotic Lower Extremity PADPAD Population (50 years and Older)Initial clinical presentationAsymptomatic PAD20%-50%Atypical leg pain40%-

7、50%Claudication10%-35%Critical limb ischemia1%-2%Progressive functional impairment1-year outcomesAlive w/ 2 limbs50%Amputation25%CV mortality25%5-year outcomes(to next slide)Hirsch AT, et al. ACC/AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal,

8、mesenteric, and abdominal aortic): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease Lower Extremity, renal, Mesenteric, and Abdominal Ao

9、rtic). Circulation. 2006;113:e463-654. Natural History of Atherosclerotic Lower Extremity PADClaudication10%-35%5-year outcomesLimb morbidityStable claudication70%-80%Worsening claudication10%-20%Critical limb ischemia1%-2%Amputation(see CLI data)CV morbidity & mortalityNonfatal CV event(MI or strok

10、e) 20%Mortality15%-30%CV causes 75%Non-CV causes25%Hirsch AT, et al. ACC/AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A report of the American College of Cardiology/American Heart Association Task Force on

11、Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease Lower Extremity, renal, Mesenteric, and Abdominal Aortic). Circulation. 2006;113:e463-654. Asymptomatic PAD20%-50%Atypical leg pain40%-50%For each of these PAD clinical syndro

12、mesPAD患者的分布和自然轉(zhuǎn)軌重癥下肢缺血：1-2%1年內(nèi)，1/4死亡1/4發(fā)展為肢體缺失1/2存活（肢體完整）間跛、肢體疼痛、運(yùn)動(dòng)能力降低：50%5年內(nèi)，70-80%維持癥狀20-30%病情進(jìn)展無(wú)癥狀：50%PRIMARY SITES OF INVOLVEMENTFemoral & Popliteal arteries: 80-90%Tibial & Peroneal arteries: 40-50%Aorta & Iliac arteries: 30%Harrisons Principles of Int Med間歇性跛行的治療策略緩解癥狀，提高運(yùn)動(dòng)能力和日常功能首先是系統(tǒng)的功能鍛煉每周

13、3次，每次45min，誘導(dǎo)3-4次疼痛為宜藥物治療西洛他唑；安步樂(lè)克降低心血管事件的風(fēng)險(xiǎn)并提高生存率 限制危險(xiǎn)因素吸煙、高血壓、高血脂、高血糖、肥胖等抗血小板治療阿司匹林、氯比格雷Indications for angiography in intermittent claudicationAngiography in a patient with intermittent claudication is usually indicated only when a decision has been made to intervene, should a suitable lesion be

14、identified男，68y，左下肢間跛300-100m，漸加重。女，66歲，間跛200m，雙側(cè)股淺動(dòng)脈支架，隨診3年。右下肢外側(cè)靜脈炎，伴行走時(shí)疼痛50m。女，66歲，右下肢間跛半年腹股溝下血管重建的材料選擇大隱靜脈較人工血管有更高的通暢率但也有文獻(xiàn)報(bào)告，保肢率基本接近自體靜脈原位或倒轉(zhuǎn)在遠(yuǎn)期通暢率上沒(méi)有差異膝上的旁路，使用PTFE人工血管也可以得到近似的短期通暢率人工血管用于膝下的旁路，遠(yuǎn)期通暢率不能令人滿意，且閉塞后的缺血癥狀更為嚴(yán)重薈萃分析：不同材料旁路術(shù)的5年通暢率隨機(jī)對(duì)照試驗(yàn)中，不同材料的影響男，74歲，間歇性跛行2月Morphological stratification of

15、 femoropopliteal lesions and recommendations for treatment單發(fā)狹窄10cm單發(fā)閉塞5cm多發(fā)病變，每個(gè)5cm單發(fā)病變15cm,且不累及膝下腘動(dòng)脈單發(fā)或多發(fā)病變，同時(shí)合并脛動(dòng)脈閉塞重度鈣化性閉塞20cm，累及腘動(dòng)脈）慢性的腘動(dòng)脈和三分叉近端的完全閉塞多發(fā)狹窄或閉塞，累計(jì)長(zhǎng)度15cm2次腔內(nèi)治療后復(fù)發(fā)的狹窄或閉塞Recommendations for ICTo treat severe symptoms only after other forms of medical therapy have been recommended and h

16、ave either failed or been rejected for good reasonWith a high benefit-to-risk ratioTo improve run-off in intermittent claudication remains to be established重癥下肢缺血的治療策略減輕缺血性疼痛規(guī)律性應(yīng)用鎮(zhèn)痛藥物治愈缺血潰瘍、預(yù)防肢體缺失控制感染潰瘍或壞疽肢體（趾）護(hù)理前列腺素類藥物提高病人的生活質(zhì)量以及延長(zhǎng)壽命截肢（趾）抗血小板藥物應(yīng)用大多數(shù)病人最終都需要血管重建男，75歲，W150560主述：右下肢間歇性跛行4年，右足靜息痛伴潰瘍10余天

17、入院情況：患者于16年前突然出現(xiàn)四肢無(wú)力，不能行走，頭暈、頭痛，就診于當(dāng)?shù)蒯t(yī)院，診斷為“腦血栓”，經(jīng)治療逐漸好轉(zhuǎn)，3年后可自主行走，但走路不快。4年前出現(xiàn)行走150余米后右小腿疼痛，休息后可以緩解，半年前行走50余米即出現(xiàn)上述癥狀，一直未診治。10余天前出現(xiàn)右足靜息痛，并伴有雙足末稍發(fā)紫，右足第三趾潰瘍，就診于邯鄲中心醫(yī)院，行下肢彩超提示“雙側(cè)股動(dòng)脈粥樣硬化伴右股動(dòng)脈栓塞，雙側(cè)腘動(dòng)脈粥樣硬化”，給予“克賽”抗凝、“銀杏葉，血塞通，華法令，辛伐他汀”等藥物治療，效果不佳，潰瘍一直未愈。既往史：高血壓15年，近4年未服用降壓藥。2005年因便秘誘發(fā)“左心衰”，出現(xiàn)下肢水腫，不能平臥，經(jīng)保守治療后好

18、轉(zhuǎn)。2003年因泌尿系結(jié)石行內(nèi)鏡取石。否認(rèn)糖尿病，高血脂病史。入院查體：雙足輕度水腫，左下肢皮溫較右側(cè)低，發(fā)涼范圍從足至大腿上部。皮膚顏色略蒼白，無(wú)花斑、雙足趾末端紫紺，右足第四趾干性潰瘍。雙下肢肢端毛細(xì)血管充盈時(shí)間延長(zhǎng)。雙側(cè)脛后、足背動(dòng)脈未觸及搏動(dòng)。雙側(cè)橈動(dòng)脈搏動(dòng)正常。雙側(cè)頸動(dòng)脈搏動(dòng)未及異常。雙Burger征陽(yáng)性。ABI：上肢最高左側(cè)145/89mmHg，右上肢137/69 mmhg，右下肢踝 113/74mmHg，左下肢踝50/26，右，左。輔助檢查：下肢彩超提示：“雙股動(dòng)脈粥樣硬化伴右股動(dòng)脈栓塞，雙側(cè)腘動(dòng)脈粥樣硬化”。入院診斷：雙下肢動(dòng)脈硬化閉塞癥高血壓病陳舊心肌梗塞房顫陳舊性腦梗診治經(jīng)

19、過(guò)：入院后完善檢查及術(shù)前準(zhǔn)備，予抗凝、擴(kuò)血管、抗血小板等對(duì)癥治療。入院兩天后癥狀稍有緩解。CRX回報(bào)：心影增大，雙肺紋理增重，右側(cè)少量胸水。心電圖示心房纖顫。超聲心動(dòng)圖回報(bào)：左室射血分?jǐn)?shù)36%，陳舊性心梗（室間隔中下段及心尖部），心尖部室壁瘤形成，左心房室增大，二尖瓣輕度關(guān)閉不全，主肺動(dòng)脈增寬，左室收縮功能減低。雙下肢動(dòng)脈彩超：1.雙下肢動(dòng)脈硬化伴多發(fā)粥樣硬化斑塊形成并血栓形成。2.雙側(cè)股淺、腘動(dòng)脈、脛前、脛后、足背動(dòng)脈閉塞可能性大。雙下肢動(dòng)脈CTA：1.腹主動(dòng)脈及其分支及其遠(yuǎn)端動(dòng)脈管壁鈣化，血栓形成，符合動(dòng)脈硬化改變。2.兩側(cè)股動(dòng)脈及脛前動(dòng)脈閉塞，兩小腿供血?jiǎng)用}為脛后動(dòng)脈。雙頸動(dòng)脈及鎖骨下動(dòng)

20、脈彩超示：雙頸動(dòng)脈粥樣硬化，多發(fā)斑塊形成，左側(cè)頸內(nèi)動(dòng)脈不除外狹窄，雙側(cè)椎動(dòng)脈血流緩慢，右側(cè)椎動(dòng)脈不除外狹窄，雙鎖骨下動(dòng)脈顯示不清，右側(cè)近端多發(fā)斑塊形成。內(nèi)科會(huì)診意見(jiàn)：1.高風(fēng)險(xiǎn)手術(shù)，圍手術(shù)期發(fā)生心臟事件的危險(xiǎn)因素多，建議行腺苷心肌核素顯像評(píng)價(jià)目前患者是否有可逆性的心肌缺血，若有則行冠脈介入治療后再考慮下肢血管的手術(shù)；2.開(kāi)始冠心病二級(jí)預(yù)防及慢性心衰的治療。3.建議長(zhǎng)期華法令抗凝（INR2-3）4.圍手術(shù)期注意監(jiān)測(cè)出入量，避免誘發(fā)心衰。遂按照內(nèi)科意見(jiàn)行相關(guān)檢查及圍手術(shù)期治療。ICU會(huì)診意見(jiàn)：1.高危因素多，圍手術(shù)期危險(xiǎn)極高，向家屬充分說(shuō)明，進(jìn)一步完善心內(nèi)科檢查。2.術(shù)中、術(shù)后維持血流動(dòng)力學(xué)穩(wěn)定，

21、減少心腦并發(fā)癥發(fā)生率。麻醉科會(huì)診意見(jiàn)：1.患者高齡，有腦梗、心梗、心衰、高血壓、房顫病史，未規(guī)律治療，LVEF低，室壁瘤形成，心功能級(jí)。行全身麻醉風(fēng)險(xiǎn)極高，圍手術(shù)期心腦血管并發(fā)癥機(jī)率大，死亡率高，2.術(shù)前為評(píng)價(jià)心肌缺血程度及心功能儲(chǔ)備，建議行心肌核素顯像，檢查后請(qǐng)心內(nèi)科協(xié)助評(píng)價(jià)患者目前心功能。3.麻醉中加強(qiáng)監(jiān)護(hù)，行有創(chuàng)動(dòng)、靜脈監(jiān)測(cè)。術(shù)中維持血壓于平日血壓值20%范圍內(nèi)， 控制心室率不宜過(guò)快，防止心肌缺血進(jìn)一步加重，動(dòng)態(tài)監(jiān)測(cè)心電圖，必要時(shí)行12導(dǎo)聯(lián)心電圖檢查。術(shù)中維持出入量平衡，避免前負(fù)荷過(guò)多增加心臟負(fù)擔(dān)。靜息心肌灌注顯像示：EF:36%,左室腔明顯增大，心功能明顯減低；左室心尖、前壁、下壁心肌

22、灌注明顯減低，符合心梗改變。遂于區(qū)域阻滯麻醉下行“右髂動(dòng)脈球囊擴(kuò)張支架植入、右股-腘動(dòng)脈人工血管膝上搭橋術(shù)、右股動(dòng)脈內(nèi)膜剝脫右股動(dòng)脈取栓術(shù)”，手術(shù)順利，患者生命體征平穩(wěn)，右脛后動(dòng)脈搏動(dòng)良好。術(shù)后安返ICU病房。經(jīng)ICU密切監(jiān)護(hù)治療下，患者一般情況良好，于轉(zhuǎn)回我科病房。并于病情好轉(zhuǎn)出院。男，75歲，下肢間歇性跛行4年，右足靜息痛伴潰瘍10余天腦血栓、左心衰X光：心影增大，雙肺紋理增重，右側(cè)少量胸水。心電圖：心房纖顫。超聲心動(dòng)圖：左室射血分?jǐn)?shù)36%，陳舊性心梗，心尖部室壁瘤形成。靜息心肌顯像：心功能明顯減低；左室心尖、前壁、下壁心肌灌注明顯減低。Extremely high risk patientsAt least 3 risk factors:Age over 70HypertensionAnginaPrior myocardial infarctionHeart failureCardiac str