接力穿刺技术治疗无对侧股动脉入路的下肢动脉硬化闭塞症的应用研究

doi:10.3877/cma.j.issn.2095-5782.2018.02.011

目的：

研究接力穿刺技术治疗无对侧股动脉入路的下肢动脉硬化闭塞症患者的有效性和安全性。

方法：

选取2014年4月—2017年9月入住我院的22例无对侧股动脉入路的下肢动脉硬化闭塞症患者，22例中对侧股动脉植入覆膜支架5例，主髂动脉病变已行对吻支架6例，主髂动脉病变同时累及双侧股动脉3例，腹主动脉瘤腔内修复术后4例，对侧截肢术后4例，采用接力穿刺技术（先肱动脉入路完成患侧髂股动脉病变治疗，获得患侧股动脉安全穿刺区，然后接力顺行穿刺患侧股动脉完成股腘动脉、甚至膝下动脉病变的腔内治疗）进行一期血运重建，治疗其下肢动脉硬化闭塞症，总结手术成功率及并发症情况。

结果：

手术成功率为100%，共植入103枚支架，平均4.7枚/人。所有缺血症状术后立即得到缓解，患肢踝肱指数（ABI）显著提高[（0.90±0.16）vs.（0.33±0.18），t=18.80，P<0.01）。随访2~36月(平均19.5个月)，围手术期及随访期间无严重手术相关并发症，术后1年的一期通畅率为81.8%（18/22）。

结论：

应用接力穿刺技术治疗无对侧股动脉入路、肱动脉入路腔内器械过短无法完成血运重建的下肢动脉硬化闭塞症是安全、有效的，可以作为首选治疗方法。

关键词: 下肢动脉硬化闭塞症, 腔内治疗, 肱动脉穿刺, 接力技术

Objective:

To anlyze the safety and efficacy of the relay puncture technique in treatment of arteriosclerosis obliterans of lower extremities in patients without contralateral femoral artery approach.

Methods:

From April 2014 to September 2017, 22 cases of symptomatic peripheral arterial disease (PAD) without contralateral femoral access (5 cases with implantation of covered stents in the contralateral common femoral artery, kissing stents in aortoiliac lesion in 6 patients, 4 cases of abdominal aortic aneurysm endovascular repair, 3 patients with arotoiliac lesions involves bilateral femoral artery and 4 underwent limb amputation to the contralateral leg) were enrolled in. All cases used relay puncture technique for lesions revascularization over the same period. First, trans-brachial artery approach was used to recanalize ipsilateral iliac femoral artery, which could create a safety zone in ipsilateral femoral artery to puncture for revascularization of the femoropopliteal, even the artery below the knee, which was called relay puncture technique. The antegrade puncture on the femoral artery after the branchial artery puncture was just like a relay race. Post-operation success rate and complication were reported.

Results:

Success rate of operation was 100% with 103 stents deployed (4.7 stents per case) , and the ischemia symptoms decreased immediately after the treatment. Post-operation ankle-brachial index (ABI) was significantly higher than pre-operation (0.90±0.16 vs. 0.33±0.18, t=18.80, P<0.01) . All the patients were followed up for 2~36 (median time, 19.5) months, without serious complications during perioperative period and follow-up period. The 1-year primary patency rate was 81.8% (18/22) .

Conclusions:

Relay puncture technique is a safe and effective method to revascularize the blood flow of patients with challenging artery lesions whose contralateral femoral artery cannot obtain and short-shaft of the devices through the brachial artery approach, and can be used as the preferred treatment.

Key words: Peripheral arterial disease, Endovascular treatment, Brachialartery puncture, Relay puncture technique

表1 患者一般临床资料

参数		例(%)
合并症		?
?	高血压	17(77.3)
?	2型糖尿病	10(45.5)
?	胰岛素	7(31.8)
?	冠心病	12(54.5)
?	经皮冠状动脉介入治疗(PCI)术后	8(36.4)
?	慢性阻塞性肺疾病	3(13.6)
?	肾功能不全	5(22.7)
?	吸烟史	9(40.9)
病变部位		?
?	髂-股-腘长段闭塞	4(18.2)
?	股腘动脉全程闭塞病变	13(59.1)
?	累及股总动脉的膝下动脉病变	5(22.7)

表1 患者一般临床资料

参数		例(%)
合并症		?
?	高血压	17(77.3)
?	2型糖尿病	10(45.5)
?	胰岛素	7(31.8)
?	冠心病	12(54.5)
?	经皮冠状动脉介入治疗(PCI)术后	8(36.4)
?	慢性阻塞性肺疾病	3(13.6)
?	肾功能不全	5(22.7)
?	吸烟史	9(40.9)
病变部位		?
?	髂-股-腘长段闭塞	4(18.2)
?	股腘动脉全程闭塞病变	13(59.1)
?	累及股总动脉的膝下动脉病变	5(22.7)

图1 典型病例（男性，78岁，双下肢动脉硬化闭塞症）应用接力穿刺技术治疗前后

表2 手术前后的ABI及Rutherford分级比较

项目	时间	均值或中位数	统计量	P值
踝肱指数	术前	0.33±0.18	?	?
(ABI)	术后	0.90±0.16	t=18.80	<0.01
?	术后3个月	0.91±0.13	t=17.01	<0.01
?	术后6个月	0.84±0.13	t=14.66	<0.01
Rutherford	术前	5	?	?
分级（级）	术后	0	Z=4.17	<0.01
?	术后3个月	0	Z=4.17	<0.01
?	术后6个月	0	Z=4.19	<0.01

表2 手术前后的ABI及Rutherford分级比较

项目	时间	均值或中位数	统计量	P值
踝肱指数	术前	0.33±0.18	?	?
(ABI)	术后	0.90±0.16	t=18.80	<0.01
?	术后3个月	0.91±0.13	t=17.01	<0.01
?	术后6个月	0.84±0.13	t=14.66	<0.01
Rutherford	术前	5	?	?
分级（级）	术后	0	Z=4.17	<0.01
?	术后3个月	0	Z=4.17	<0.01
?	术后6个月	0	Z=4.19	<0.01

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Application of relay puncture technique in treatment of arteriosclerosis obliterans of lower extremities in patients without contralateral femoral artery approach

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Application of relay puncture technique in treatment of arteriosclerosis obliterans of lower extremities in patients without contralateral femoral artery approach