术中髂动脉支架结合股动脉旁路术治疗多节段动脉硬化闭塞症

摘要

目的探讨术中髂动脉腔内成形及支架植入结合股-动脉旁路术治疗多节段动脉硬化闭塞症的初步临床经验。方法采用术中同时行髂动脉腔内成形和支架植入结合股-动脉旁路术治疗多节段动脉硬化闭塞症10例（12条肢体）。结果术中11条髂动脉行腔内成形和支架植入均获成功，9条肢体行股-动脉人工血管旁路术，3条肢体行股-股-动脉人工血管旁路系列转流术；1条肢体股-动脉旁路术失败。本组患者无重要脏器并发症和手术死亡。平均随访时间6个月（1～12个月），髂动脉腔内支架通畅率100%；3条股-股动脉耻骨上人工血管转流均通畅；而股-动脉人工血管通畅率83.3%；截肢率8.3%。结论术中髂动脉腔内支架结合股-动脉旁路术是治疗多节段动脉硬化闭塞症的安全、有效方法。%Objective　To study intraoperative iliac angioplasy and stenting combined with infrainquinal revascularization in multilevel atherosclerotic occlusive disease.　Methods　Intraoperative iliac angioplasty and stenting combined with simultaneous femoro-popliteal bypass were performed on 12 lower extremities of 10 patients with multilevel atherosclerotic occlusive disease (8 men and 2 women, aged on average 72 years). The indications for the procedures included disabling claudication 3 patients and rest pain 7 (including tissue gangrenes in 2 patients). The mean preoperative ankle-brachial index (ABI) was 0.31±0.21.　Results　Eleven iliac angioplasty and stent procedures were performed with simultaneous 9 femoro-popliteal bypass and 3-femoro-femoral-popliteal bypass in the 12 limbs. Angioplasty and stent placement were successful in all patients. One contralateral femoral-popliteal bypass failed after femoro-femoral-popliteal bypass because of poor outflow and prosthetic thrombosis; but the donor iliac stent and femoro-femoral graft remained patent. There were no additional instances of procedural or postoperative morbidity or mortality, and no wound-related complications. Postoperative ABI was 0.72±0.20 (P＜0.01). Follow-up for 6 months on average (range 1-12 months) revealed that, one femoro-infrapopliteal graft became occluded after 7 months as a result of thrombosis secondary to distal intimal hyperplasia and poor run-off. Above-knee amputation was required because of the failare of thrombectomy and thrombolysis and foot gangrene. The cumulative primary patency rate of stented iliac arteries and femoro-popliteal bypass grafts was 100%(11/11) and 83.3%(10/12), respectively. All the femoro-femoral bypass grafts were patent. The amputation rate was 8.3%(1/12).　Conclusions　Intraoperative iliac artery PTA and stent placement can be safely and effectively performed simultaneously with infrainguinal revascularization for multilevel atherosclerotic occlusive disease by skilled vascular surgeons, using a portable C arm fluoroscopy. Iliac artery PTA and stenting were valuable adjunct to distal bypass either to improve inflow and outflow or reduce the extent of traditional surgical intervention, and also, any angioplasty and stenting-related complications can be immediately controlled.