王曰偉，李永欣，李長(zhǎng)風(fēng)，張中旺，李君，王豪夫

(青島大學(xué)附屬醫(yī)院血管外科，青島 266003)

隨著人口老齡化和代謝異常導(dǎo)致的發(fā)病率增高，下肢動(dòng)脈硬化性閉塞癥(arteriosclerosis obliterans，ASO)已成為老年人突出的問(wèn)題，其中>70歲的老年人患病率達(dá)20%[1]。動(dòng)脈閉塞引起下肢缺血癥狀，輕則間歇性跛行，重則靜息痛、肢體壞疽，嚴(yán)重影響患者生活質(zhì)量。嚴(yán)重肢體缺血(critical limb ischemia，CLI)患者1年截肢率27%，5年死亡率46%[2]。對(duì)于ASO的治療，泛大西洋學(xué)會(huì)共識(shí)(Trans-Atlantic Inter-Society Consensus, TASC)Ⅱ[3]根據(jù)病變的部位、程度和范圍進(jìn)行了分級(jí)，并推薦了相應(yīng)的治療原則，A級(jí)、B級(jí)和高危C級(jí)病變首選血管腔內(nèi)治療，D級(jí)病變首選手術(shù)治療。隨著腔內(nèi)技術(shù)和器材的發(fā)展，如支架植入、斑塊旋切、血栓抽吸、準(zhǔn)分子激光消融、藥物涂層球囊[3-7]，目前腔內(nèi)治療已成為D級(jí)病變的重要手段，但尚未有大數(shù)據(jù)支持和指南推薦D級(jí)病變首選腔內(nèi)治療。而對(duì)于復(fù)雜D級(jí)病變，即主髂動(dòng)脈或股腘動(dòng)脈D級(jí)病變分別合并流出道或流入道C級(jí)以上病變，病變廣泛復(fù)雜，需要同期處理主髂動(dòng)脈和股腘動(dòng)脈病變，改善流入道或流出道。單純腔內(nèi)治療成功率低，操作復(fù)雜，單純手術(shù)創(chuàng)傷大，患者難以耐受，因此，對(duì)于該類患者尤其還多合并基礎(chǔ)疾病和全身血管病變的患者進(jìn)行治療乃是血管外科醫(yī)師比較糾結(jié)的臨床問(wèn)題。我科根據(jù)病變部位、類型和患者身體狀況，采取手術(shù)和腔內(nèi)聯(lián)合方式共治療復(fù)雜D級(jí)髂股動(dòng)脈病變27例，取得良好效果，報(bào)道如下。

1 對(duì)象與方法

1.1 研究對(duì)象

回顧性分析2007年1月至2013年12月期間我院接收的27例復(fù)雜TASC D級(jí)病變患者，男性25例，女性2例；年齡62～89(75.1±7.3)歲；患者Rutherford[3]Ⅲ、Ⅳ、Ⅴ級(jí)分別有10、12和5例，合并癥包括高血壓19例，冠心病9例，2型糖尿病11例，腦栓塞5例，高脂血癥9例，吸煙15例。入組患者均為復(fù)雜D級(jí)髂股動(dòng)脈病變，即D級(jí)主髂動(dòng)脈病變合并C級(jí)或D級(jí)股腘動(dòng)脈病變或D級(jí)股腘動(dòng)脈病變合并C級(jí)主髂動(dòng)脈病變。

1.2 方法

所有患者術(shù)前行CT血管成像(computed tomography angiography, CTA)，根據(jù)TASC病變分級(jí)原則，將患者分為C級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變14例，D級(jí)主髂動(dòng)脈病變合并C級(jí)股腘動(dòng)脈病變7例，D級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變6例。因?yàn)榛颊呔菑?fù)雜D級(jí)病變，合并流出道或流入道C級(jí)以上病變，我科根據(jù)病變類型和患者身體狀況采取個(gè)體化治療，選擇創(chuàng)傷較小的手術(shù)方式；記錄術(shù)前、術(shù)后6、12、24和36個(gè)月踝肱指數(shù)(ankle-brankial index, ABI)，并分析術(shù)前及術(shù)后隨訪12、24和36個(gè)月的通暢率。

1.3 統(tǒng)計(jì)學(xué)處理

2 結(jié) 果

2.1 術(shù)中所見

C級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變14例。其中8例行髂動(dòng)脈支架植入、股深動(dòng)脈成形、股腘動(dòng)脈旁路；C級(jí)主髂動(dòng)脈病變包括單側(cè)髂外動(dòng)脈長(zhǎng)段狹窄(3例)及單側(cè)髂外動(dòng)脈閉塞累及髂內(nèi)動(dòng)脈或股總動(dòng)脈近端(5例)，D級(jí)股腘動(dòng)脈病變是股淺動(dòng)脈全程閉塞，股深動(dòng)脈狹窄且膝關(guān)節(jié)動(dòng)脈網(wǎng)存在。髂動(dòng)脈支架植入后行股深動(dòng)脈成形、股腘動(dòng)脈人工血管旁路，其中3例直視下順行穿刺股總動(dòng)脈吻合口近端前外側(cè)壁，置入導(dǎo)管鞘于人工血管內(nèi)，行下肢動(dòng)脈造影、膝下動(dòng)脈球囊擴(kuò)張(圖1)。其余6例行髂動(dòng)脈取栓、支架植入、股腘動(dòng)脈人工血管旁路；C級(jí)主髂動(dòng)脈病變表現(xiàn)為髂外動(dòng)脈閉塞累及股總動(dòng)脈，D級(jí)股腘動(dòng)脈病變表現(xiàn)為股淺動(dòng)脈全程閉塞；術(shù)中發(fā)現(xiàn)股總動(dòng)脈血栓，切開股總動(dòng)脈，行髂動(dòng)脈導(dǎo)管取栓、球囊擴(kuò)張、支架植入，后行股腘動(dòng)脈人工血管旁路，其中2例術(shù)中穿刺股總動(dòng)脈，行膝下動(dòng)脈球囊擴(kuò)張(圖2)。

D級(jí)主髂動(dòng)脈病變合并C級(jí)股腘動(dòng)脈病變7例。D級(jí)主髂動(dòng)脈病變是患側(cè)髂及髂外動(dòng)脈閉塞，其中對(duì)側(cè)髂動(dòng)脈狹窄1例， 髂動(dòng)脈瘤1例； C級(jí)股腘動(dòng)脈病變是股淺動(dòng)脈多發(fā)狹窄和閉塞。雙側(cè)腹股溝切口，游離股動(dòng)脈，若對(duì)側(cè)髂動(dòng)脈正常，直接行股股動(dòng)脈人工血管旁路；若對(duì)側(cè)髂動(dòng)脈狹窄，先行髂動(dòng)脈支架植入，再行股股動(dòng)脈人工血管旁路，后直視下順行穿刺患側(cè)股總動(dòng)脈吻合口近端前外側(cè)壁，行股淺動(dòng)脈球囊擴(kuò)張、支架植入(圖3)。

D級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變6例。其中2例單側(cè)髂總動(dòng)脈遠(yuǎn)段和髂外動(dòng)脈全程閉塞，脛后動(dòng)脈受累1例，脛前動(dòng)脈和腓動(dòng)脈同時(shí)受累1例；游離患側(cè)股動(dòng)脈，先用取栓導(dǎo)管取出髂動(dòng)脈血栓，若取栓導(dǎo)管無(wú)法通過(guò)髂動(dòng)脈閉塞段，導(dǎo)管、導(dǎo)絲通過(guò)后，再交換取栓導(dǎo)管，殘余閉塞和狹窄支架植入，后行股腘動(dòng)脈人工血管旁路，再直視下順行穿刺股動(dòng)脈，置入導(dǎo)管鞘于人工血管內(nèi)，行膝下動(dòng)脈球囊擴(kuò)張。2例患側(cè)髂動(dòng)脈全程閉塞，對(duì)側(cè)髂動(dòng)脈狹窄，行對(duì)側(cè)髂動(dòng)脈支架植入、股股動(dòng)脈人工血管旁路、股腘動(dòng)脈人工血管旁路，其中1例行股深動(dòng)脈成形、膝下動(dòng)脈球囊擴(kuò)張。2例主髂動(dòng)脈閉塞，行腹主動(dòng)脈切開取栓、閉塞側(cè)股動(dòng)脈切開取栓，再行主股動(dòng)脈人工血管旁路。直視下順行穿刺吻合口近側(cè)股動(dòng)脈前外側(cè)壁，行下肢動(dòng)脈造影、球囊擴(kuò)張、股動(dòng)脈支架植入(圖4)。術(shù)中主髂動(dòng)脈病變經(jīng)肱動(dòng)脈穿刺建立通路4例；髂動(dòng)脈植入覆膜支架8例，其中Fluency 3例，Viabahn 5例；股股動(dòng)脈旁路人工血管為8 mm×40 cm外支撐環(huán)(巴德)，股腘動(dòng)脈旁路人工血管為6 mm×50 cm袖狀碳涂層(巴德)，股動(dòng)脈內(nèi)膜剝脫9例，腘動(dòng)脈內(nèi)膜剝脫6例。

圖1 C級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變雜交手術(shù)Figure 1 Hybrid surgery of type C aorto-iliac lesion and type D femoro-popliteal lesion

A: CT angiography shows occlusive lesions of the iliac and femoral artery; B: stenosis and occlusion of the bilateral iliac artery(DSA); C: balloon dilation of the right iliac artery after stenting; D: balloon dilation of the left iliac artery after stenting; E: the patent iliac artery after stenting(DSA); F: severe stenosis of the popliteal artery distal to the anastomosis after femoro-popliteal bypass and endarterectomy(DSA); G: balloon dilation of the popliteal artery; H: the patent popliteal and peroneal artery(DSA). DSA: digital subtraction angiography

圖2 C級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變雜交手術(shù)Figure 2 Hybrid surgery of type C aorto-iliac lesion and type D femoro-popliteal lesion

A: occlusive lesion of the right iliac artery involving the common femoral artery(DSA); B: balloon dilation of the iliac artery after thrombectomy of the iliac artery; C: the patent right iliac artery after stenting(DSA); D: extensive occlusive lesions below the knee after femoro-popliteal bypass(DSA); E: the patent popliteal artery after balloon dilation(DSA); F: the patent arteries bellow the knee(DSA). DSA: digital subtraction angiography

圖3 D級(jí)主髂動(dòng)脈病變合并C級(jí)股腘動(dòng)脈病變雜交手術(shù)Figure 3 Hybrid surgery of type D aorto-iliac lesion and type C femoro-popliteal lesion

A: CT angiography shows occlusive lesions of the iliac and femoral artery associated with the left iliac atrey aneurysm; B: the left iliac artery aneurysm and occlusive lesion of the right iliac artery(DSA); C: balloon dilation after stent-graft of the left iliac artery; D: femoro-femoral bypass with prosthesis; E: stenosis and occlusion of the right femoral artery(DSA); F: balloon dilation of the femoral artery. DSA: digital subtraction angiography

2.2 圍手術(shù)期情況

圍術(shù)期并發(fā)癥：1例股動(dòng)脈穿刺點(diǎn)假性動(dòng)脈瘤，行修補(bǔ)術(shù)；1例左側(cè)臀部血腫，行臀下動(dòng)脈栓塞術(shù)；無(wú)死亡病例。隨訪9～43(25.48±9.4)個(gè)月，失訪2例，死亡2例。

2.3 患者ABI及通暢率

患者6、12、24和36個(gè)月ABI(0.91±0.16、0.85±0.14、0.82±0.17、0.77±0.13)比術(shù)前(0.47±0.24)均顯著升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.01)；術(shù)后ABI有下降趨勢(shì)，但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后12、24、36個(gè)月通暢率分別為95.7%、80.2%、72.9%(圖5)。

3 討 論

D級(jí)髂股動(dòng)脈病變的特點(diǎn)是閉塞段長(zhǎng)，多部位、多節(jié)段性病變，合并流出道和流入道病變，其術(shù)后通暢率要低于其他類型病變。流出道差是動(dòng)脈重建后再狹窄的獨(dú)立危險(xiǎn)因素[8]，通過(guò)雜交治療能夠改善流出道和流入道[9]。因此， 對(duì)于D級(jí)髂股動(dòng)脈病變，要同期開通流入道或流出道，解決血流的高阻力，維持遠(yuǎn)期通暢。隨著器材發(fā)展和腔內(nèi)技術(shù)進(jìn)步，D級(jí)病變開通成功率提高，文獻(xiàn)報(bào)道其通暢率不亞于旁路手術(shù)，且并發(fā)癥少于傳統(tǒng)手術(shù)，提出修正TASCⅡ[10]，但是缺乏大數(shù)據(jù)和隨機(jī)對(duì)照試驗(yàn)支持，因此我們遵循TASCⅡ推薦，根據(jù)病變部位、程度和患者狀況，選擇合適的個(gè)體化治療方案?；颊咝g(shù)后1、2和3年通暢率分別達(dá)到95.7%、80.2%和72.9%，潰瘍肢體愈合，靜息痛消失，生活質(zhì)量得到改善。

圖4 D級(jí)主髂動(dòng)脈病變合并D級(jí)股腘動(dòng)脈病變雜交手術(shù)Figure 4 Hybrid surgery of type D aorto-iliac lesion and type D femoro-popliteal lesion

A: stenosis of the abdominal aortic and right iliac artery, occlusion of the left iliac artery(DSA); B: the patent abdominal aortic and right iliac artery after stenting(DSA); C: the anastomosis of the popliteal artery of femoro-popliteal bypass; D: severe stenosis of the popliteal artery distal to the anastomosis(DSA); E: balloon dilation of the popliteal artery; F: the patent popliteal and peroneal artery after balloon dilation(DSA). DSA: digital subtraction angiography

圖5 D級(jí)髂股動(dòng)脈病變患者術(shù)后通暢率Figure 5 The patency rate of type D iliac and femoral lesions after operation

對(duì)于D級(jí)主髂動(dòng)脈病變，盡管主股動(dòng)脈旁路通暢率高于腔內(nèi)治療和解剖外旁路(包括股股動(dòng)脈旁路，腋股動(dòng)脈旁路)，但是創(chuàng)傷大，并發(fā)癥多，死亡率高，不能及早恢復(fù)日?；顒?dòng)，本組病例為多節(jié)段D級(jí)病變，其他臟器血管如心、腦和腎存在不同程度病變，多不能耐受主股動(dòng)脈旁路。因此，高齡、高危D級(jí)病變多選擇單側(cè)髂動(dòng)脈支架置入、股股動(dòng)脈旁路。部分C級(jí)、D級(jí)病變是動(dòng)脈狹窄或閉塞基礎(chǔ)上繼發(fā)了血栓形成，縮小了動(dòng)脈管徑，增加了病變段長(zhǎng)度，造成一種假象，應(yīng)先行導(dǎo)管取栓，將其轉(zhuǎn)變?yōu)锽級(jí)，甚至A級(jí)病變，再行球囊擴(kuò)張或支架植入。對(duì)于髂外動(dòng)脈閉塞累及股總動(dòng)脈的病變，行股動(dòng)脈內(nèi)膜剝脫。文獻(xiàn)報(bào)道髂動(dòng)脈閉塞雜交手術(shù)(髂動(dòng)脈支架、股動(dòng)脈內(nèi)膜剝脫)住院時(shí)間短，并發(fā)癥少，與開放手術(shù)相比，早期和遠(yuǎn)期效果類似，對(duì)于高危手術(shù)患者應(yīng)當(dāng)考慮雜交手術(shù)[11，12]。同時(shí)警惕髂動(dòng)脈取栓、球囊擴(kuò)張導(dǎo)致破裂可能，因此對(duì)于環(huán)狀鈣化，取栓過(guò)程中取出動(dòng)脈內(nèi)膜，首選植入覆膜支架[13]。

對(duì)于D級(jí)股腘動(dòng)脈病變，首選股腘動(dòng)脈旁路，大隱靜脈作為旁路移植物遠(yuǎn)期通暢率高于人工血管，但是部分患者缺乏合適靜脈移植物，創(chuàng)傷較大，且針對(duì)膝關(guān)節(jié)以上水平，人工血管通暢率達(dá)到了靜脈移植物水平，因此我們采用袖狀接頭碳涂層人工血管，遠(yuǎn)端吻合口位于膝關(guān)節(jié)以上。對(duì)于合并膝下動(dòng)脈病變，單純股腘動(dòng)脈旁路無(wú)法保證高的通暢率，需要同期開通膝下動(dòng)脈，至少保證一條通暢的流出道血管[14，15]。吻合口處腘動(dòng)脈嚴(yán)重狹窄，行內(nèi)膜剝脫，吻合口遠(yuǎn)端腘動(dòng)脈球囊擴(kuò)張。股淺動(dòng)脈閉塞，股深動(dòng)脈開口或近段狹窄，導(dǎo)致通過(guò)側(cè)支循環(huán)的血流減少，影響手術(shù)的通暢率，因此需行股深動(dòng)脈成形來(lái)作為主髂動(dòng)脈手術(shù)的流出道或股腘動(dòng)脈旁路的流入道，其適用于股深動(dòng)脈開口及近段狹窄、膝關(guān)節(jié)動(dòng)脈網(wǎng)存在的患者。我們采取的手術(shù)方式是根據(jù)股深動(dòng)脈狹窄長(zhǎng)度，自股淺動(dòng)脈開口以遠(yuǎn)切斷，剝脫內(nèi)膜，將股總、股深、股淺動(dòng)脈“人”字形剖開，股深動(dòng)脈成形，擴(kuò)大股深動(dòng)脈開口及起始段，增加股深動(dòng)脈供血，通過(guò)其側(cè)支提高肢體遠(yuǎn)端血流灌注壓力，維持肢體存活的重要血供來(lái)源。

此外，術(shù)中直視下穿刺股動(dòng)脈，為血管腔內(nèi)治療提供了便利，避免了鄰近組織的損傷，減少穿刺引起的并發(fā)癥?？鼓委熤陵P(guān)重要，復(fù)雜D級(jí)病變合并流入道和流出道病變，流入血流慢，流出血流高阻力，導(dǎo)致血流淤滯，極易形成血栓，術(shù)中、術(shù)后均需要肝素抗凝治療，預(yù)防血栓形成。若術(shù)中造影發(fā)現(xiàn)殘存血栓，留置導(dǎo)管鞘、溶栓導(dǎo)管，泵入尿激酶，擇期復(fù)查造影、二期處理。

復(fù)雜D級(jí)髂股動(dòng)脈病變累及主髂動(dòng)脈和股腘動(dòng)脈，是多節(jié)段病變，需要同期處理流入道和流出道，以獲得遠(yuǎn)期通暢。根據(jù)TASCⅡ推薦的治療原則，術(shù)前評(píng)估患者的基礎(chǔ)狀態(tài)和病變的位置、范圍、程度，選擇合適的雜交治療，降低麻醉和手術(shù)的打擊，相對(duì)安全，中期效果好，尤其適合于下肢嚴(yán)重缺血、高齡、高危患者。

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