股浅动脉狭窄及闭塞的介入治疗现状.ppt

股浅动脉狭窄 闭塞的治疗现状 BASIL BypassvsAngioplastyinSevereIschemiaoftheLeg multicenter randomisedcontrolledtrialBypasssurgeryvsballoonangioplasty27UKhospitals5 5y 1999 2004 452patients severelimbischemiaduetoinfra inguinaldisease 269men 183women meanage75228surgery 1 3SFA PA AK 1 3SFA PA 1 3cruralarteries224angioplasty 36 transluminal 50 subintimal 14 mixed 162 80 SFA 126 62 includemoredistalvesselsPrimaryendpoint amputationordeath40 DM 1 3smokersFollow 449 99 1y336 74 2y216 48 3y99 22 4y37 8 5y AdamDJ Bypassversusangioplastyinsevereischemiaoftheleg BASIL Multicentre randomisedcontrolledtrial TheLancet Dec3 Dec9 2005 366 1925 1934 BalloonangioplastybypasssurgeryN 224n 228M F128 96141 87Age 80 30 46 24 35 39 26 Rt Ltleg46 54 43 57 Smokingstatusnever21 18 current32 40 not 1y46 42 DMnotknown58 58 insulin dep17 17 non insulin dep25 25 Angina19 18 PreviousMI20 15 Previousstroke TIA18 25 Painatrest92 90 Tissueloss75 73 HT63 59 Baselinecharacteristicsoftrialpatients 248 55 ptshadnotreachedtheprimaryendpoint ie werealivewiththeirtriallegintact 38 8 werealivewiththeirtriallegamputated36 8 haddiedsubsequenttohavingtheirtriallegamputated130 29 haddiedwithoutamputation Attheendoffollow up DuringsamehospitalFollowingdischargefromstayas1stinterventionhospitalafter1stinterventionAngioplastySurgeryAngioplastySurgeryN 237n 197n 230n 186Mortality71100Morbidityangina4412MI61322Stroke1320hematoma16 2 19 9 1 0 5 0 woundinfection18452529chestinfection41032Urineinfection8726falseaneurysm0 0 2 1 0 0 0 0 venousthromboembolism1020Furtherinterventionsangioplasty3110surgery212130amputation201732graftre exploration0500embolectomy1210thrombectomy0301wounddebridement3611 Mortality morbidity andre interventionwithin30daysafter1stintervention Angioplastyallocatedin224pts 216underwentattemptedangioplasty43 20 immediatetechnicalfailure12months 50 resultedinclinicalfailureSurgeryallocatedin228pts 195underwentattemptedsurgery12months 56 werealivewiththetriallegintactRe interventionrate surgery41 18 vsangioplasty59 26 Survivalsurgery1 y68 3 y57 angioplasty1 y71 3 y52 Results Inpatientcost surgery 23322 20096hospitalstay 3225procedurecost angioplasty 17419 15381 2039 Intheshortterm surgeryassociatedwithasignificantlyhigherrateofmorbidity hospitalstay Inthelongterm after2years surgeryassociatedwithasignificantlyreducedriskoffutureamputationand ordeath Results TheBASILtrialclearlyindicatesthat almostirrespectiveofwhattreatmentisreceived manypatientswithseverelimbischemiahaveanextremelypoorprognosis Patientswhoundergorevascularizationforseverelimbischemia eitherbysurgeryorangioplasty seemtorepresentthetipofaniceberg thetruedimensionsofwhichremainincompletelydefined Themedium termresultsofBASILtrialindicatethat patientspresentingwithseverelimbischemiaduotoinfrainguinalatherosclerosisandwhoseemtechnicallysuitableforbothtreatmentcanreasonablybetreatedwitheithermethodinthefirstinstance dependingonindividualcharacteristicsandlocalexpertise Conclusions Patientswhoareexpectedtoliveforlessthan1 2yearsandhavesignificantcomorbidityshouldprobably whenpossible beofferedangioplastyfirst Inpatientsexpectedtolivemorethan2yearsandrelativelyfit theapparentimproveddurabilityandreducedre interventionrateofsurgerycouldoutweighttheshort termconsiderationsofincreasedmorbidityandcost Angioplastyandbypasssurgeryareassociatedwithbroadlysimilaroutcomesintermsofamputation freesurvival Conclusions TASC TransAtlanticInter SocietyConsensus classificationofSFAlesions TypeA short focalstenoses 3cmTypeB stenoses3 5cmwithcalcifiedlesionTypeC occlusionslongerthan5cmandmultiplelesionsTypeD long totalocclusionTypeA endovasculartreatment PTA TypeD surgicalbypassTypeB C norecommendation DormandyJA Managementofperipheralarterialdisease PAD TASCWorkingGroup TransAtlanticInter SocietyConcensus TASC JVascSurg2000 31 S1 296 Patencyofabove knee AK veinbypassPatencyofAKprostheticbypass BergaminiTM Experiencewithinsitusaphenousveinbypassesduring1981to1989 determinantfactorsoflong termpatency JVascSurg1991 13 137 47KlinkertP Veinvspolytetrafluoroethyleneinabove kneefemoropoplitealbypassgrafting 5 yearresultsofarandomisedcontrolledtrial JVascSurg2003 37 149 55 PatencyofSFAwithcoveredstents AhmadiRFemoropoplitealarteries immediateandlong termresultswithaDacron coveredstent graft Radiology2002 223 345 50 PatencyofSFAwithHemobahnendoprosthesisPatencyofSFAwithbarestents BrayPJ Percutaneoustreatmentoflongsuperficialfemoralarteryocclusivedisease efficacyoftheHemobahnstent graft JEndovascuTher2003 10 619 28VroegindeweijD Balloonangioplastycombinedwithprimarystentingversusballoonangioplastyaloneinfemoropoplitealobstructions acomparativerandomisedstudy CardiovascInterventRadiol1997 20 420 5 PatencyofSFAwithnitinolstentsPatencyofSFAafterPTA VogelTR Efficacioususeofnitinolstentsinthefemoralandpoplitealarteries JVascSurg2003 38 1178 84MartinDR Percutaneoustransluminalangioplastyofinfrainguinalvessels AnnVascSurg1999 13 184 7 PatencyofSFAafterSA LaxdalE Subintimalangioplastyasatreatmentoffemoropoplitealarteryocclusions EurJVascEndovascSurg2003 25 578 82 Endovasculartherapyinthetreatmentofinfrainguinalatheroscleroticdiseaseremainscontroversial TheliteraturedescribingthetreatmentofSFAdiseasedescribesacontinualevolutionintherapeuticoptions Whilethecurrentliteraturedoesnotallowdirectcomparisonofthedifferenttreatmentmodalities itdoesprovideageneraloverviewoftheindicationsforwhichtheyareused Conclusions DorrucciV Treatmentofsuperficialfemoralarteryocclusivedisease JCardiovSurg2004 45 193 201 Surgicalbypassforthetreatmentoflong totalocclusionsisthehistoricalgoldstandardinthetreatmentofPAD andiswelldocumentedatlongfollow uptimes Endovasculargraftscomparefavorablytosurgicalbypassouttoatleast3years Nitinolstentsseemtoperformbetterthanballoon expandablestentsintheSFA butlong termperformancehasnotbeendocumented PTAappearstobeeffectiveintreatingshortstenoticlesions whileSAisprimarilyusedtotreatcriticallimbischemia wherewoundhealingistheprimarygoal Conclusions TreatmentofPVD peripheralvasculardisease Drugtherapy Antiplatelet riskreductionof22eventsper1000ptstreatedfor2years vasculareventsincludingstroke nonfatalMI deathfromvascularcause aspirin75 150mg dayclopidogrel equallyeffectiveandpossiblymoreHypercholesterolemia Lipid loweringHTDMOthertreatment endovascularstent thrombolysis angioplasty angioplastywithbrachytherapy bypassgraftingTodate therearenofirmevidence basedcriteriafordecidingwhichpatientsWillbenefitfromagivenprocedure Locationoflesion patient relatedrisk surgery relatedrisk typeofclot etal SontheimerDL AmericanFamilyPhysician2006 73 11 1971 76 67M右髂外动脉狭窄右股浅动脉闭塞 67M右髂外动脉狭窄 支架植入右股浅动脉闭塞 手术搭桥 71M右髂总动脉狭窄 支架植入右股浅动脉狭窄 支架植入左髂外动脉闭塞 手术搭桥 治疗方法仍无定论 八仙过海 短 10cm 的闭塞行病变 手术搭桥其他病变 因人而异 年轻 生存期长 手术搭桥 年长 生存期短 介入治疗 SFA病变 谢谢