袁良喜：下肢动脉硬化闭塞症诊治指南解读——间歇性跛行的治疗

2015-10-12 MedSci MedSci原创

在2015年国际腔内血管学大会上，来自长海医院血管外科的袁良喜博士为我们解读了下肢动脉硬化闭塞症诊治指南中关于间歇性跛行的治疗。间歇性跛行的治疗流程保守治疗（控制危险因素、运动治疗、药物治疗3-6个月），效果良好则随访；疗效不佳，影像学可见病变，要考虑是否适合腔内治疗，若不适合则行传统外科手术治疗。间歇性跛行的运动和康复治疗运动治疗必须在专业指导下进

在2015年国际腔内血管学大会上，来自长海医院血管外科的袁良喜博士为我们解读了下肢动脉硬化闭塞症诊治指南中关于间歇性跛行的治疗。

间歇性跛行的治疗流程

保守治疗（控制危险因素、运动治疗、药物治疗3-6个月），效果良好则随访；疗效不佳，影像学可见病变，要考虑是否适合腔内治疗，若不适合则行传统外科手术治疗。

间歇性跛行的运动和康复治疗

运动治疗必须在专业指导下进行，每此步行30-45min,每周至少3次，至少持续12周。

推荐的运动方式有行走、伸踝和屈膝运动。

与无指导的运动相比，有指导的运动治疗更好地改善PAD患者的最大步行距离。

国外指南推荐药物治疗3-6个月

TASC第2版PAD管理指南指出：3-6个月疗程的药物治疗可以减轻跛行症状，有证据显示可改善运动功能和生活质量。

2011ESC PAD诊断和治疗指南指出：间歇性跛行的管理中，保守治疗（控制危险因素，运动训练，药物治疗3-6个月）

间歇性跛行的药物治疗

前列腺素类药物

分为静脉和口服剂型，前者如前列腺素E1(前列地尔)等，后者如贝前列素钠及伊洛前列素等

药理作用是扩张血管和抗动脉粥样硬化（保护血管内皮、抗内膜增生、抗血小板）

可提高患者ABI，改善由下肢缺血引发的间歇性跛行，静息痛以及溃疡等症状。

西洛他唑

是一种强效磷酸二酯酶III抑制剂

具有抗血小板活性和舒张血管特性

沙格雷酯

5-HT2受体选择拮抗药

选择性地拮抗5-HT2与HT2受体的结合，抑制血小板聚集和血管收缩。

应根据患者的自身情况个体化选择合理的血运重建方式，包括腔内治疗，手术治疗和血运重建后的抗血小板和抗凝治疗。

腔内治疗

可用于运动或药物治疗效果不佳

许多中心选择腔内治疗作为首选的血运重建方法

腔内治疗并发症发生率和死亡率均较低

治疗失败还可以改用开放手术治疗

治疗下肢ASO的血管腔内技术：1.经皮球囊扩张成形术（PTA） 2.支架置入 3.斑块切除术 3.切割球囊 4.药物球囊 5.冷冻球囊 6.药物溶栓治疗或血栓吸除

轻、中度间歇性跛行患者在运动和药物治疗的基础上，接受PTA可带来额外获益

接受有指导的运动治疗和药物治疗的轻、中度间歇性跛行患者，随机分配至两个多中心研究中，93例分配至股腘的研究，其中48例患者在上述治疗的基础上接受PTA，比较PTA和非PTA的绝对步行距离（AWD）;分配至髂的研究，其中19例患者在上述治疗的基础上接受PTA，比较PTA和非PTA的跛行距离（ICD）。

结果显示与非PTA相比，PTA的AWD增加了38%（P=0.04）；ICD增加了785(P=0.05)。

主-髂动脉病变

主-髂动脉TASCA~C级病变推荐首选腔内治疗。当TASC D级病变合并严重的内科疾病或存在其他手术禁忌时也可以选择腔内治疗，但应在有经验的中心完成。

当球囊扩张效果不满意时（如跨病变压力差持续存在、残余狭窄>50%或发生影响血流的夹层）应植入支架。

股-腘动脉病变

股-腘动脉TASCA~C级病变推荐首选腔内治疗。当TASC D级病变合并严重的内科疾病或存在其他手术禁忌时也可以选择腔内治疗，但应在有经验的中心完成。

对于股-腘动脉病变，球囊扩张成形术是最常用的腔内治疗方法：支架植入可作为球囊扩张效果不满意或失败后（如压力差持续存在、残余狭窄大于50%或发生影响血流的夹层）的补救治疗方法。

在治疗股-腘动脉病变时，药物涂层球囊较普通球囊具有更高的近期通畅率。

开放手术治疗

手术适应症

1.严重间歇性跛行影响患者生活质量，经保守治疗效果不佳

2.影像学评估流入道和流出道解剖条件适合手术

3.全身情况能够耐受

小于50岁患者的动脉粥样硬化病变的进展性更强，导致疗效不持久，这类患者间歇性跛行的手术治疗效果不明确，手术干预要相当谨慎。手术应在有经验的医疗中心进行。

手术方式

可以通过解剖旁路或解剖外旁路来重建病变部位血供

当需要通过手术重建主髂动脉血运时一般选用人工合成材料，需要重建腹股沟韧带以下肢体血运时，可以采用自体静脉或人工合成材料

对于复杂的多节病变，也可采用复合手术（手术联合腔内治疗）的方法分别改善流入道和流出道

手术后随访

影响手术通畅率的主要因素

影响手术早期（<30天内）通畅率的主要因素包括被开通血管近端和远端的血管情况、围手术期的抗凝措施和医生的手术技术操作等。

影响远期（>90天）通畅率的主要因素包括内膜增生再狭窄以及动脉硬化病变的进展等。

定期随访

记录跛行症状好转情况

病变近端、移植物和远端血管的脉搏情况

多普勒超声检查整个移植物并记录收缩期速度峰值

计算跨病变部位的速度比

测量ABI

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2019-01-20 1321f36813m

非常好！感谢感谢！

121 0
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2016-01-23 仁医06

#间歇性#

69 0
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2015-11-10 minzju5062

#下肢动脉硬化闭塞症#

95 0
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2015-12-31 swallow

#下肢动脉#

70 0
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2016-01-28 zhixianchen

#动脉硬化闭塞症#

76 0
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2015-10-19 sunlong28

赞一个~

169 0
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2015-10-19 sunlong28

非常感谢~

156 0
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2015-10-19 sunlong28

感谢分享

173 0
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2015-10-19 sunlong28

为了积分我也是拼了~

168 0
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likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97277, encryptionId=60649e277d4, topicName=间歇性跛行)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=28c414125928, createdName=lifestar, createdTime=Wed Oct 14 07:07:00 CST 2015, time=2015-10-14, status=1, ipAttribution=)]
2015-10-14 lifestar

#间歇性跛行#

100 0

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袁良喜：下肢动脉硬化闭塞症诊治指南解读——间歇性跛行的治疗

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