下肢动脉硬化判断及处理-.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,下肢动脉硬化判断及处理,张磊,动脉粥样硬化示意图,下,肢,动,脉,硬化,闭塞症的血管腔内成形术治,疗,外,科,手术,Bypass graft,搭桥,Amputation,截,肢,Endarterectomy,手术切除,腔内介入治疗,PTA,球囊,扩,张,Stenting,支架术,Atherectomy,切,除,Cutting balloon and drug coated balloon,切割球囊及药物球囊,“Endovascular-first approach is the current standard of care for,symptomatic infrainguinal atherosclerotic disease”,腔内,介,入是,目,前,下,肢,动,脉粥样,硬,化闭塞症的,首,选,治,疗方,法,Inter-Society Consensus for the Management of Peripheral Arterial Disease(TASC II,)JEVT Aug 3,2015,Time to POBA,Charles Dotter（1920-1985）,1964,年第一个阐述血管成形术被称为“介入放射学之父”，并获,1978,年诺贝尔医学奖提名。,Andreas Gruentzig,（,1939-1985,）,1974,年提出并发明了经皮,球囊,血管成形术，并于,1977,年,9,月完成了人类首例经皮冠状动脉成形术,J Vasc Surg 1997;25:74-83,1,Circ Cardiovasc Interv 2010;3:267-276 19:1-9.,2,Circ Cardiovasc Interv 2011;4:495-504.,3,Circulation,.2013;127:25352541 22:22-27.,4,N Engl J Med 2006;354:1879-1888,5,Cath Cardiovasc Interv 2009;74:1090-1095,45%,逆行跨越,SFA,病变,SFA,应用,PTA,球囊扩张及扩张后造影,But,支架断裂，支架内再狭窄,目前难以处理的病变,In-Stent Restenosis,支架内再狭窄,处理手段少，再狭窄率高,Critical Limb Ischemia,重症下肢缺血症,多血管，多层次的复杂病变，较多出现远端小血管狭窄,Chronic Total Occlusion,慢性完全闭塞性病变,带有高密度纤维帽，导丝难以通过,斑块特征,海绵状快速生长内膜层，弹性强,过度钙化的斑块,发生率,股腘动脉支架术后一年内再狭窄率为,40%,In-Stent Restenosis,支架内再狭,窄,常规球囊或切割球囊术效果不理想,6,个月再狭窄率,73%,1,重,新处理后,2,年内再狭窄率,65%,3,内膜钙化和中膜钙化;但二者常常混有,内膜钙化:常见,与动脉粥样硬化强相关,偏心性,中膜钙化:同心性,可能是特发的,与糖尿病和肾功能不足相关,钙化病变需要更高的球囊压,1,2,钙化斑块发生夹层的几率更大,3,Makam.J Invasive Cardiol.2013;25(2):85-8.,Fitzgerald,et al.Circulation.1992;86(1):64-70.,Demer.Circulation.1991;83:2083-2093.,钙化病变需要更高的球囊扩张压,钙化存在于外周血管疾病中,1,4050%的外周CTO病变有严重的钙化,2,钙化的CTO病变,以下并发症机会更高:,技术成功率低;夹层;穿孔;远端栓塞;扩张不足;支架回缩,Bishop,et al.Ann Vasc Surg.2008;22:799-805.,Bolia A et al,Cardiovasc Interv Radiol 1990;13:357-363,钙化影响DCB的药物吸收,钙化是药物获得最佳吸收的障碍,Fanelli,F.,Cannavale,A.,Gazzetti,M.,Lucatelli,P.,Wlderk,A.,Cirelli,C.,et al.(2014).Calcium Burden Assessment and Impact on Drug-Eluting Balloons in Peripheral Arterial Disease.,Cardiovascular and Interventional Radiology,37,(4),898907.doi.org/10.1007/s00270-014-0904-3,钙化的临床分型,PACSS,Calcium Burden Assessment,Compliance 360,drei,zwei,ein,PACSS,Rocha-Singh,2014,年提出,评判因素:,单侧/双侧;,涉及内膜/中膜;,长度5cm),Rocha-Singh,K.J.,Zeller,T.,&Jaff,M.R.(2014).Peripheral arterial calcification:Prevalence,mechanism,detection,and clinical implications.,Catheterization and Cardiovascular Interventions,83,(6),E212E220.doi.org/10.1002/ccd.25387,Calcium Burden Assessment,F.Fanelli,2014年文献,评判因素:,四个象限,长度(3cm),Fanelli,F.,Cannavale,A.,Gazzetti,M.,Lucatelli,P.,Wlderk,A.,Cirelli,C.,et al.(2014).Calcium Burden Assessment and Impact on Drug-Eluting Balloons in Peripheral Arterial Disease.,Cardiovascular and Interventional Radiology,37,(4),898907.doi.org/10.1007/s00270-014-0904-3,Compliance 360,Raymond Dattilo,2014,年文献,评判因素:,单侧/双侧;,累及病变段长度;,Dattilo,Himmelstein,Cuff,Complance 360 degress trial,J Invasive Cardiol 2014,临床分型的不足,血管钙化不一定与血管病变相关联,分型适合临床研究,不适合临床实际工作,需要更加严密设计的研究来完善钙化标准,Nein,不知道,XXXXXX,钙化的腔内处理(国际),Atherectomy(斑块去除术),Lithoplasty(震荡波碎石成形术),Laser,（准分子激光腔内消蚀）,Stent(支架术),谢谢！,