下肢动脉硬化闭塞症支架植入术后再狭窄治疗方法的对比研究
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摘要
目的观察下肢动脉硬化闭塞症(ASO)支架植入术后再狭窄的各种治疗方法的疗效,讨论支架后再狭窄的预防和治疗。方法纳入2014年6月至2017年5月在南京鼓楼医院治疗ASO支架植入术后再狭窄闭塞的患者77例(107条肢体),分为开放手术20条,复合手术12条,血管腔内成形术56条,基因药物治疗3条,截肢16条。术后再狭窄闭塞发生的时间为术后0.5~48个月,平均12.27个月。结果术后随访69例,随访率88.23%。随访时间3~24个月,平均12.2个月。随访期间出现支架内再狭窄39例,发生率为56.52%,术后3、6个月各组治疗效果比较差异无统计学意义(P>0.05)。术后12个月,各组治疗效果有区别,差异有统计学意义(P=0.049)。术后24个月,各组治疗效果有显著区别,其中外科手术旁路术组的再狭窄率最低(15.00%),单纯球囊扩张组的再狭窄率最高(78.57%)。结论临床治疗中应根据每个再狭窄患者的具体情况定制个体化治疗方案,尽量避免过多支架植入。必要时应配合开放手术,术后予以正规药物治疗。
Objective To observe the efficacy of various treatment methods of restenosis after stent implantation for arteriosclerosis obliterans( ASO) of lower extremities, and to discuss the prevention and treatment of restenosis after stent implantation. Method A total of 77 patients(107 limbs) with restenosis after lower limb artery stent implantation in Drum Tower Hospital of Nanjing from June 2014 to May 2017 were divided into open surgery(20 cases), hybridization(12 cases), intravascular 56 cases of angioplasty,3 cases of gene therapy, amputation in 16 cases. The duration of postoperative restenosis occlusion was 0.5-48 months postoperatively with an average of 12.27 months. Results 69 patients were followed up, the follow-up rate was 88.23%. Follow-up time of 3 to 24 months, an average of 12.2 months. There were 39 cases of stent restenosis during follow-up, the incidence rate was 56.52%. There was no significant difference between the two groups at 3 months and 6 months after operation(P >0.05). After 12 months,there was a difference between the groups in the treatment effect, the difference was statistically significant(P =0.049). At 24 months after operation, there was a significant difference between the two groups. The restenosis rate was the lowest in surgical bypass surgery group(15.00%) and the highest in restenosis group(78.57%) in balloon-only group. Conclusions In clinical treatment, individualized treatment plans should be tailored to the specific circumstances of each patient. In the treatment of primary disease, we must also be careful treatment of repeated endovascular treatment. Try to avoid excessive stent implantation. When necessary, should be accompanied by open surgery, postoperative formal drug treatment.
Objective To observe the efficacy of various treatment methods of restenosis after stent implantation for arteriosclerosis obliterans( ASO) of lower extremities, and to discuss the prevention and treatment of restenosis after stent implantation. Method A total of 77 patients(107 limbs) with restenosis after lower limb artery stent implantation in Drum Tower Hospital of Nanjing from June 2014 to May 2017 were divided into open surgery(20 cases), hybridization(12 cases), intravascular 56 cases of angioplasty,3 cases of gene therapy, amputation in 16 cases. The duration of postoperative restenosis occlusion was 0.5-48 months postoperatively with an average of 12.27 months. Results 69 patients were followed up, the follow-up rate was 88.23%. Follow-up time of 3 to 24 months, an average of 12.2 months. There were 39 cases of stent restenosis during follow-up, the incidence rate was 56.52%. There was no significant difference between the two groups at 3 months and 6 months after operation(P >0.05). After 12 months,there was a difference between the groups in the treatment effect, the difference was statistically significant(P =0.049). At 24 months after operation, there was a significant difference between the two groups. The restenosis rate was the lowest in surgical bypass surgery group(15.00%) and the highest in restenosis group(78.57%) in balloon-only group. Conclusions In clinical treatment, individualized treatment plans should be tailored to the specific circumstances of each patient. In the treatment of primary disease, we must also be careful treatment of repeated endovascular treatment. Try to avoid excessive stent implantation. When necessary, should be accompanied by open surgery, postoperative formal drug treatment.
引文
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[9]Liistro F,Angioli P,Porto I,et al.Paclitaxel-eluting balloon vs.standard angioplasty to reduce recurrent restenosis in diabetic patients with in-stent restenosis of the superficial femoral and proximal popliteal arteries:the DEBATE-ISRstudy[J].J Endovasc Ther,2014,21:1-8.
[10]Shammas NW,Shammas GA,Helou TJ,et al.Safety and oneyear revascularization outcomes of Silverhawk atherectomy in treating in-stent restenosis of femoropopliteal arteries:a retrospective review from a single center[J].Cardiovasc Revasc Med,2013,6:S29-S30.
[11]Werner M,Scheinert D,Henn M,et al.Endovascular brachytherapy using liquid Beta-emitting rhenium-188 for the treatment of long-segment femoropopliteal in-stent stenosis[J].J Endovasc Ther,2012,19:467-475.
[12]Trentmann J,Charalambous N,Djawanscher M,et al.Safety and efficacy of directional atherectomy for the treatment of instent restenosis of the femoropopliteal artery[J].J Cardiovasc Surg(Torino),2010,51:551-560.
[13]谷涌泉.下肢动脉硬化闭塞症腔内治疗的新进展[J].中国普通外科杂志,2014,23:719-723.
[14]Virga V,Stabile E,Biamino G,et al.Drug-eluting balloons for the treatment of the superficial femoral artery in-stent restenosis:2-year follow-up[J].JACC Cardiovasc Interv,2014,7:411-415.
[15]袁时芳,崔风强,陈江浩.药物涂层球囊治疗下肢动脉缺血病变的应用现状[J/CD].中国血管外科杂志(电子版),2017,9:84-86.
[16]Francesco L,Simone G,Italo P,et al.Drug-eluting balloon in peripheral intervention for the superficial femoral artery:the DEBATE-SFA randomized trial(drug eluting balloon in peripheral intervention for the superficial femoral artery)[J].JACC Cardiovasc Interv,2013,6:1295-1302.
[17]Erbel R,Di Mario C,Bartunek J,et al.Temporary scaffolding of coronary arteries with bioabsorbable magnesium stents:a prospective,non-randomised multicentre trial[J].Lancet,2007,369:1869-1875.
[2]Schillinger M,Sabeti S,Loewe C,et al.Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery[J].N Engl J Med,2006,354:1879-1888.
[3]包俊敏.下肢动脉闭塞腔内治疗策略的新思考[J/CD].中国血管外科杂志(电子版),2017,9:81-83.
[4]史作磊,王坤,于振海.下肢动脉硬化闭塞症手术或介入治疗后血管再狭窄的影响因子[J/CD].中国血管外科杂志(电子版),2014,6:183-185.
[5]Inoue T,Croce K,Morooka T,et al.Vascular inflammation and repair:implications for re-endothelialization,restenosis,and stent thrombosis[J].JACC Cardiovasc Interv,2011,4:1057-1066.
[6]Maffia P,Grassia G,Meglio PD,et al.Neutralization of interleukin-18 inhibits neointimal formation in a rat model of vascular injury[J].Circulation,2006,114:430-437.
[7]Gibbons GH,Dzau VJ.The emerging concept of vascular remodeling[J].N Engl J Med,1994,330:1431-1438.
[8]Bosiers M,Deloose K,Callaert J,et al.Superiority of stentgrafts for in-stent restenosis in the superficial femoral artery:twelve-month results from a multicenter randomized trial[J].JEndovasc Ther,2015,22:1-10.
[9]Liistro F,Angioli P,Porto I,et al.Paclitaxel-eluting balloon vs.standard angioplasty to reduce recurrent restenosis in diabetic patients with in-stent restenosis of the superficial femoral and proximal popliteal arteries:the DEBATE-ISRstudy[J].J Endovasc Ther,2014,21:1-8.
[10]Shammas NW,Shammas GA,Helou TJ,et al.Safety and oneyear revascularization outcomes of Silverhawk atherectomy in treating in-stent restenosis of femoropopliteal arteries:a retrospective review from a single center[J].Cardiovasc Revasc Med,2013,6:S29-S30.
[11]Werner M,Scheinert D,Henn M,et al.Endovascular brachytherapy using liquid Beta-emitting rhenium-188 for the treatment of long-segment femoropopliteal in-stent stenosis[J].J Endovasc Ther,2012,19:467-475.
[12]Trentmann J,Charalambous N,Djawanscher M,et al.Safety and efficacy of directional atherectomy for the treatment of instent restenosis of the femoropopliteal artery[J].J Cardiovasc Surg(Torino),2010,51:551-560.
[13]谷涌泉.下肢动脉硬化闭塞症腔内治疗的新进展[J].中国普通外科杂志,2014,23:719-723.
[14]Virga V,Stabile E,Biamino G,et al.Drug-eluting balloons for the treatment of the superficial femoral artery in-stent restenosis:2-year follow-up[J].JACC Cardiovasc Interv,2014,7:411-415.
[15]袁时芳,崔风强,陈江浩.药物涂层球囊治疗下肢动脉缺血病变的应用现状[J/CD].中国血管外科杂志(电子版),2017,9:84-86.
[16]Francesco L,Simone G,Italo P,et al.Drug-eluting balloon in peripheral intervention for the superficial femoral artery:the DEBATE-SFA randomized trial(drug eluting balloon in peripheral intervention for the superficial femoral artery)[J].JACC Cardiovasc Interv,2013,6:1295-1302.
[17]Erbel R,Di Mario C,Bartunek J,et al.Temporary scaffolding of coronary arteries with bioabsorbable magnesium stents:a prospective,non-randomised multicentre trial[J].Lancet,2007,369:1869-1875.