摘要
糖尿病是一种常见疾病,随着医疗水平的提高及经济的发展,糖尿病的发病率逐年上升,患者带病生存的年限延长,其下肢血管并发症出现的机会增加,尽管现已有多种方法治疗糖尿病足,但对严重者仍需截肢手术。目前已有多种方法确定截肢平面,但其可靠性及安全性各有优劣。近年来随着CTA技术的发展,下肢动脉显影被广泛应用于临床,由于其结果的直观性对临床治疗方案的确定有一定价值,被广大临床医生所接受,但根据CTA结果确定截肢平面是否安全可靠仍需进一步研究。
目的
总结严重糖尿病足的临床特点,分析对比CTA相比于其他检测手段对确定截肢平面的优势和如何利用CTA确定糖尿病足的合适、安全的截肢平面。
材料与方法
回顾性总结160例严重糖尿病足病人全面身体检查及相关辅助检查结果,根据术前确定截肢平面检查方法分组归类,总结其方法的优劣性。A组44例患者根据多普勒超声结果于动脉完全闭塞平面以近5cm以上进行截肢；B组30例患者遵照患者家属意见进行截肢；C组40例患者根据数字减影血管造影(DSA)评分标准进行截肢；D组46例患者根据CT动脉造影结果参照DSA评分标准进行评分,按照对应的评分标准确定截肢平面。术后所有病例常规抗生素抗炎,引流,控制血糖稳定及换药等治疗,观察切口愈合情况。
结果
本组糖尿病足患者平均年龄为(65.35±7.18)岁,平均血压(145±23)/(80±12)mmHg,BMI(24.8±1.5)kg/m2,吸烟患者占40.5%,有饮酒史占25.5%。糖尿病患者最常见的并发症为周围神经病变、冠心病、下肢血管病变、高血压等,糖尿病足高发年龄71～80岁,平均病程7～11年,糖尿病足溃疡发生的主要诱因为外伤；研究资料中wagner分级3～4级患者居多,足溃疡好发于足趾。A组44例患者切口甲级愈合率为24.8%,乙级愈合率为45.2%,再截肢率为30%；B组30例患者切口甲级愈合率为10%,乙级愈合率为20%,再截肢率为70%；C组40例患者切口甲级愈合率为70%,乙级愈合率为20%,再截肢率为13.3%；D组46例患者切口甲级愈合率为65%,乙级愈合率为21.7%,再截肢率为13.3%,经x2检验,A组与B组、C组、D组有显著性差异(P<0.05),B组与C组、D组有显著性差异(P<0.05),C组与D组无显著性差异(P>0.05)。
结论
CTA可以帮助确定糖尿病足的截肢平面,准确程度优于多普勒超声及医生经验,与DSA造影具有高度一致性。
Diabetes is a common disease.With healthcare and economic development, the incidence of diabetic patients is increasing every year, the patients'life extension, it induce the opportunities of lower limb vascular complications increase. even though now there are a variety of method to treat diabetic foot, but still severe cases need amputation. With the development of CTA technology, lower limb cta is widely used clinically, the majority of clinicians accept this method for it's direct results, but whether the amputation level determined by CTA results are safe and effective requires further study.
Objective
To investigate the clinical features of severe diabetic foot, and analysis of the advantages of contrast CTA compared to traditional testing methods and how to use the CTA to determine the appropriate and safe amputation.
Materials and methods
160patients with severe diabetic foot do comprehensive physical examination and related auxiliary check. When the glycemic controled, group A contained44patients amputate according the Doppler ultrasound findings, Group B,30patients were combined with the views of the family members of patients and doctors'experience to amputate, group C40patients according to digital subtraction angiography (DSA) score to amputate, and group D46patients, according CT angiography and clinical signs score to amputate, after operation,give treatment of conventional antibiotics, anti-inflammatory, drainage, control of blood sugar stable and change dressing, wound healing was observed.
Results
The average age of hospital diabetic foot patients is (65.35±7.18) years, the average blood pressure is (145±23)/(80±12) mmHg, The average BMI is (24.8±1.5) kg/m2, smokers accounted for40.5%,the patients with the history of alcohol consumption accounted for25.5%. Peripheral neuropathy, coronary heart disease, lower extremity vascular disease are the most common complication in diabetic patients.71to80years old have a high incidence of diabetic foot, the average course is7to11years.A major cause of diabetic foot ulcer is trauma; research data in wagner classification3to4patients are the majority,the foot ulcers more often in the toe.Group A of40patients with incision Grade A healing rate is24.8%, grade B healing rate is45.2%, the re-amputation rate is30%; Group B of30patients with incision Grade A healing rate is10%, grade B healing rate is20%, the re-amputation rate is70%; Group C of46patients with incision Grade A healing rate is65%, grade B healing rate is 20%, the re-amputation rate is10%; Group D of46patients with incision Grade A healing rate is65%, grade B healing rate is21.7%, the re-amputation rate is13.3%.By the x2test, group A and group B, group C, group D have significant differences (P<0.05), group B and group C group D have significant difference (P<0.05), group C and group D have no significant difference (P>0.05).
Conclusions
CTA can help determine diabetic foot amputation level, and is superior to Doppler ultrasound and doctors experience,similar to DSA.
引文
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[2]Dorrestejin JA,Kriegsman DM,Assendeift WJ,Valk GD.Patient education for perventing diabetic foot ulceration.Cochrane Database system rev.2010,129
[3]谷涌泉,糖尿病足诊疗新进展,北京,人民卫生出版社,2006,44
[4]Andrew B.The diabetic foot.epeidemiology、risk factors and the status of care.Diabetes voice,2005,50,5-7
[5]丁红.彩色多普勒超声对下肢动脉疾病闭塞性疾病的诊断价值[J].中国医学影像技术,1999,15：483.
[6]常宝成,2010版美国糖尿病协会糖尿病诊疗标准修订内容解读,国际内分泌代谢杂志,2010.9.30,第5期
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[18]Gulliford MC. Controlling non-insulin-dependent diabetes mellitus in developing countries [J]. Int J epidemiol,1995,24(suppl):53.
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[21]Miraude E,Marc C,etal.Peropheral Disease:Therapeutic Confidence of CT versus Digital Subtraction Angiography and Effects on additional Imaging Recommendations[J].Radiology 2004;233:385-391
[22]张林.MSCTA诊断下肢动脉闭塞性疾病的临床应用研究山东泰山医学院,2005
[23]Martin MI,Tag KH,Flak B,et al.Multidetector CT angiography of the aortoiliac system and lower extremities:a prospective com-parison with digital subtraction angiography[J].AJR,2003,180(4):1085-1091.
[24]Jorgensen HR, Pedersen NW, Oxhoj H, et al. Selection of amputation level in ischemia.Skin blood flow arid perfusion pressure equally predictive.ActaOrthop Scand 1990k61(1):62-5
[25]Poredos P, Rakovec S, Guzic- Salobir B. Determination of amputation level in ischaemic limbs using tcPO2 measurement. Vasa 2005k34(2):108-12
[26]Misuri A, Lucertini G, Nanni A, et al. Predictive value of transcutaneous oximetry for selection of the amputation level.J Cardiovasc Surg (Torino) 2000;41(1):83-7
[27]Wutschert R, Bounameaux H. Determination of amputation level in ischemic limbs. Reappraisal of the measurement of TcPo2.Diabetes Care 1997k20(8):1315-8
[28]张龙江,包颜明,杨亚英.多层螺旋CT血管成像[M].昆明：云南科技出版社,2004,12.
[29]谷涌泉.血管性截肢平面术前预测的初步研究[J].外科理论与实践,2001,5：298-30
[30]Gu YQ.Determination of amputation level in ischaemic lower limbs.ANZ J Surg 2004k74(1-2):31-3
[31]de Lima MA,Cabrine-Santos M,Tavares MG,et al.Interstitial cells of Cajal in chagasic megaesophagus [J]. Ann Diagn Pathol,2008,12(4):271-274.
[32]Der T,Bercik P,Donnelly G,et al.Interstitial cells of cajal and inflammation-induced motor dysfunction in the mouse small intestine[J]. Gastroentrol,2000, 119(6):1590-1599.
[33]Gherghiceanu M, Hinescu ME, Andrei F, et al. Interstitial Cajal-like cells (ICLC) in myocardial sleeves of human pulmonary veins[J]. J Cell Mol Med,2008,12 (5A):1777-1781.
[34]Morel E, Meyronet D, Thivolet-Bejuy F, et al. Identification and distribution of interstitial Cajal cells in human pulmonary veins[J].Heart Rhythm,2008,5(7): 1063-1067.
[35]张磊,糖尿病下肢病变的磁共振相关造影诊断[J].内分泌分册,2004,24(5)：312-314.
[36]Frykberg RGAn evidence -based approach to diabetic foot infections[J].Am J surg,2003,186(5A):44S-54S
