主髂动脉闭塞的外科手术和腔内治疗

脉重度狭窄的近远期疗效.中华外科杂志,2001,39(7):5142 516

14　Moore WS,K empczinski RF,Nelson JJ,et al.Recurrent carotid stenosis:results of the asymptomatic carotid atherosclerosis study.

Stroke,1998,29(10):201822025

15　Sundt TM,Whisnant J P,Houser OW,et al.Prospective study of the effectiveness and durability of carotid endarterectomy.Mayo Clin Proc,1990,65(5):6252635

16　Moore WS,Barnett H J,Beebe HG,et al.Guidelines for carotid en2 darterectomy.A multidisciplinary consensus statement from the Ad Hoc Committee,American Heart Association.Circulation, 1995,91(2):5662579

17　符伟国,韩伟,王玉琦,等.转流管在颈动脉内膜切除术中的应用(附11例报告).外科理论与实践,2004,9(1):24226

18　Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angio2 plasty Study(CAVATAS):a randomised ncet,2001,357 (9270):172921737

19　Brooks WH,McClure RR,Jones MR,et al.Carotid angioplasty and stenting versus carotid endarterectomy:randomized trial in a community hospital.J Am Coll Cardiol,2001,38(6):158921595 20　Alberts MJ,McCann R,Smith TP,et al.A randomized trial of carotid stenting vs.endarterectomy in patients with symptomatic carotid stenosis:study design.J Neurovasc Dis,1997,2(2):2282 234

21　Alberts MJ for the Publications Committee of the Wallstent Trial.

Results of a multicenter prospective randomized trial of carotid artery stenting vs carotid endarterectomy(abstr).Stroke,2001, 32(1):325

22　Regarding“Carotid endarterectomy in SAPPHIRE2eligible high2 risk patients:implications for selecting patients for carotid angio2 plasty and stenting”.J Vasc Surg,2004,40(3):5952596

23　Roubin GS,Hobson RW,White R,et al.CREST and CARESS to evaluate carotid stenting:time to get to work!J Endovasc Thera2 py,2001,8(2):1072110

24　Roubin GS,Y adav S,Iyer SS,et al.Carotid stent2supported angio2 plasty:a neurovascular intervention to prevent stroke.Am J Cardiol,1996,78(3A):8212

25　K achel R.Results of balloon angioplasty in the carotid arteries.J Endovasc Surg,1996,3(2):22230

26　Diethrich EB,Ndiaye M,Reid DB,et al.Stenting in the carotid artery:initial experience in110patients.J Endovasc Surg,1996,3

(1):42262

27　Wholey MH,Wholey M,Bergeron P,et al.Current global status of carotid artery stent placement.Catheter Cardiovas Diagn,1998, 44(1):126

28　Wholey MH,Wholey M,Mathias K,et al.G lobal experience in cervical carotid artery stent placement.Catheter Cardiovasc In2 terv,2000,50(2):1602167

29　Veith FJ,Amor M,Ohki T,et al.Current status of carotid bifur2 cation angioplasty and stenting based on a consensus of opinion

leaders.J Vasc Surg,2001,33(suppl2):S1112S116

(2005-01-09收稿)

作者单位:北京协和医院血管外科(100730)

E2mail:liucw@

文章编号:1005-2208(2005)04-0200-03

主髂动脉闭塞的外科手术

和腔内治疗

刘昌伟　管　珩　叶　伟　刘　暴

中图分类号:R6 文献标识码:A

主髂动脉闭塞是指腹主动脉和髂动脉同时存在严重狭窄和(或)闭塞的血管病变,是血管外科常见而严重的疾病之一。临床上主要分为急性和慢性两大类。

1　急性主髂动脉闭塞

急性主髂动脉闭塞主要见于急性主动脉骑跨栓和特发性动脉血栓形成。其特点是发病急骤,病情凶险,可突发双下肢严重缺血、甚至截瘫,病死率很高,可高达30%～50%,主要死亡原因是严重的再灌注损伤、电解质紊乱和酸碱平衡失调、严重而迅速的多器官功能衰竭,临床也称之为肌病肾病代谢综合征(myonephropathic metabolic syndrome, MNMS)[1]。特发性血栓形成常合并有免疫或血液系统疾病(如白塞病、系统性红斑狼疮、抗磷脂综合征、红细胞增多症、高同种半胱氨酸血症等),病人多为年老体弱或有严重的血液高凝状态。

根据突然发病的病史如突发双下肢疼痛、肢体苍白、双下肢无脉、感觉异常、甚至肢体运动功能障碍等急性肢体缺血症状,基本可以诊断急性主髂动脉闭塞。当临床考虑有该病后,应进一步的诊断,主要有4点:(1)是突发的主动脉骑跨栓还是主动脉血栓形成。(2)是在原有的慢性下肢缺血基础上的急性加重还是血栓栓塞。(3)肢体缺血的严重程度,是否已经有肢体坏死。(4)是否伴随有其他内科疾病。临床问诊要全面仔细,根据有无心脏病房颤的病史和有无间歇性跛行病史可以对诊断提供帮助。彩色多普勒超声可以帮助诊断,但是动脉造影并不可取,因为这样的病人肾脏损害的概率较高,动脉造影会加重肾脏损害的发生,而且动脉造影费时,会延误治疗时机。

急性主髂动脉闭塞的治疗主要是救急。急诊手术是唯一有效的治疗方法。手术治疗方法主要是急诊手术取栓,多数病例可以通过及时的取栓手术获得治愈。但是手术中要特别注意的问题是要适量的放出缺血组织内淤积的静脉血。对于缺血严重的应当考虑行血液滤过或行红细胞清洗。急性主髂动脉闭塞的治疗,救急是关键。同时要注意内科伴发病的存在,特别是对于年轻人的急性动脉血栓形