Lipsitz Evan C, Ohki Takao, Veith Frank J, Suggs William D, Wain Reese A, Cynamon Jacob, Mehta Manish, Cayne Neal, Gargiulo Nicholas
Division of Vascular Surgery, Department of Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, NY 10467, USA.
J Vasc Surg. 2003 Feb;37(2):386-91. doi: 10.1067/mva.2003.20.
Subintimal angioplasty (SIA) has been advocated to treat long segment lower extremity arterial occlusions, but many question its value. We evaluated the role of SIA in a group of patients with severe lower extremity arterial occlusive disease.
During a 2.5-year period, 39 patients with arterial occlusions (median length, 8 cm; range, 2 to 31 cm) were treated on an intention-to-treat basis with SIA. Twenty-five patients had gangrene, five had rest pain, and nine had disabling (<one block) claudication. There were 24 superficial femoral, two superficial-femoral-popliteal, four popliteal, two popliteal-tibial, five tibial, and two external iliac artery lesions. With fluoroscopic guidance, via a prograde common femoral artery puncture (n = 29) or a contralateral common femoral artery puncture (n = 9), a subintimal dissection plane was created across the occlusion with a standard guidewire and catheter. The arterial lumen was reentered distal to the occlusion, and the recanalized segment balloon was dilated. All patients were followed prospectively with arterial duplex scan.
SIA was technically successful in 34 of 39 patients (87%). All five failures were from an inability to reenter the patent lumen distally. These five patients underwent successful bypasses that in no case were more distal than would have been required before SIA. In the 34 technically successful SIAs, pain completely resolved (14/14) and areas of gangrene (21/25) healed. The cumulative patency rate in patients who underwent successful SIA was 74% +/- 10% at 12 months. The mean increase in ankle-brachial index after SIA was 0.34 (range, 0.1 to 0.69). There were two distal embolic events, successfully treated surgically (n = 1) or with catheter-directed techniques (n = 1). Three patients underwent subsequent bypass, and the remaining five patients remain asymptomatic.
SIA is feasible and can be effective in some patients with lower extremity arterial occlusions and threatened limbs. These results, plus SIA's many advantages, support an increasing role for it in the treatment of lower extremity arterial occlusive disease.
有人主张采用内膜下血管成形术（SIA）治疗长段下肢动脉闭塞，但许多人质疑其价值。我们评估了SIA在一组严重下肢动脉闭塞性疾病患者中的作用。
在2.5年的时间里，对39例动脉闭塞患者（中位长度8cm；范围2至31cm）按意向性治疗原则采用SIA进行治疗。25例患者有坏疽，5例有静息痛，9例有致残性（<一个节段）间歇性跛行。有24例股浅动脉、2例股浅-腘动脉、4例腘动脉、2例腘-胫动脉、5例胫动脉和2例髂外动脉病变。在透视引导下，通过顺行股总动脉穿刺（n = 29）或对侧股总动脉穿刺（n = 9），用标准导丝和导管在闭塞处创建一个内膜下剥离平面。在闭塞远端重新进入动脉腔，并对再通段进行球囊扩张。所有患者均接受前瞻性动脉双功扫描随访。
39例患者中有34例（87%）SIA技术成功。所有5例失败均是由于无法在远端重新进入通畅的管腔。这5例患者均成功进行了旁路手术，且在任何情况下都不比SIA前所需的更远端。在34例技术成功的SIA中，疼痛完全缓解（14/14），坏疽区域（21/25）愈合。成功接受SIA的患者12个月时的累积通畅率为74%±10%。SIA后踝肱指数平均增加0.34（范围0.1至0.69）。发生了2例远端栓塞事件，分别通过手术（n = 1）或导管导向技术（n = 1）成功治疗。3例患者随后接受了旁路手术，其余5例患者仍无症状。
SIA是可行的，对一些下肢动脉闭塞且肢体受到威胁的患者可能有效。这些结果，加上SIA的诸多优点，支持其在下肢动脉闭塞性疾病治疗中发挥越来越大的作用。
