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小球囊血管扩张成形术——重症肢体缺血的现代治疗策略
当肢体供血动脉出现严重狭窄或闭塞而危及患者肢体的生存或生命时被称之为重症肢体缺血(criticaIlimb ischemia,CLI).CLI是下肢动脉硬化症为严重的临床表现,具有较高的致残率和死亡率.CLI的病理生理基础是:组织的氧合状态处于非常危急的水平,即便在静息时,其组织细胞的重要功能也不能得到保证.此时患者通常表现为严重的静息痛、足趾溃疡和坏疽,生活质量很低,因此迫切需要通过血管再生法将血液直接灌输到肢体内.
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心脏静脉球囊扩张后植入左心室电极导线疗效观察一例
患者女性,43岁,反复胸闷、心悸、下肢凹陷性水肿2年人院.心电图示:QRS时限140 ms,完全左束支阻滞.超声心动图示:扩张性心肌病,双平面法测左心室射血分数(LVEF)为0.12,左心室舒张末内径(LVEDD)84 mm.
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Objective Restenosis after balloon angioplasty resuits from abnormal proliferation of phenotypically modulated vascular smooth muscle cells (SMCs) that migrate and synthesize large amounts of extracellular matrix. A vafety of growth factors have been shown to play a role in the development of restenotic lesions including transforming growth factor-β (TGF-β).
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Objective To undertake animal experimentation and clinical study on the safety and efficacy of percutaneous transluminal angioplasty (PTA) and intraarterial papaverine (IAP) infusion for treatment of refractory symptomatic cerebral vasospasm (CVS). Methods In the experimental study, vasospasm was induced in rabbits by double injections of blood into the cisterna magna, IAP infusion was given on either the 4th day or the 7th day after occurrence of subarachnoid hemorrhage (SAH), and then neurological observation, angiography, light and electron microscopy were done. In the clinical study, since September 1996, 22 patients with refractory symptomatic CVS involving 50 vascular territories received dilation therapy by PTA and IAP within 24 hours of clinical neurological deterioration. Results In the experimental study, all the rabbits except two in the 'the 4th day' group showed angiographic dilation in all of the spastic basilar arteries, and neurological improvement; in the ' the 7th day' group angiographic dilation appeared in 4 (57. 1% ) out of 7 rabbits. After 24 hours, 1 rabbit in each group had recurrence of neurological deficits and angiographic constriction. In the clinical study after aneurysm clipping or endovascular coil embolization was done, within 72 hours of SAH all patients underwent endovascular treatment: PTA alone in 3 cases, IAP alone in 14 cases, PTA and IAP in the remaining 5 cases. All vessel segments were dilated satisfactorily after endovascular treatment. Clinical improvement was significant in 13 cases,moderate in 7, minimal or none in 2; 2 cases died on the 7th day after endovascular dilation treatment. Conclusion Endovascular dilating techniques, namely, PTA, IAP and a combination of PTA and IAP, are safe and effective for treatment of symptomatic CVS refractory to medical therapy.
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冠状动脉造影在采用新器械进行PTCA时的意义和界限
选择性冠状动脉造影自1959年Sones等报道以来,作为缺血性心脏病诊断的金标准正普及.进而,Grüntzig在1977年应用此法成功地进行了经皮冠状动脉成形术(percutaneous transluminal coronary angioplasty,PTCA).目前似乎做为缺血性心脏病冠状动脉再建术的一种方法已被确立.但是,尽管采用此种球囊的PTCA(plain old balloon angioplasty,POBA)方法简便,损伤性小,但仍残留再狭窄冠状动脉夹层,而致急性冠状动脉闭塞,高度钙化的硬性狭窄病变手术成功率低的问题.
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缺血性心脏病
1977年Gruntzig(德)开始用球囊进行经皮冠状动脉腔内成形术(plain old balloon angioplasty,POBA),继而缺血性心脏病的经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)迅速在全世界广泛开展.适应证的扩大,也带来了治疗中不尽人意之处,其中大的问题是必须克服再狭窄.1990年代开发了许多器械及方法,如冠脉内旋切术、旋磨术.1994年BENESTENT、STRESS等大规模临床试验报告了裸金属支架(bare metal stent,BMS)比POBA后再狭窄发生率呈有意义的减少.但是又出现了新问题,即支架内再狭窄.抑制支架内新生内膜增生,预防再狭窄的药物洗脱支架(DES)的问世,使PCI获得划时代的进步.2004年8月日本通过了适用保险并很快积累了使用经验.本文就1年来在日本应用DES等治疗冠心病方面的进展作一概述.
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Stenting reduces acute complications and restenosis compared to balloon angioplasty and other devices. However, in- stent restenosis (ISR) is an important clinical problem. The current serial intravascular ultrasound (IVUS)analysis was undertaken to determine whether the acute results obtained during the treatment of ISR influence the long term results and whether this is true for patients treated with and without adjunct brachytherapy.
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局部放射治疗预防再狭窄
经皮腔内冠状动脉成形术(PTCA)是近20年冠心病治疗的重要进展之一,目前,全球每年约100万人接受PTCA治疗,但是,其术后再狭窄问题至今仍未得到很好地解决.新近再狭窄机制的研究认为[1],再狭窄的形成与创伤愈合过程非常相似,也就是说,新生内膜增殖(瘢痕形成),和继而发生的慢性期重塑(瘢痕收缩)是再狭窄的两大原因.近年,局部放射疗法作为新的再狭窄预防办法而引起关注.