经足背-足底或足底-足背动脉环逆行腔内成形术治疗糖尿病踝下动脉闭塞性病变的临床研究

Retrograde transdorsal-to-plantar or transplantar-to-dorsal intraluminal re-entry treatment following unsuccessful subintimal angioplasty for below-the-ankle arterial occlusion

目的评价经足背-足底(transdorsal-to-plantar,TDP)或经足底-足背(transplantar-to-dorsal,TPD)动脉环逆行腔内成形技术,治疗踝下动脉闭塞性病变的可行性和疗效。方法 8例踝下闭塞性病变患者共8条患肢,行传统腔内成形技术失败后接受TDP或者TPD逆行腔内成形技术治疗。所有患者临床症状,足背或者足底动脉搏动评分和踝-臂指数(ABI)术前术后均行比较。随访内容包括疼痛缓解,伤口愈合,肢体挽救及靶血管的再狭窄。结果经TDP或者TPD逆行腔内成形技术在8例患者中的5例(62.5%)获得成功。足部疼痛明显改善,动脉搏动评分和ABI指数从术前的0.60±0.55和0.32±0.20分别上升至术后的2.40±0.55和0.75±0.12(P<0.01)。12个月随访结束时,视觉疼痛评分从术前的7.40±1.14改善至2.20±1.48(P=0.002)。2例难愈性溃疡患者术后1例完全愈合,1例明显缩小。所有手术成功患者均未接受截肢。随访磁共振血管成像(MRA)显示1条靶血管再狭窄。结论经TDP和TPD动脉环逆行腔内成形技术治疗常规腔内成形术失败的糖尿病足部缺血患者是可行和有效的。

Objective To assess the technical feasibility and efficacy of transdorsal-to-plantar（TDP）or transplantar-to-dorsal（TPD）intraluminal re-entry procedure following unsuccessful subintimal angioplasty for the treatment of arterial occlusion below the ankle.Methods TDP or TPD retrograde intraluminal re-entry angioplasty was carried out in 8 diseased limbs of 8 diabetic patients（5 males and 3 females,aged 62 ～ 81 years with a mean age of 75 ± 8 years）,who were accompanied with chronic below-the-ankle arterial occlusive disease,after the standard transtibial subintimal angioplasty had failed.Both before and after the procedure the clinical symptoms,dorsal or plantar arterial pulse volume scores and ankle-brachial indexes（ABI）were determined in all patients,the results were compared and statistically analysed.During the follow-up period,the degree of pain relief,the healing of the wound,the salvage of the diseased limb and the restenosis occurrence of the target vessels were evaluated.Results Of the total 8 patients,TDP or TPD retrograde intraluminal re-entry angioplasty was successfully performed in 5（62.5%）.After the treatment the foot pain was markedly relieved,the median pulse volume scores and ankle-brachial indexes were increased from 0.60 ± 0.55 and 0.32 ± 0.20 before the procedure to 2.40 ± 0.55 and 0.75 ± 0.12 after the procedure,respectively（P 0.01 for both）.At the end of the follow-up lasting for twelve months,the visual analogue scale was apparently improved,the scores decreased from preoperative 7.40 ± 1.14 to 2.20 ± 1.48（P = 0.002）.Of two cases with intractable skin ulcer,the skin lesion was completely healed in one and was significantly decreased in size in another.No amputation surgery was needed in all successfully treated patients.Magnetic resonance angiography revealed that one target vessel developed re-stenosis.Conclusion TDP and TPD retrograde intraluminal re-entry techniques are clinically feasible and effective for the treatment of foot ischemia in diabetic patients when standard below-the-ankle angioplasty has failed.