仰卧体位下经腘动脉逆行入路治疗股浅动脉慢性完全闭塞

Chronic Total Occlusion Recanalization of Superficial Femoral Artery Performed with Popliteal Retrograde Approach in the Supine Position

目的:评估股浅动脉(superficial femoral artery,SFA)慢性完全闭塞(chronic total occlusion,CTO)顺行开通失败后,在仰卧体位下行腘动脉逆行入路的可行性和有效性。方法:2011年5月—2012年10月21例SFA出现CTO病变的患者,在仰卧体位下接受经腘动脉逆行入路开通手术,SFA平均病变长度(87.4±5.8)mm,21例患者术前均表现为间歇性跛行,7例患者有静息痛,3例患者有足趾缺血性溃疡。患者均先行经对侧股总动脉穿刺入路,当顺行开通失败后采用经腘动脉逆行开通,在路径图或X线的引导下行腘动脉穿刺,一旦导丝逆行通过闭塞段进入真腔以后,再顺行置入球囊预扩、释放支架、后扩。结果:21例患者均在仰卧体位下通过路径图或结合X线成功穿刺腘动脉,成功率为100%,无穿刺点出血、血肿、假性动脉瘤、动静脉瘘、夹层等并发症。临床症状明显改善。7例术前存在静息痛患者术后缓解,术后1个月及6个月随访均未再出现静息痛症状。3例足部溃疡患者2例术后1个月内愈合,1例术后2个月内完全愈合。21例间歇性跛行患者术后1个月及6个月随访均未再出现间歇性跛行症状,3例患者于术后12个月再次出现间歇性跛行,造影证实支架内存在不同程度的再狭窄,随后予以球囊扩张,症状得到缓解。结论:患者仰卧体位下经腘动脉逆行开通治疗股浅动脉慢性完全闭塞病变可行且安全有效,尤其对于自股浅动脉起始端就完全闭塞、闭塞段位于股浅动脉中远段或者有较大的侧枝从股浅动脉闭塞段发出的病变,一旦顺行入路失败,经腘动脉逆行入路可作为首选的下一步治疗方案。

Objective：To evaluate the feasibility and effectiveness of popliteal retrograde approach in the supine position after failure of femoral antegrade approach in the treatment of chronic total occlusion （CTO） of superficial femoral artery （SFA）. Methods：From May 2011 to Oct 2012,21 patients with CTO of SFA were recanalized through popliteal retrograde approach in the supine position. All of the 21 patients suffered from intermittent claudication;7 patients had rest pain; and 3 patients had ischemic ulceration on toes. SFA average occlusion length was （87.4 ± 5.8） mm. At first, the contralateral common femoral ar- tery was punctured with antegrade approach. After the femoral antegrade approach failed, the popliteal retrograde approach was tried. The popliteal artery was then punctured using a 21-G needle under fluoroscopic guidance with a roadmap technique with the patient in supine position. Once SFA was recanalized with the guide wire entering into the true lumen through the retrograde popliteal access,angioplasty and stenting could be performed through the femoral approach. Results： Technical success rate of recanalization performed with popliteal retrograde approach in the supine position achieved 100 %. Hematomas, pseudoaneu- rysm or arteriovenous fistulas was not found in the popliteal puncture site. Clinical symptoms were relieved obviously. Rest pain of the 7 patients were relieved after the procedure and didn＇t reoccur during 1 and 6 month follow-up. In 3 patients with ulcera- tion on toes,2 patients were healed within 1 month after the procedure and 1 patient was healed within 2 months after the proce- dure. In 21 patients, intermittent claudieation did not reoccur during 1 and 6 month follow-up, but 3 patients suffered from in- termittent elaudication again at 12 months after the procedure, and instent restenosis with various degrees were confirmed by angiography and symptoms were relieved by following balloon angioplasty. Conclusions： Recanalization through popliteal retro- grade approach in the supine position is feasible, safe and effective, especially when occlusion starts at the beginning of SFA or occlusion locates at the middle and distal part of the SFA or there are larger collateral arteries arising from the occlusion. Once antegrade approach fails,popliteal retrograde approach maybe the further preferred strategy.