慢性Leriche综合征侧支动脉开放类型的CT分析

CT analysis of different types of collateral arteries in chronic Leriche syndrome

目的分析慢性主髂动脉闭塞(Leriche综合征)的CT表现,总结该病侧支动脉开放类型,提高对慢性Leriche综合征的认识。方法回顾性收集本院2016年1月~2018年9月确诊为慢性Leriche综合征患者36例。36例患者治疗前均行主动脉CTA检查。24例行主动脉-股动脉人工血管旁路移植术和6例行介入治疗(球囊扩张和/或支架成形术);6例行内科治疗。结果36例主髂动脉CTA均表现为腹主动脉-髂总动脉分叉闭塞,根据闭塞近心端(上端)位置分3型:(1)近肾动脉旁型16例;(2)肠系膜下动脉上型8例;(3)肠系膜下动脉下型12例。全部病例闭塞或次全闭塞远心端(下端)达单侧或双侧髂内、外动脉水平。36例慢性Leriche综合征侧支动脉开放类型有5种:(1)A型(Winslow通路,出现率100%,36/36),开放侧支为双侧腹壁上动脉,通过胸廓内动脉与腹壁下动脉吻合,连接于髂外动脉。(2)B型(出现率92%,33/36):开放侧支为双侧下肋间动脉、肋下动脉/腰动脉,通过旋髂深动脉连接髂外动脉或股动脉。(3)C型(出现率50%,18/36):开放侧支为肠系膜上动脉分支(中结肠动脉),通过Riolan弓连接肠系膜下动脉或其分支直肠上动脉。(4)D型(出现率36%,13/36):开放侧支为双侧或单侧肋下动脉,通过髂腰动脉连接髂内动脉。(5)E型(出现率53%,19/36):开放侧支为直肠上动脉,通过骶动脉丛/直肠下动脉连接髂内动脉。A型和B型侧支动脉的开放可提供下腹壁和下肢动脉的血供。C型出现于闭塞近端位于肠系膜下动脉以上的患者,以代偿肠系膜下动脉供血区的血运。D型和E型为少见类型。结论慢性Leriche综合征患者的侧支动脉开放有多种类型,侧支动脉开放与主髂动脉闭塞范围相关。正确识别和描述侧支动脉有助于为临床提供更全面的诊断信息。

Objective To analyze CT manifestations of patients with chronic iliac artery obstruction (Leriche syndrome), and to summarize different types of collateral arteries in chronic Leriche syndrome. Methods 36 patients with chronic Leriche syndrome in our institution from January 2016 to September 2018 were included in this study. Aortic CT angiogram (CTA) was performed on all patients within one week before treatment. Patients underwent external aortofemoral artery bypass grafting (24), percutaneous transarterial balloon dilation and/or stenting (6) or conservative medical treatment (6). Results CTA showed aortic occlusion extending to the bilateral internal or external iliac arteries. According to the proximal end of the occlusion, the patients were categorized as juxta-renal (16), supra-inferior mesenteric (8), or infra-inferior mesenteric (12) occlusion. There were 5 types of collateral arteries including type A Winslow pathway (100%, 36/36) with the bilateral superior abdominal arteries forming collateral pathways to the external iliac arteries via internal thoracic and inferior abdominal arteries. In type B (92%, 33/36), the bilateral inferior intercostal/lumbar arteries formed collateral pathways with external iliac or femoral arteries via the deep circumflex iliac arteries. Type C (50%, 18/36) collateral pathway arose from a middle colon artery branch of superior mesenteric artery to connect with the inferior mesenteric artery or its superior rectal artery branch through Riolan arch. In type D (36%, 13/36), the bilateral or unilateral subcostal artery formed collateral pathways with the internal iliac artery through iliolumbar artery. Type E (53%, 19/36) was superior rectal artery forming collateral pathway with internal iliac artery through the sacral plexus or inferior rectal artery. Type A and B collateral arteries provided blood supply to the lower abdominal wall and lower limb arteries. The type C collateral arteries only appeared in juxta-renal occlusion and supra-inferior mesenteric occlusion providing blood supply to the inferior mesenteric artery. Conclusion There are many types of collateral arteries in patients with chronic Leriche syndrome depending on the extent of the iliac artery occlusion. Identification of collateral arteries can provide more comprehensive diagnostic information.