中国糖尿病下肢缺血外科治疗的进展

Progress in surgical treatment of lower limb ischemia in diabetes in China

糖尿病是我国常见病之一。约有15%~25%的糖尿病患者会发生糖尿病足,严重者会导致截肢。糖尿病下肢缺血是糖尿病足发生的最主要原因,通过手术处理重建血流是糖尿病下肢缺血的重要治疗手段。下肢动脉旁路移植术是治疗糖尿病下肢缺血的经典开放术式,随着腔内治疗的发展其应用逐渐减少,但对于某些特定患者仍是可靠的治疗选择。腔内治疗已是糖尿病下肢缺血的一线手术治疗方法,球囊扩张成形术是其中的基本方法,目前通常作为血管准备的手段。动脉腔内减容术是血管准备的另一种重要方式。针对不同场景,多种减容方法可通过去除动脉内的斑块、血栓、增生内膜等物质,减少动脉内负荷。药物涂层球囊可在血管准备后将紫杉醇等药物输送到靶血管处以抑制内膜增生,提高远期通畅率。除球囊外,支架的应用对于糖尿病下肢缺血的腔内治疗尤为重要,但国内目前尚无被批准应用于膝下血管的支架。除手术治疗外,自体骨髓干细胞移植、基因治疗等血管新生疗法应用于糖尿病下肢缺血也在不断地探索中。

Diabetes is one of the common diseases in China.About 15%to 25%of people with diabetes develop diabetic foot,which in severe cases can lead to amputation.Diabetic lower limb ischemia is the main cause of diabetic foot,and reconstruction of blood flow through surgery is an important treatment method for diabetic lower limb ischemia.Lower extremity arterial bypass graft is a classic open surgery for the treatment of diabetic lower limb ischemia.Although the application of arterial bypass graft has gradually decreased,it is still a reliable treatment option for some specific patients.Endovascular therapy has been the first-line surgical treatment for diabetic lower extremity ischemia,of which balloon angioplasty is the basic method and is now commonly used as an approach of vascular preparation.Debulking atherectomy is another important way for vascular preparation.For different scenarios,different debulking devices can reduce the arterial load by removing plaque,thrombus,and hyperplastic intima in the artery.The drug-coated balloon can deliver drugs such as paclitaxel to the target vessel after vessel preparation to inhibit intimal hyperplasia and improve long-term patency rate.In addition to the balloon,the application of stents is particularly important for the endovascular treatment of diabetic lower limb ischemia.However,no stents have been approved for the application of subpatellar vessels in China.In addition to surgical treatment,autologous bone marrow stem cell transplantation,gene therapy and other angiogenesis therapies for diabetic lower limb ischemia are also being explored.