血管成形術(shù)及支架植入術(shù)

1、血管成形術(shù),第一節(jié) 血管成形術(shù)基本概念,一、PTA的定義 二、PTA的發(fā)展簡(jiǎn)史 三、PTA的治療機(jī)制 四、PTA的適應(yīng)癥和禁忌癥 五、PTA的并發(fā)癥及其預(yù)防 六、PTA后再狹窄的機(jī)制 七、支架成形術(shù),第一節(jié) 血管成形術(shù)基本概念,Clinical Manifestayions of Vascular Pathology Manife

2、station Example Obstruction to flow forward Arterial and venous stenoses Increased flow forward Arteriovenous fistula, m

3、alformation Increased flow backward Varicose veins due to reflux through incompetent venous valves Los

4、s of vessel wall integrity Aneurysm, dissection, bleeding These can occur alone or in any combination.,第一節(jié) 血管成形術(shù)基本概念,Atherosclerosis is an arterial disease that is prevalent in industrialized nations. Veins do not

5、 develop atherosclerotic lesions unless they are exposed to arterial pressures and flow over extended periods of time.The risk factors for atherosclerosis include environmental and genetic factors. There are multiple t

6、heories of causation, including intimal trauma, an autoimmune response,and infection. Whatever the underlying pathogenesis, the key point to remember is that atherosclerosis is a systemic disease, affecting arteries in a

7、ll vascular beds.,第一節(jié) 血管成形術(shù)基本概念,Risk Factor for Atherosclerosis Genetic predispositionSmoking DietDiabetesChronic renal failureHypertensionHomocysteinuriaAdvanced ageHyperlipidemiaObesity

8、 Elevated lipoprotein (a) Atheromatous plaque. Eccentric atheroma,第一節(jié) 血管成形術(shù)基本概念,第一節(jié) 血管成形術(shù)基本概念,Angiographic appearance of concentric stenosis of the left common iliac artery,Angiographic app

9、earance of bulky, eccentric plaque in the SFA,第一節(jié) 血管成形術(shù)基本概念,Hypertrophied collateral arteries around a short chronic occlusion of the distal superficial femoral artery (SFA),. DSA showing an abrupt cutoff of flow with a

10、filling defect (arrow) consistent with thrombus. There is a paucity of collateral vessels and lack of reconstitution of distal vessels.,第一節(jié) 血管成形術(shù)基本概念,Intimal hyperplasia is not a true disease or disorder,but a biolog

11、ic response to injury to the vessel wall.Causes of Intimal Hyperplasia Cause Examples Injury Surgical anastomosis, clamps, angioplasty

12、 denudation of intima by any device Foreign body Stents, suture material, catheters Abnormal flow Arterialization of veins, turbulence,Fibromuscular Dysplasia Vasculitis(Takayasu's arteritis)Oth

13、er factors,irregular beaded appearance (arrow) and location of the abnormality in the distal main renal artery,DSA arch aortogram showing occlusion of the left CCA (arrow) at the origin, long stenosis of the right CCA (a

14、rrowhead), and stenosis of the right subclavian artery origin,Takayasu's arteritis,第一節(jié) 血管成形術(shù)基本概念,一、PTA的定義 經(jīng)皮經(jīng)腔血管成形術(shù)（Percutaneous Transluminal Angioplasty,PTA）：采用導(dǎo)管擴(kuò)張技術(shù)使狹窄或閉塞的血管開(kāi)通。,第一節(jié) 血管成形術(shù)基本概念,二、PTA的發(fā)展

15、簡(jiǎn)史 1964年，Dotter 和Judkins 采用同軸同導(dǎo)治療動(dòng)脈粥樣硬化。開(kāi)創(chuàng)了介入放射新紀(jì)元——同軸導(dǎo)管(Coaxial Catheter )血管成形術(shù),The first percutaneous angioplasty, 1964. A, Focal stenosis in the popliteal artery (arrow). B, Using progressively large coa

16、xial catheters, the lesion was dilated. The patient's rest pain resolved and toe ulcers healed .C, Coaxial catheter.,c,,Pre-PTA Post-PTA,第一節(jié) 血管成形術(shù)基本概念,二、PTA的發(fā)展簡(jiǎn)史 1、原理：粗大導(dǎo)管通過(guò)狹窄血管時(shí)產(chǎn)生外向性壓力，使血管腔擴(kuò)大。 2

17、、缺點(diǎn)：入路部位血管的損傷大，應(yīng)用范圍小。,第一節(jié) 血管成形術(shù)基本概念,二、PTA的發(fā)展簡(jiǎn)史 1974年，Grüntzig發(fā)明了雙腔帶囊導(dǎo)管—球囊血管成形術(shù) (Balloon Angioplasty) 。1978年球囊材料進(jìn)行了改進(jìn)。,PTA-Balloon(percutaneous transluminal angioplasty),第一節(jié) 血管成形術(shù)基本概念,二、PTA的

18、發(fā)展簡(jiǎn)史 1978年Grüntzig報(bào)導(dǎo)了PTA用于腎性高血壓的治療，同時(shí)進(jìn)行了4例冠脈PTA實(shí)驗(yàn)。,第一節(jié) 血管成形術(shù)基本概念,二、PTA的發(fā)展簡(jiǎn)史1984年Inoue 進(jìn)行了二尖瓣球囊擴(kuò)張術(shù) (PTMA)的臨床應(yīng)用研究。,第一節(jié) 血管成形術(shù)基本概念,三、PTA的機(jī)制 ——控制損傷性理論1、控制：控制球囊的直徑2、損傷：血管壁的機(jī)械性損傷，膨脹的球囊使血管的

19、內(nèi)膜和中膜局限性撕裂，血管壁成分，特別是中膜的過(guò)度伸展以及動(dòng)脈硬化斑塊的斷裂。,Schematic of the mechanism of angioplasty. A, Concentric stenosis with a small residual lumen. B, An appropriately sized angioplasty balloon is inflated (arrows) in the lumen. C,

20、Fracturing, fissuring, and subintimal dissection of the plaque greatly increase the cross-sectional area of the lumen.,The primary mechanism of balloon angioplasty is controlled fracture of the obstructing plaque. This r

21、esults in formation of fissures in the plaque itselt, and tearing of the edges of the plaque away from the adjacent normal intima. With proper oversizing of the balloon, the muscular media is stretched as well. Plaque is

22、 not remodeled, redistributed, or vaporized by the balloon.,Distal embolization of microscopic and, occasionally, macroscopic debris does occur, but is usually asymptomatic. Visualization of "cracks" or small d

23、issections in lesions following angioplasty is a normal finding at angiography. Over time these areas may remodel and the lumen resume a more normal appearance.,Normal angiographic appearance of an artery following angi

24、oplasty. A, Diseased segment of superficial femoral artery. B, After angioplasty with a 5-mm balloon, there is fissuring (arrows) of the plaque. This is a normal postangioplasty appearance and requires no further interve

25、ntion unless it is flow-limiting.,A B,第一節(jié) 血管成形術(shù)基本概念,四、PTA適應(yīng)證（Indications) 1、動(dòng)脈粥樣硬化2、大動(dòng)脈炎3、血管搭橋術(shù)（bypass) 后的吻合口狹窄4、人造血管狹窄5、血管肌發(fā)育不良6、靜脈血管狹窄或閉塞,第一節(jié) 血管成形術(shù)基本概念,五、PTA禁忌證(Contraindication)

26、 1. 碘過(guò)敏（可用CO2造影）。 2.嚴(yán)重心律紊亂，心功能不全。 3.肝、腎功能不全，或凝血機(jī)制異常 4.有動(dòng)脈瘤形成 5.大動(dòng)脈炎活動(dòng)期。,第一節(jié) 血管成形術(shù)基本概念,六、術(shù)后并發(fā)癥及預(yù)防 1、常規(guī)血管介入治療并發(fā)癥 2 、遠(yuǎn)端栓塞 3、球囊破裂 4、出血

27、 5、動(dòng)脈夾層,balloon rupture,vessel rupture,第一節(jié) 血管成形術(shù)基本概念,七、PTA后再狹窄機(jī)制 1、急性再狹窄 2、早期再狹窄 3、晚期再狹窄,第一節(jié) 血管成形術(shù)基本概念,七、PTA后再狹窄機(jī)制 1、急性再狹窄：PTA后立即或不久產(chǎn) 生的血管狹窄或閉塞。 原因：①

28、、血管痙攣 ②、血管壁的彈性回縮 ③、血管壁剝離，夾層形成,第一節(jié) 血管成形術(shù)基本概念,七、PTA后再狹窄機(jī)制 2、早期再狹窄：PTA后1-2個(gè)月至1年內(nèi) 發(fā)生的再狹窄，是最常見(jiàn)的再狹窄類(lèi)型； 主要原因： ①、PTA后血管壁損傷處的內(nèi)皮細(xì)

29、 胞的過(guò)度增生。 ②、病變血管壁的彈性回縮。,第一節(jié) 血管成形術(shù)基本概念,七、PTA后再狹窄機(jī)制 3、晚期再狹窄：PTA后1年以上發(fā)生 的再狹窄 原因： ①、PTA后血管壁損傷處的內(nèi)皮 細(xì)胞的過(guò)度增生。 ②、原有病變的加重或發(fā)展。,第

30、一節(jié) 血管成形術(shù)基本概念,七、PTA后再狹窄機(jī)制 4、再狹窄的預(yù)防 ①、藥物：抗凝、抗血小板聚集。 ②、改進(jìn)方法：減少血管損傷。 ③、 stent 置入。,第二節(jié) 支架成形術(shù)基本概念,一、支架成形術(shù)（Stent Angioplasty） 血管內(nèi)支架（Endovascular Stent，ES） 是預(yù)防PTA后再狹窄的重要的手段，已廣

31、泛應(yīng)用于臨床， 是介入放射學(xué)發(fā)展史上一個(gè)新的里程碑(milestone)。二、stent的含義及來(lái)源 stent:支撐器，通常指金屬支架?！皊tent”一詞來(lái)源一位口腔科醫(yī)生“charles stent”的名字。為紀(jì)念發(fā)明的一種支撐皮膚移植物的裝置，將這種支撐器稱(chēng)為stent。,第二節(jié) 支架成形術(shù)基本概念,金屬支架：現(xiàn)在通常所說(shuō)的支架多為（stent），是一種用于支撐管道的器材，釋放后對(duì)管壁有永久的支撐力。 內(nèi)涵

32、管：臨床上實(shí)際運(yùn)用的尚有一種塑料支架，為了區(qū)別起見(jiàn)，將其稱(chēng)為內(nèi)涵管。 支架移植物（stent-graft):在支架上覆蓋特種塑料的薄膜，對(duì)已擴(kuò)張的瘤腔起隔絕作用。,第二節(jié) 支架成形術(shù)基本概念,三、支架發(fā)展簡(jiǎn)史1964年血管成形術(shù)支付Dotter及Jukins預(yù)言血管內(nèi)支撐物可以成形內(nèi)膜化1969年成功地在豬的腘動(dòng)脈進(jìn)行了動(dòng)物實(shí)驗(yàn)1982年發(fā)明了不銹鋼絲編織支架Wallstent1983年Dotter、Cragg報(bào)道了鎳鈦

33、記憶合金的支架動(dòng)物實(shí)驗(yàn)結(jié)果以后，各種支架開(kāi)始不斷出現(xiàn)1985年P(guān)almaz報(bào)道了球囊擴(kuò)張式支架，Wright報(bào)道了不銹鋼“z”型自膨式支架1987-1989年，Sigwart、Rousseau、Strecker、Robkin等相繼報(bào)道了一些新的支架,第二節(jié) 支架成形術(shù)基本概念,四、支架分類(lèi)1、按膨脹方式分為： 自膨式支架（self-expandable stent) 球囊膨脹式支架

34、 （balloon-expandable stent),第二節(jié) 支架成形術(shù)基本概念,四、支架分類(lèi) 2、按支架結(jié)構(gòu)分為： 編織焊接支架：國(guó)產(chǎn)支架、wallstent、 symphony 激光切割支架：smart、zilver、palmaz、

35、 saxx-stent、lumingnexx 螺旋狀支架：IntraCoil、EndoCoil,,第二節(jié) 支架成形術(shù)基本概念,四、支架分類(lèi) 3、按支架表面情況分為： 裸支架(Bare stent) 覆膜支架（Covered stent),第二節(jié) 支架成形術(shù)基本概念,五、支架 置入步驟,,,第二節(jié) 支架成形術(shù)基本概念,Stents pro

36、vide an intravascular scaffold for the vessel lumen. The mechanism of action of stents is very different from angioplasty, as the plaque and vessel wall are literally pushed aside by the stent to enlarge the lumen,Schema

37、tic of the mechanism of angioplasty. A, Concentric stenosis with a small residual lumen. B, An appropriately sized angioplasty balloon is inflated (arrows) in the lumen. C, Fracturing, fissuring, and subintimal dissecti

38、on of the plaque greatly increase the cross-sectional area of the lumen.,The primary mechanism of balloon angioplasty is controlled fracture of the obstructing plaque. This results in formation of fissures in the plaque

39、itselt, and tearing of the edges of the plaque away from the adjacent normal intima. With proper oversizing of the balloon, the muscular media is stretched as well. Plaque is not remodeled, redistributed, or vaporized by

40、 the balloon.,第二節(jié) 支架成形術(shù)基本概念,六、適應(yīng)癥 1、PTA術(shù)后并發(fā)癥或療效不佳者 2、狹窄性病變累及主動(dòng)脈壁或粥樣硬化明顯者 3、頸部及顱內(nèi)具有血流動(dòng)力學(xué)意義的狹窄 4、腔靜脈和較大靜脈分支的狹窄或閉塞 5、重建血管通道 6、支架移植物用于動(dòng)脈瘤及主動(dòng)脈夾層的治療 7、其他,Indications for stent p

41、lacement ArterialRecanalization of chronic occlusionOcclusive or flow-limiting dissection following angioplastyElastic or recurrent stenosisLesion suspected as source of distal emboliInflow lesion prior to distal s

42、urgical bypass procedureOstial lesion (especially renal artery)Thoracic aortic coarctation/pulmonary artery stenosis (pediatric)VenousRecanalization of chronic occlusionExtrinsic compression by malignancyElastic, f

43、ibrotic, or recurrent stenosisOtherBridging mouth of aneurysm prior to coil placementReinforce stent-graft,第二節(jié) 支架成形術(shù)基本概念,七、禁忌癥1、嚴(yán)重的心肺腎功能不全2、大動(dòng)脈炎活動(dòng)期3、肢體廣泛的動(dòng)脈病變4、生長(zhǎng)發(fā)育未成熟者5、其他,第二節(jié) 支架成形術(shù)基本概念,八、并發(fā)癥與預(yù)防1、支架移位或血管壁破裂2、血