颈动脉支架植入术(CAS)临床应用逐年增多,术后可能发生心脑血管事件甚至死亡,术后管理尤为重要.该文通过查阅近年来国内外文献并进行整理、分类、比较和分析,就CAS术后低血压控制目标与治疗管理,术后高血压和脑过度灌注综合征(CHS)处理,抗血小板药物、他汀类药物应用管理作一综述.术后密切监测,个体化维持血流动力学稳定,有效的抗血小板药物治疗和他汀类药物治疗是减少并发症发生的手段.

在外周动脉硬化闭塞性病变的治疗中自膨式裸支架已成为必不可少的治疗手段,而自膨式覆膜支架在股腘和主髂动脉病变的使用也获得了较好的效果.然而在某些特殊解剖部位的病变,由于临近动脉分叉和重要的分支血管,常需要支架的精准定位,同时还需要避免血管破裂,球扩式覆膜支架的应用展示其独特优势.本文探讨其在外周动脉硬化闭塞性病变治疗中的初步应用体会.

弥漫性中线胶质瘤是一种具有广泛侵袭性的恶性肿瘤，好发于7～9岁的儿童，偶见于成人。儿童弥漫性中线胶质瘤生长于神经系统的中线结构，其常见的部位包括丘脑、脑干和脊髓，呈弥漫性生长，易出现转移和复发，且预后不良。目前的治疗手段主要为手术切除辅以放射治疗和化疗的综合疗法。

目的 分析锁骨下动脉闭塞复杂型病变的治疗结果,研究锁骨下动脉病变特点与外科治疗策略的关系.方法 统计188例锁骨下动脉近端完全性闭塞患者资料,探讨锁骨下动脉复杂病变特点与治疗成功率关系及右侧病变采取脑保护伞等.结果 患者治疗总成功率为70.75％,左侧成功率为76.36％,右侧成功率为50.0％.12个月的通畅率是98.2％,3年为91.2％,5年为83.8％.病变长度与腔内治疗成功率有关(χ2=4.89,P<0.05).且长段病变(>3 cm)治疗成功率降低(χ2=21.27,P<0.05);病变形态与腔内治疗成功率有关(χ2=11.01,P<0.05),处理右侧闭塞病变应用颈动脉保护伞可防止脑栓塞.结论 闭塞较短、位置及形态较好的病变应首选腔内治疗,而长段及严重钙化的起始部病变,旁路手术优先选择,腔内处理右侧闭塞病变应用颈动脉保护伞预防脑栓塞的方案更安全.

目的 腹主动脉瘤依据其症状表现可分为症状型腹主动脉瘤(symptomatic abdominal aortic aneurysm,sAAA)及非症状型腹主动脉瘤(asymptomatic abdominal aortic aneurysm,aAAA),该研究旨在探究两者形态学数据的差异性及相关性.方法 将首都医科大学宣武医院血管外科2013年1月至2019年1月被诊断为肾下型腹主动脉瘤的107例病人纳入研究,以是否有相关的背部和(或)腹部疼痛分为症状型(27例)及非症状型(80例)两组,依据CT血管造影(CTA)的相关数据,分析比较两组间主要的形态学指标(瘤体的最大直径,瘤颈,瘤颈的角度等)的差异及相关性.结果 sAAA组的瘤体最大直径大于aAAA组,差异有统计学意义[(5.40±1.58)cm比(4.73±1.02)cm,P=0.047],瘤颈长度[(2.87±1.27)cm比(2.76±1.43)cm,P=0.711]及瘤颈角度(48.06° ±36.06°比36.66° ±21.65°,P=0.131),两组之间差异无统计学意义,偏心性动脉瘤在sAAA组的比例相对较高,且差异具有统计学意义(51.9％ 比30.0％,P=0.04).瘤颈长度与瘤体最大直径存在负相关关系(rs=-0.36,P<0.01),瘤颈角度与瘤体最大直径之间存在正相关关系(rs=0.258,P=0.007).结论 在sAAA与aAAA的瘤体最大直径 、瘤颈长度 、瘤颈角度的几何学变量中,瘤体最大直径差异具有统计学意义,sAAA组中偏心性动脉瘤的比例相对较高,为临床上积极处理sAAA提供了支持.瘤颈长度与瘤体最大直径存在负相关关系,而瘤颈角度与瘤体最大直径存在正相关的关系,腹主动脉瘤形态学变量之间也是彼此联系,相互影响的,但不能单以瘤体最大直径来预测腹主动脉瘤破裂风险,还应从血流动力学的角度以及病理生理学的角度去分析,这样会使预测及判定更加科学.

近年来随着心血管疾病患者不断增多,人工血管在临床上的需求不断增长.人工聚合材料聚ε?己内酯[poly(ε?caprolactone),PCL]因具有生物可降解性、良好的力学性能而成为了组织工程血管材料研究的热点.但是单一PCL血管存在疏水性强、细胞黏附亲和力差等缺陷,限制了PCL材料在组织工程领域的应用.为了增强PCL材料的生物相容性,研究者们应用了各种方法对PCL材料进行表面改性或共混成复合物.本文从PCL的表面改性、复合物等方面对其研究现状进行综述.通过表面改性后的PCL及其复合物具有较好的生物相容性,提高了材料的细胞黏附和组织生长性能,这为进一步构建理想小口径人工血管提供了一定的参考.

目的 探讨术中脑保护下加压冲洗技术对颈动脉支架成形术(carotid artery stenting,CAS)术中及术后脑卒中发生的影响.方法 回顾性分析2016年6月至2018年6月于首都医科大学宣武医院血管外科行CAS治疗的202例颈动脉狭窄患者资料,按照患者术中是否进行加压冲洗分为加压冲洗组(90 例)和对照组(112 例),分析CAS 术后脑卒中发生的高危因素以及术中加压冲洗对脑卒中发生的影响.结果 患者均顺利完成CAS,术后加压冲洗组发生脑卒中2例(2.2％),对照组发生脑卒中6例(5.4％),但差异无统计学意义(P>0.05).对术后脑卒中进行COX回归分析提示,陈旧性脑梗死病史是术后脑卒中发生的独立危险因素(P=0.004),而加压冲洗是其保护因素(P=0.029).结论 CAS术中脑保护下加压冲洗可以降低术后脑卒中的发生,但还需要进一步的研究提供更充分的证据.

目前对于锁骨下动脉支架再狭窄缺乏有效的治疗手段.减容联合药涂球囊在下肢动脉支架再狭窄的腔内治疗中得到广泛应用,并取得了较为满意的疗效[1].本研究应用激光消蚀联合药涂球囊治疗左侧锁骨下动脉支架重度狭窄1例,现报道如下. 临床资料 患者女,59岁.主因眩晕1个月入院.既往5年前因左侧锁骨下动脉重度狭窄行左侧锁骨下动脉支架(8～40 mm,美敦力)植入术,术后规律抗血小板、降脂治疗;2年前复查发现左侧锁骨下动脉支架闭塞行普通球囊(6～80 mm,Invatec)成形术,术后规律抗血小板、降脂治疗.入院前1个月因上肢乏力,行CTA及血管超声(图1)检查,发现左侧锁骨下动脉支架重度狭窄.入院诊断左侧锁骨下动脉支架再狭窄,左侧椎动脉闭塞,多发腔隙性脑梗死.患者无高血压、高血脂、糖尿病,无吸烟史.

目的 应用双导丝球囊扩张联合紫杉醇灌注治疗股动脉支架再狭窄的可行性.方法 利用双导丝球囊扩张联合紫杉醇灌注技术治疗1例股腘动脉支架长段闭塞病例.手术顺利,无手术并发症.结果 患者术中未出现夹层及血栓,术后下肢缺血症状改善.动脉造影提示原支架闭塞段血流恢复通畅.结论 该技术治疗下肢动脉支架再狭窄安全可行,需要更多治疗例数和远期随访结果观察.

Objective To explore the feasibility and safety of endovascular directional atherectomy angioplasty for the treatment of severe vertebral artery stenosis.Methods Directional atherectomy combined with use of drug-coating balloon (DCB) was employed to treat one patient with severe stenosis of vertebral artery in November 2017 at authors' hospital.Protective umbrella filter was placed at the distal site of V1 segment during the procedure course.Results The operation was successfully accomplished.No postoperative complications occurred.After the operation,the clinical symptom of dizziness disappeared and the patient was well recovered.Conclusion For the treatment of severe vertebral artery stenosis,directional atherectomy combined with use of DCB is safe and feasible.

Objective To analyze the clinical characteristics of liver injury related to edaravone in treating patients with acute ischemic stroke (AIS). Methods Among the AIS patients treated with edaravone in Vascular Surgery ICU of Xuanwu Hospital Capital Medical University from January 2014 to October 2017,9 patients were diagnosed as having liver injury associated with edaravone by active monitoring. The total number of patients treated with edaravone at the same period in Vascular Surgery ICU were obtained from the hospital information system and the incidence of liver injury associated with edaravone was calculated. The clinical data of the 9 patients were collected and analyzed retrospectively. Results The incidence of liver injury associated with edaravone was 8.7% (9/103 ). The 9 patients included 6 males and 3 females. The age of the patients was 52-83 years and their average age was (65 ± 6)years. The time for the occurrence of liver injury was 3-9 days and the average time was (6 ± 2)days. The main manifestations of liver injury were increase of alanine aminotransferase (9 cases),aspartic aminotransferase (7 cases),alkaline phosphatase (4 cases),total bilirubin (2 cases),and accompanied by rash in 1 case. Using RUCAM scale,7 patients were classified as ＂highly probable＂ and 2 patients were classified as＂probable＂. Using ＂Grade of DILI severity＂＂ standard,all the 9 patients were diagnosed as ＂mild liver injury＂. After 4-13 days of edaravone withdrawal,8 patients had normal liver function and 1 case improved. Conclusions Edaravone might cause liver injury,mainly manifesting liver dysfunction. The degree of liver injury was mild,and the prognosis was good after timely intervention.

目的 建立两肾一夹型肾血管性高血压大鼠模型,并讨论彩色多普勒超声对其的应用价值.方法 15只SD大鼠,使用钛合金血管夹制作两肾一夹型肾血管性高血压大鼠模型.造模术前、术后分别使用Vevo 2100超声仪检测大鼠腹主动脉以及肾动脉狭窄处及远端,观察彩色血流显像并记录血流流速参数及波形,并测量尾动脉收缩压变化.结果 肾动脉狭窄处收缩期峰值流速由(383.79±53.20)mm/s上升至(1061.80±170.42)mm/s(t=-16.764,P<0.001);肾动脉远端收缩期峰值流速由(400.10±26.70)mm/s下降至(226.51±22.49)mm/s(t=42.457,P<0.001);肾主动脉比值由1.00±0.13上升至2.80±0.29(t=-23.632,P<0.001);尾动脉收缩压由(117±10)mm Hg上升至(150±9)mm Hg(t=-15.515,P<0.001),成功建立高血压模型.结论 高频彩色多普勒超声可清楚显示大鼠肾动脉流速变化,可做为相关实验研究的首选检查方法.

Objective To evaluated the safety and feasibility of excimer laser atherectomy (ELA) combined with drug-eluting balloon angioplasty in treating chronic ischemia of lower limbs.Methods ELA combined with paclitaxel-eluting balloon angioplasty was adopted to treat chronic ischemia of lower limbs caused by arteriosclerosis occlusive disease of lower extremity in three patients.All three patients had arteriosclerosis occlusive disease of superficial femoral artery;in two of them the disease was primary occlusive lesion and in another patient the disease was in-stent re-occlusion lesion after sten implantation.Results After the treatment,the blood flow in the diseased arteries was unobstructed,the blood supply of the lower limbs was obviously improved.No procedure-related complications occurred.Two weeks after the treatment,no recurrence of ischemic symptoms was observed,the blood flow in superficial femoral artery kept unobstructed.The patients recovered smoothly.Conclusion For the treatment of chronic ischemia of lower limbs,which are caused by the primary arteriosclerosis occlusive disease of lower extremity or by the in-stent re-occlusion lesion after sten implantation,ELA combined with paclitaxel-eluting balloon angioplasty is clinically safe and feasible,although its long-term effect needs to be clarified with more studies.

Objective:To investigate the efficacy of endovascular atherectomy in treatment of femoropopliteal artery stenosis with outflow obstruction.Methods:From July 2014 to June 2015,21 patients who had femoropopliteal artery stenosis with distal outflow tract obstruction and severe intermittent claudication as the main symptom underwent endovascular atherectomy,and then they were followed up.Results:Compared with preoperative findings,the daudication distances of the patients at 3,6 and 12 months after operation were all significantly increased with a rising trend (all P＜0.05),and the ankle-brachial indexes of the patients on 2 d,and at 3,6 and 12 months after operation were all significantly increased (all P＜0.05).Restenosis of the target vessel did not occur in any of the patients at 3 months after operation,but occurred in one case (1/21) 6 months after operation and in 2 cases (2/21) at 12 months after operation,and all stenoses were of a moderate degree.Conclusion:Endovascular atherectomy offers a satisfactory short-term efficacy in treatment of femoropopliteal artery stenosis with outflow obstruction.

目的 观察癃闭舒胶囊联合西医治疗良性前列腺增生的疗效及对中医证候积分、生活质量(QOL)积分的影响.方法 将116例良性前列腺增生患者随机分为2组,对照组58例给予盐酸坦索罗辛缓释胶囊治疗,观察组在对照组治疗基础上加用癃闭舒胶囊治疗,2组均治疗3个月.观察2组治疗效果,治疗前后中医证候积分、QOL积分变化情况及不良反应发生情况.结果 治疗后,观察组总有效率明显高于对照组(P<0.05);2组治疗后最大尿流率均高于治疗前(P均<0.05),膀胱残余尿量、前列腺体积、中医证候积分、QOL积分均显著降低(P均<0.05),且观察组上述指标改善情况均优于对照组(P均<0.05);2组不良反应发生率比较差异无统计学意义(P>0.05).结论 盐酸坦索罗辛缓释胶囊联合癃闭舒胶囊治疗良性前列腺增生疗效确切,可显著改善中医证候及生活质量,且安全可靠.

脑梗死是一种常见病、多发病,具有发病率高,致残率高、病死率高的特点.脑卒中患者中2/3以上为65岁以上老年人[1],常遗留运动、感觉、言语、吞咽和认知等神经功能的损害,导致患者不同程度丧失独立生活及工作的能力.吞咽困难可以引起肺炎和营养不良等并发症,是预测脑梗死后患者死亡率的独立危险因素[2].本文通过介绍脑梗死患者吞咽困难的流行病学、机制及诊治特点,为早期发现高风险吞咽困难患者提供临床依据,以期减少患者吸入性肺炎的发生,改善预后,降低脑梗死患者死亡率.

Objective To evaluate the feasibility of endovascular aortic repair (EVAR) under local anesthesia without using any contrast agent for abdominal aortic aneurysm in patients with high allergic risk to contrast agent.Methods Under local anesthesia and with no use of any contrast,percutaneous EVAR was performed in a patient with abdominal aortic aneurysm who carried high allergic risk to contrast agent.Results Percutaneous EVAR was successfully accomplished.Postoperative follow-up MRI examination showed that the abdominal aortic aneurysm was completely isolated with no endoleak.The blood flow was unobstructed in the covered stent,and bilateral renal arteries were well visualized.Conclusion For the treatment of abdominal aortic aneurysm in patients who are highly allergic to contrast agent and who have contraindications to general anesthesia,percutaneous EVAR performed under local anesthesia and using no contrast agent is safe and effective.Strict observation of indications and sufficient preoperative evaluation of clinical conditions is the key to ensure a successful operation.

Objective:To summary the effect of Angio Jet thrombus aspiration system with stent in upper limb deep vein thrombosis patient.Method:With superficial vein angiography and antegrade puncture of the brachial vein,Angio Jet thrombus aspiration system was introduced along the guidewire after recanalization of left subclavian vein,and the urokinase was repeated injected into the left subclavian vein and left axillary vein thrombosis.Again angiography showed residual venous stenosis,a Wallstent stent was implanted in the the left subclavian vein.After balloon post-dilatation,angiography presented recovery patency of left subclavian vein,no obvious residual stenosis and contrast medium retention and extravasation.Result:The patient's operation time was 111 min and the intraoperative blood loss was 10 ml.Patient underwent AngioJet thrombus aspiration system combined with stent implantation without chest tightness,shortness of breath and other symptoms and left subclavian vein and axillary vein blood flow recovered patency.Oral xarelto treatment after the operation,6 months follow-up,the patient's left upper limb swelling less than before and ultrasound examination showed left deep vein blood flow patency.Conelusion:AngioJet Ultra thrombus aspiration system combined with stent implantation was applied in upper limb deep vein thrombosis patient.

Endovascular aortic repair (EVAR) has been the main treatment means for abdominal aortic aneurysm.It has become an expert consensus that in the case of abdominal aortic aneurysm that is complicated by iliac aneurysm,the preservation of internal iliac artery is necessary because it can prevent the occurrence of gluteal muscle ischemnia,sigmoid ischemia,male sexual dysfunction and other complications.In recent years,with the continuous updating of the endovascular devices it has become possible to retain the internal iliac artery in the performance of EVAR.At present,the reconstruction of internal iliac artery in EVAR includes a variety of techniques,including intraluminal iliac branched device (IBD) technique,sandwich technique,common iliac artery covered-stent bell-bottom (BBT) technique,external iliac artery-internal iliac artery intraluminal shunt technique (reverse "chimney" technique),and spring coil embolism technique.This article aims to make a summary of all the above mentioned techniques.

Objective To explore the building of clinical training mode with the post competence as a core, in order to cultivate qualified medical talents.Methods After looking up the domestic and foreign literature, questionnaire survey, brainstorming, expert consultation and other research methods, the teaching experts from school and the experienced clinical teachers had been invited to discuss the training content and curriculum plan, the organization management system and organization framework, the positioning objective, the preparation of syllabus, the refi nement of curriculum implementation plan and the improvement of evaluation system, which were applied in the 2008, 2009 and 2010 steps of long-term system undergraduates’ clinical practice, to make multi-faceted questionnaire survey and evaluation.Results The evaluation effect of the training scheme were well through the questionnaire of feedback from students, teachers, practice departments, the formative assessment of practice, and the analysis and comparison of students’ results of examination.Conclusion The training mode of medical talents with the post competence as a core can help to improve medical students' comprehensive ability in clinical practice.