内膜下血管成形 vs 腔内血管成形.ppt

BOLIA－－SIA的适用范围 腔内PTA可能会失败的坚硬的慢性闭塞病变－－技术难度低 导丝难以经腔内通过的长段闭塞 既往失败的PTA SFA齐开口病变 PTA治疗效果通常较差的长段狭窄 严重钙化的病变 弥漫性病变，常常混杂有PTA难于处理的闭塞段 搭桥血管失败后自体闭塞动脉 腘动脉闭塞累及三分叉，可以对所有流出道血管进行重建 PTA术中出现动脉穿孔后，可采用内膜下技术隔绝穿孔部位 * 扩张后和治愈过程的组织学分析表明，球囊扩张引起的主要的病理学变化是发生在内膜和中层。 ???? 内膜：扩张后最初内皮层磨损，暴露了破损的内弹力层。血小板在10分钟内聚集在损伤的内膜上，30分钟内血小板细胞脱颗粒（degranulation）.一周时，新生内膜开始形成，1-2月损伤表面完全再内皮化。内弹力层的修复此时并没开始。 ???? 中层：中层是由弹性蛋白，胶原 蛋白和肌纤维组成。球囊扩张后的中层过度延展，导致中层各种成分的广泛破坏，同时也失去弹性。特别是肌细胞的损伤和永久过度延展。它们的核在组织学上表现为“螺旋锥”（corkscrew）样，提示这是一种持久的损害。肌细胞的损害是血管成形术机理的基础部分。弹性纤维的延展和破碎也发生。经过3天，来自损伤和死亡的肌细胞的碎片被清除。在第一周的末期，中层以肌纤维母细胞浸润的形式重建中层，以此基础上发生新的肌细胞形成和胶原增生。这一过程持续3-6个月。球囊充分的扩张到中层的破裂仅存留浆膜保护血流通过。这种情况下中层由疤痕修复愈合。 来自冠脉的研究经验 冠脉PTA 后，球囊最大横截面5.3mm2，PTA前管腔1mm2，扩张后2.8mm2，弹性回缩达到近50％ 弹性回缩由动脉近端至远端加重 偏心性病变弹性回缩更明显 斑块负担重的病变弹性回缩比较少 * Approximately one-fifth of infrainguinal subintimal recanalizations fail because of failure to re-enter the true lumen distal to the CTO2,3 对于Outback而言，Significant calcification at the proposed re-entry site is a strong predictor of device failure。Outback 是14导丝系统，穿刺针是23G的镍钛合金针 Limitations of the Outback LTD re-entry device in femoropopliteal chronic total occlusions Susanna H. Shin，J Vasc Surg 2011;53:1260-4. * Bolia et al2 were the first to report on this technique and emphasized that during subintimal passage, the guidewire does not pass the medial layer。 On the other hand, Reekers et al3 observed that large, extensive, medial calcifications often result in the inability to perform this technique and concluded that the passage through the medial layer is necessary. Reekers et al, therefore, preferred to call this technique percutaneous intentional extraluminal revascularization. Figure 1. Schematic overview of a subintimal angioplasty procedure. A, Artery with occluding atherosclerotic plaque in the lumen (dark gray), internal elastic lamina (black), and media (gray). B through D, An angle-tipped guidewire is introduced into the subintimal space (B) and encouraged to form a loop by moving the catheter tip downward (C),