血管成形术及支架植入术.ppt

血管成形术 第一节 血管成形术基本概念 一、PTA的定义 二、PTA的发展简史 三、PTA的治疗机制 四、PTA的适应症和禁忌症 五、PTA的并发症及其预防 六、PTA后再狭窄的机制 七、支架成形术 第一节 血管成形术基本概念 Clinical Manifestayions of Vascular Pathology Manifestation Example Obstruction to flow forward Arterial and venous stenoses Increased flow forward Arteriovenous fistula,malformation Increased flow backward Varicose veins due to reflux through incompetent venous valves Loss of vessel wall integrity Aneurysm,dissection,bleeding These can occur alone or in any combination.第一节 血管成形术基本概念 Atherosclerosis is an arterial disease that is prevalent in industrialized nations.Veins do not 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 theories 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 all vascular beds.第一节 血管成形术基本概念 Risk Factor for Atherosclerosis Genetic predisposition Smoking Diet Diabetes Chronic renal failure Hypertension Homocysteinuria Advanced age Hyperlipidemia Obesity Elevated lipoprotein(a)Atheromatous plaque.Eccentric atheroma 第一节 血管成形术基本概念 第一节 血管成形术基本概念 Angiographic appearance of concentric stenosis of the left common iliac artery Angiographic appearance of bulky,eccentric plaque in the SFA 第一节 血管成形术基本概念 Hypertrophied collateral arteries around a short chronic occlusion of the distal superficial femoral artery(SFA).DSA showing an abrupt cutoff of flow with a filling defect(arrow)consistent with thrombus.There is a paucity of collateral vessels and lack of reconstitution of distal vessels.第一节 血管成形术基本概念 Intimal hyperplasia is not a true disease or disorder,but a biologic response to injury to the vessel wall.Causes of Intimal Hyperplasia Cause Examples Injury Surgical anastomosis,clamps,angioplasty denudation of intima by any device Foreign body Stents,suture material,catheters Abnormal flow Arterialization of veins,turbulence Fibromuscular Dysplasia Vasculitis(Takayasus arteritis)Other 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(arrowhead),and stenosis of the right subclavian artery origin Takayasus arteritis 第一节 血管成形术基本概念 一、PTA的定义 经皮经腔血管成形术（Percutaneous Transluminal Angioplasty,PTA）：采用导管扩张技术使狭窄或闭塞的血管开通。第一节 血管成形术基本概念 二、PTA的发展简史 1964年，Dotter 和Judkins 采用同轴同导治疗动脉粥样硬化。开创了介入放射新纪元 同 轴 导 管(Coaxial Catheter)血管成形术 The first percutaneous angioplasty,1964.A,Focal stenosis in the popliteal artery(arrow).B,Using progressively large coaxial catheters,the lesion was dilated.The patients rest pain resolved and toe ulcers healed.C,Coaxial catheter.c Pre-PTA Post-PTA 第一节 血管成形术基本概念 二、PTA的发展简史 1、原理：粗大导管通过狭窄血管时产生外向性压力，使血管腔扩大。2、缺点：入路部位血管的损伤大，应用范围小。第一节 血管成形术基本概念 二、PTA的发展简史 1974年，Grntzig发明了双腔带囊导管球囊血管成形术 (Balloon Angioplasty)。1978年球囊材料进行了改进。PTA-Balloon(percutaneous transluminal angioplasty)第一节 血管成形术基本概念 二、PTA的发展简史 1978年Grntzig报导了PTA用于肾性高血压的治疗，同时进行了4例冠脉PTA实验。第一节 血管成形术基本概念 二、PTA的发展简史 1984年Inoue 进行了二尖瓣球囊扩张术(PTMA)的临床应用研究。第一节 血管成形术基本概念 三、PTA的机制 控制损伤性理论 1、控制：控制球囊的直径 2、损伤：血管壁的机械性损伤，膨胀的球囊使血管的内膜和中膜局限性撕裂，血管壁成分，特别是中膜的过度伸展以及动脉硬化斑块的断裂。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,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 results 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 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 dissections 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 angioplasty.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 intervention unless it is flow-limiting.A B 第一节 血管成形术基本概念 四、PTA适应证（Indications)1、动脉粥样硬化 2、大动脉炎 3、血管搭桥术（bypass)后的吻合口狭窄 4、人造血管狭窄 5、血管肌发育不良 6、静脉血管狭窄或闭塞 第一节 血管成形术基本概念 五、PTA禁忌证(Contraindication)1.碘过敏（可用CO2造影）。2.严重心律紊乱，心功能不全。3.肝、肾功能不全，或凝血机制异常 4.有动脉瘤形成 5.大动脉炎活动期。第一节 血管成形术基本概念 六、术后并发症及预防 1、常规血管介入治疗并发症 2、远端栓塞 3、球囊破裂 4、出血 5、动脉夹层 balloon rupture vessel rupture 第一节 血管成形术基本概念 七、PTA后再狭窄机制 1、急性再狭窄 2、早期再狭窄 3、晚期再狭窄 第一节 血管成形术基本概念