糖尿病性下肢缺血性血管病的外科治疗

目的：探讨糖尿病性下肢缺血性血管病的治疗方法.方法：对24例Ⅰ型糖尿病患者合并下肢动脉缺血性疾病的39条肢体体进行了手术,其中动脉旁路手术31例,占79%.对3例患者进行了下肢截肢处理.结果：接受动脉旁路手术的患者出院时动脉血流均保持通畅.一例51岁男性患者四肢肿胀、变黑,经治疗无效死亡.结论：糖尿病性缺血性血管病可以通过外科手术治疗.如下肢远端动脉旁路移植、腔内血管成型术等.外科治疗的方法正在探讨阶段,研究方法不断进展.外科治疗不仅可以挽救肢体或降低截肢平面,而且可为足部创面的愈合提供较好的营养环境,有利于创面的愈合和提高生活质量.     

糖尿病性下肢动脉硬化闭塞症的护理体会

目的:探讨糖尿病性下肢动脉硬化闭塞症的护理措施.方法:对糖尿病性下肢动脉闭塞症的52例患者,给予适当的心理疏导,合理调整饮食,加强患肢和创面护理,有效的时症处理,以及有针对性的出院指导等系列护理措施.结果:合理恰当的护理措施可以有效地促进糖尿病性下肢动脉硬化闭塞症患者的恢复.结论:糖尿病性下肢动脉硬化闭塞症患者除采用恰当的外科治疗手段,实施高质量的,有针对性的护理措施十分重要.     

基于"湿性愈合"理论的新型敷料在糖尿病足溃疡创面处理中的应用

目的:观察基于"湿性愈合"理论的新型敷料用于糖尿病足溃疡创面的处理的治疗效果。方法:首先评估糖尿病足溃疡创面,然后根据不同情况采用不同新型敷料,应用湿性伤口愈合理论对48例糖尿病足溃疡的患者进行临床研究,选取48例传统方法处理的同类患者作为对照。结果:结果显示湿性愈合组患者出院时的创面愈合率较对照组明显提高,治疗周期明显缩短(P<0.05),换药次数明显减少(P<0.05)。结论:基于"湿性愈合"理论的新型敷料在糖尿病足溃疡创面的处理中取得了良好效果,值得进一步研究与应用。     

2型糖尿病周围血管病的危险因素分析

目的:探讨2型糖尿病周围血管病发病的风险因素。方法:随机选取342例2型糖尿病患者,其中279例2型糖尿病合并周围血管病,63例未合并周围血管病,对比分析两组的性别、年龄、BMI指数、病程、有无吸烟史、有无高血压病史、尿酸、胱抑素C、总胆红素、直接胆红素、间接胆红素、前白蛋白等。依据双下肢动脉狭窄程度将279例合并周围血管病患者分为4组:狭窄率50%(组1)、狭窄率50%至75%(组2)、狭窄率75%(组3)、下肢闭塞(组4),分析和比较不同狭窄程度组间上述各项基础资料及指标间差异,危险因素采用多元Logistic回归分析。结果:下肢动脉狭窄程度与胱抑素C为正相关关系(r=0.227,P0.05);下肢动脉狭窄程度与前白蛋白为负相关关系(r=-0.181,P0.05)。结论:胱抑素C为2型糖尿病周围血管病的危险因素,前白蛋白为2型糖尿病周围血管病的保护因素,临床可将二者用于糖尿病周围血管病患者的诊治监测指标。     

使用富血小板血浆对下肢慢性创面缺损的临床研究分析

目的:研究和探讨使用富血小板血浆(platelet-rich plasma, PRP)在人体下肢慢性创面缺损中的治疗作用,并试图寻找更佳的治疗皮肤慢性缺损的治疗方式。方法:对2016.03-2017.03一年以来在我科治疗,明确诊断为慢性创面缺损的,经纳入和排除标准筛选的共计16名患者进行分析。将其分为实验组(8人)与对照组(8人)。实验组通过对静脉血(肘部)进行抽取离心来制备富血小板血浆并加以覆盖。对照组则使用重组人表皮生长因子进行替代。两组患者均以7天为一疗程,进行换药和更换辅料。比较两组患者的创面愈合情况并比较其血液指标。结果:实验组患者在治疗后1周时观察创面,发现创面无明显渗出及感染征象,其面积缩小约1/4。对照组在1周后进行观察,发现1例有感染可能,给予再次清创并使用抗生素后辅料包扎。其余患者创面肉芽生长可,面积缩小约1/6。在治疗2周后再次进行观察,发现实验组患者创面面积缩小约2/3。而对照组患者面积缩小约1/4。在治疗后3周时,实验组所有患者创面已基本愈合85%以上。在延迟治疗1-2周后该组患者全部愈合。对照组患者在治疗3周后有两例患者愈合面积在50%以上。给予继续使用该治疗方法。剩余6例患者接受外科治疗(VSD+植皮/皮瓣)。实验组患者在各治疗观察点皮肤愈合情况较对照组均有显著改善(P0.05)。两组所有患者均未出现严重并发症。结论:对于下肢慢性创面,使用富血小板血浆进行治疗,能够有效的促进创面愈合,减少手术及外科治疗的风险,降低治疗费用,且相对安全,具有非常重要的临床推广价值。     

糖尿病下肢溃疡影响因素分析及治疗方法

目的探讨糖尿病下肢溃疡的原因和治疗方法。方法回顾总结我院近年来急诊科临床收治的糖尿病并发下肢溃疡患者12例,全部病例均使用胰岛素控制血糖、抗生素抗感染、静脉滴注活血化瘀的中药、常规局部换药并结合使用具有去腐、生肌、消炎作用的中药膏剂进行治疗,同时对患者进行糖尿病相关知识的教育和自我护理技能培训。结果全部病人均治愈出院,其中截趾术后伤口愈合出院1例,点状邮票植皮后伤口愈合1例,经换药伤口愈合10例。随访期间全部病例溃疡未复发。结论糖尿病下肢溃疡是由血管、神经、感染等多重因素造成的。对糖尿病并发下肢溃疡患者采用多种方法综合治疗可以取得较好的疗效,同时强调重视糖尿病的管理和教育。     

间充质干细胞治疗糖尿病皮肤损伤的研究进展

糖尿病患者的皮肤组织易受内源性及外源性的各种损伤,且创面具有愈合慢、易感染等特点,这种特点在下肢皮肤创伤中表现尤为突出,常伴有高截肢风险,故糖尿病皮肤损伤可严重影响患者的生活质量。间充质干细胞（MSCs）是一类多能干细胞,其具有易分离、易培养、多向分化和免疫源性低等特征,目前已被广泛应用于创伤修复、组织再生等研究。对于糖尿病皮肤损伤,MSCs的临床移植治疗已成为继药物、手术之后的又一种治疗新技术。本文结合MSCs的生物学特性,对其应用在糖尿病皮肤损伤方面的研究进展做一综述。     

MESS评分在肢体严重软组织损伤治疗中的应用评估

目的:探讨MESS评分在治疗肢体严重软组织损伤中的应用价值。方法:回顾性分析我科2010年8月至2014年5月收治的50例肢体严重软组织损伤患者的临床资料,其中男34例,女16例,年龄23~53岁,平均38岁。所有患者入院时均采用MESS评分表进行评分,根据病情给予清创、保肢或截肢以及创面修复等系列治疗,并随访3个月~3年。按照治疗结果将患者分为保肢组、Ⅰ期截肢组和Ⅱ期截肢组,分析和比较三组的MESS分值、住院天数、手术次数、并发症的发生率及患者满意率。结果:保肢组32例,MESS评分6-11分,平均8.63±1.26分。截肢组18例,MESS评分11-14分,其中Ⅰ期截肢组10例,平均12.60±0.97分;Ⅱ期截肢组8例,平均12.88±0.83分。保肢组患者的MESS分值显著低于Ⅰ期截肢组(P0.05)和Ⅱ期截肢组(P0.05)。此外,保肢组患者满意率显著高于Ⅰ期截肢组(P0.05)和Ⅱ期截肢组(P0.05)。而Ⅰ期截肢组的住院时间、手术次数和并发症发生率均短于或少于Ⅱ期截肢组,患者满意率高于Ⅱ期截肢组(P0.05)。结论:对于MESS评分11分的患者行保肢治疗可收到满意的效果,而对MESS评分11分的患者,采取Ⅰ期截肢的治疗效果优于Ⅱ期截肢。     

老年难愈性创面患者临床特征及创面细菌学分析

目的 分析老年难愈性创面患者的临床特征、创面细菌学及疗效,为临床治疗提供参考依据。方法 回顾性分析我科2012年1月至2017年12月收治的114例老年难愈性创面患者的临床资料。对患者合并内科基础疾病、生理机能状况、创面病因和部位、创面分泌物细菌和多重耐药菌分布、创面治疗效果等进行分析。结果 患者常见内科基础疾病有高血压（63例）、糖尿病（42例）、脑血管疾病（38例）和心脏病（31例）,常见生理指标异常为白蛋白降低（89例）和贫血（70例）。本组共有186处创面（37例患者有1个以上创面）,常见病因为烧伤（44.62%）、压迫（35.48%）,常见病变部位为下肢（67.74%）。创面分离出病原菌113株,革兰阴性菌占71.68%。常见菌为铜绿假单胞菌（35.40%）、金黄色葡萄球菌（25.66%）、大肠埃希菌（12.39%）。多重耐药菌检出率为71.68%（81/113）。本组创面的治疗效果为：治愈94处、好转64处、未愈28处。38.17%创面进行了手术治疗。手术治疗的疗效为治愈58处、好转10处、未愈3处,明显优于非手术治疗（Z= -6.478,P=0.000）。结论 老年难愈性创面患者合并内科基础病多、生理机能状况差,创面细菌以革兰阴性球菌为主、多重耐药菌比例高,创面治疗效果偏差,手术比例低,但手术治疗取得了较好疗效。     

VSD用于足踝部皮肤软组织缺损行腓动脉穿支皮瓣修复的效果分析

目的探讨负压封闭引流(vacuum sealing drainage,VSD)用于足踝部皮肤软组织缺损行腓动脉穿支皮瓣修复的临床效果。方法将2014年1月~2016年2月我院收治的24例足踝部皮肤软组织缺损患者采用VSD联合腓动脉穿支皮瓣进行修复,观察治疗后皮瓣成活率、创面愈合效果及踝关节功能改善情况,并对治疗前后美国骨科足踝外科协会(AOFAS)踝-后足评分进行比较。结果治疗后皮瓣成活率为100%,创面、切口Ⅰ期愈合,踝关节功能优良率95.83%,治疗后AOFAS评分高于治疗前(P0.05)。结论 VSD能显著降低创面感染发生率,促进创面愈合和肉芽组织的生长,应用于足踝部皮肤软组织缺损行腓动脉穿支皮瓣修复的效果确切,值得临床推广应用。     

Critical evaluation of endovascular surgery for limb salvage

Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.     

Simultaneous off-pump coronary artery bypass grafting and ascending aortobifemoral bypass graft via ventral abdominal route

Aortoiliac disease often coexists with coronary artery disease. It is not uncommon to subject a patient to two separate interventions. We report two cases in which in simultaneous off-pump coronary artery bypass grafting was done with an ascending aortobifemoral bypass graft through the ventral abdominal route without any additional morbidity. Combining a technically simple method of limb bypass with an off-pump cardiac surgery is a promising procedure for revascularization of myocardium and lower limbs. We discuss the merits of combining an off-pump coronary artery bypass grafting procedure with a limb bypass.     

聚桂醇在治疗下肢静脉曲张中初步临床应用

目的:探讨聚桂醇在治疗下肢大隐静脉曲张中的应用价值。方法:回顾性分析2013年9月-2015年9月医院确诊的下肢大隐静脉曲张患者75例(75条患肢)病例资料,根据治疗方案分为两组,33例(33条患肢)超声引导下注射聚桂醇泡沫硬化剂作为聚桂醇组,42例(42条患肢)行大隐静脉高位结扎+剥脱术作为手术组,记录手术时间、术中出血量、下床活动时间、住院时间、治疗费用及术后并发症发生率,门诊随访术后6、12个月,记录复发率。结果:聚桂醇组手术时间、下床活动时间均短于手术组,术中出血量、住院费用少于手术组,差异有统计学意义(P0.05);聚桂醇组皮下血肿、皮肤麻木感发生率明显低于手术组,差异有统计学意义(P0.05);聚桂醇组12个月复发率为12.12%低于手术组的33.33%,差异有统计学意义(P0.05)。结论:聚桂醇泡沫硬化剂注射是治疗下肢大隐静脉曲张的可选疗法。     

沙格雷酯治疗2型糖尿病伴下肢动脉硬化闭塞症患者的疗效评估

目的:探讨沙格雷酯治疗2型糖尿病伴下肢动脉硬化闭塞症(ASO)患者的临床疗效。方法:选择2014年4月~2015年5月我院2型糖尿病伴下肢ASO患者80例,给予口服沙格雷酯100 mg,3次/日,连续8周,监测治疗前后患肢的症状与体征、双下肢动脉峰值血流速度、血糖、血脂及血液流变学等指标的变化。结果:口服沙格雷酯8周后,患者疼痛感、冷感、间歇性踱行、麻木感及下肢溃疡等主观症状有效率均大于91%,临床总有效率为93.75%。治疗后患者左、右下肢动脉血管直径与治疗前比较,差异无统计学意义(P0.05),但左、右下肢动脉峰值血流速度比治疗前显著降低,差异有统计学意义(P0.05)。治疗后患者的甘油三酯、总胆固醇、低密度脂蛋白、全血高切黏度及全血低切黏度比治疗前降低,差异有统计学意义(P0.05)。结论:沙格雷酯可改善2型糖尿病伴下肢ASO患者的症状,降低双下肢动脉峰值血流速度,临床疗效确切,值得临床推广应用。     

Results of surgical and conservative treatment for multi-level atheromatous arterial occlusion of the lower limb after five years]

After 5 years of observation, materials of 239 patients treated operatively and 96 patients treated conservatively because of multisegmental arterial occlusion of lower limbs were obtained within the framework of multi-central programme of investigation. The results of the treatment with these methods have been evaluated according to the site of the atheromatous changes and the degree of ischemia of lower limbs. It has been ascertained, that after operative therapy, the percentage of good results and the percentage of death in the case of occlusion comprising the aorto-ilio-femoral segment is higher than in the case of occlusion of femoro-popliteal and peripheral segments, whereas in the case of conservative therapy, the situation is reverse. The results of therapy (operative and conservative) of multilevel arterial occlusion, in all kinds of location, depend upon blood supply in the limbs. The results are best (the highest percentage of good results and without improvement, the least number of amputation and death) in the II period of disease and they become worse when the degree of ischemia increases. It appears that the operative therapy is less effective than the conservative therapy in the case of atheromatous multilevel changes manifesting clinically in the form of intermittent claudication, whereas in the case of the IV degree of ischemia, only the operation can save the limb or even the patient's life.     

Late results of surgical and conservative treatment for atheromatous ischemia of the lower limb in young patients]

The study was carried out within a multicenter program. Hundred fifty four patients under 40 years were treated (73 conservatively, and 81 surgically) for the atheromatous ischemia of the lower limbs in 14 Departments of Vascular Surgery in Poland within 5 years. The results of the treatment were evaluated according to the site of atheromatous lesions, type of surgery, and mainly according to the progress in pathologic process expressed by the degree of limb ischemia. It was found that surgery performed in the II period of the disease produces the best results. Surgery produces positively better results than conservative treatment in patients with the II period of the disease whereas both surgical and conservative therapy are ineffective in the III and IV degrees of ischemia. Sympathectomy may be effective in the occlusion of crural arteries even of the IV degree ischemia. In case of the II degree ischemia better results are produced by the operation of aorto-iliaco-femoral segment (transplantation or thrombendarterectomy) than that involving distal segment (sympathectomy) whereas the results of conservative therapy are better in peripheral and iliaco-femoral occlusion than those in aortofemoral and multisegmental arterial occlusion. An opinion of several authors on the specificity of atheromatous ischemia of the lower limbs in young patients was not confirmed.     

Isotope limb blood flow measurement in patients undergoing peripheral laser angioplasty

A technique of isotope limb blood flow (ILBF) measurement employing Technetium-labelled human albumin and a gamma camera, was used to assess limb perfusion in 19 patients undergoing percutaneous laser angioplasty, both before and one month after treatment. Twenty-three limbs with femoro-poplited occlusions ranging in length from 3–35 cm (median 8cm) were recanalized using an Nd-YAG laser and sapphire tipped optical fibre. Primary angiographic success was achieved in 19 lesions of which 6 re-occluded within the first month, and 13 remained patent with relief of symptoms. Clinically successful procedures were associated with a large increase in ILBF. However, normal blood flow was restored in only 54% of limbs. There was a slight decrease in limb perfusion after failed laser angioplasty but this was not statistically significant in this small series. Furthermore, there was no clinically apparent circulatory compromise, or need for urgent surgical bypass in failed cases. We conclude that ILBF is a useful means of assessing patients undergoing laser angioplasty, particularly for detecting small flow changes in patients who are unable to complete a standard exercise test. Its use can be recommended for assessing blood flow changes following other forms of limb revascularization.     

子宫动脉栓塞术后并发血栓的临床病例分析和诊治探讨

目的:探讨剖宫产瘢痕妊娠(CSP)患者经子宫动脉栓塞术(UAE)后并发下肢深静脉血栓(DVT)的临床病例的诊断治疗要点。方法:回顾性分析2014年-2016年我院收治的剖宫产瘢痕妊娠患者经子宫动脉栓塞术后并发下肢深静脉血栓(DVT)5例患者的临床特点及诊断、治疗方法。结果:2014年-2016年,我院CSP患者经UAE治疗后发生DVT的发病率为1.63%,患者平均年龄35.2岁。DVT临床症状出现于UAE术后3-6天,多表现为下肢的疼痛及酸胀,深静脉血栓均出现在介入穿刺处肢体。用彩色多普勒血流显像诊断深静脉血栓安全可靠。采用低分子肝素皮下注射抗凝治疗均取得较好效果。结论:剖宫产瘢痕妊娠患者经子宫动脉栓塞术治疗后有发生下肢深静脉血栓风险,DVT发生与穿刺处肢体制动,血管受压,血液回流障碍有关。手术前后应采取预防措施,低分子肝素钠抗凝对DVT治疗有效。     

The erect posture as an aid to the circulation in the feet in the presence of arterial obstruction

When the main artery in the lower limb is occluded and narrow collateral vessels by-passing the obstruction offer the limiting resistance to blood flow, the increase in arterial pressure at the ankle on assuming the erect posture is greater than would be predicted by consideration of the hydrostatic factors. In seven patients with femoral artery occlusion the pressure at the ankle was greater than expected in all and on the average by 8.0 mm. Hg±1.5 S.E. when sitting, (P<0.01) and in the four patients tested, by 12.4 mm. Hg±0.5 S.E. when standing (P<0.01). Rate of blood flow in subdermal tissue of the forefoot estimated by xenon-133 clearance was an average of 21% less when sitting than when supine in five limbs of four normal subjects while in five limbs with occlusion or severe stenosis of the superficial femoral artery the rate of flow was an average of 44% greater.     

肢体负压对犬后肢动脉闭塞病影响的实验研究

目的为研究肢体负压疗法的疗效及探讨其作用机理,我们对犬后肢进行实验研究。方法。实验犬分三组,治疗组为左后肢缺血模型犬并行患者肢负压治疗;对照组同治疗组但不做治疗：自身对照组为双后肢缺血模型犬,左侧行负压治疗,右侧作为对照。