【摘要】目的 探討經(jīng)皮腔內(nèi)血管成形術(shù)(PTA)聯(lián)合部分支架植入術(shù)治療糖尿病足動(dòng)脈病變的臨床價(jià)值。方法 選擇我院年2月至年3月收治的60例糖尿病足動(dòng)脈病變患者，共78條肢體，F(xiàn)ontaine分期Ⅰ­—Ⅱ期3例，Ⅱ—Ⅲ期35例，Ⅲ—Ⅳ期22例，采用新sedinger法穿刺股動(dòng)脈，行糖尿病足動(dòng)脈病變經(jīng)皮腔內(nèi)血管成形術(shù)(PTA)，部分聯(lián)合支架植入術(shù)。結(jié)果 78條肢體中技術(shù)成功69條(成功率88.5%)，臨床成功73條(成功率92.5%)。觀察術(shù)后1個(gè)月，3個(gè)月，6個(gè)月的皮膚溫度，踝肱指數(shù)，跛行距離分別較術(shù)前增加，與術(shù)前相比較，下肢缺血癥狀明顯改善，所有患者的肢體癥狀均沒見加重或復(fù)發(fā)。結(jié)論 經(jīng)皮腔內(nèi)血管成形術(shù)(PTA)聯(lián)合部分支架植入術(shù)，可作為治療糖尿病足動(dòng)脈病變的優(yōu)選治療方法，有效改善遠(yuǎn)段肢體血供，有效防止糖尿病足動(dòng)脈病變發(fā)展，促進(jìn)肢端創(chuàng)面愈合，提高患者生存質(zhì)量，近期療效顯著，值得臨床應(yīng)用和進(jìn)一步推廣。

　　【關(guān)鍵詞】糖尿病足 經(jīng)皮腔內(nèi)血管成形術(shù)(PTA) 支架植入術(shù)Interventional Therapy in Arterial Pathological

　　lesio
Of the Diabetic Foot

　　DU Zi-zhong，WANG Cheng，HUANG Bang-rong，ZHANG Yong-ping，DU Jun-ke，SUN Yan，YANG Di

　　(Traditional Chinese Medicine Hospital of Ga
u Province)(No.1 People’s Medicine Hospital of Lan zhou， Radiology)

　　【Abstract】 [Objective] To explore the clinical value of the treatment in arterial pathological lesio
of the diabetic foot, using the percutaneous tra
luminal angioplasty (PTA) combined with partial stent implantation therapy. [Methods] Selecting 60 patients with arterial pathological lesio
of the diabetic foot, who were treated in our hospital from February to March , we got 78 limbs. According to the Fontaine, there were 3 cases in theⅠ­—Ⅱperiod; 35 cases in the Ⅱ—Ⅲ period ; 22 cases in the Ⅲ—Ⅳperiod among them. Using the new Seldinger technique, we punctured arteria femoral, carried out the percutaneous tra
luminal angioplasty (PTA) combined with partial stent implantation operation on the patients who suffered from the arterial pathological lesio
of the diabetic foot. [Results] Among 78 limbs, 69 ones are successful in technology (the success rate: 88.5%), 73 ones are successful in clinical treatment (the success rate: 92.5%). By observing for one month, three months, six months of postoperation, the skin temperature, the ankle-brachial index and the limp distance were increased respectively. Compared with preoperation periods, the hind limb ischemic symptoms were improved obviously. All the patients symptoms didn’t become wo
e or were recurring. [Conclusion] After using the percutaneous tra
luminal angioplasty (PTA) combined with partial stent implantation methods, it can be the best treatment in arterial pathological lesio
of the diabetic foot, effectively improving body blood supply to the far end, effectively preventing the development for arterial pathological lesio
of the diabetic foot , promoting the wound healing of acra , improving the quality of survival of the patients. Because of its effective in treatment recently, the method is worth being applied in clinical treatment and being further promoted.

　　【Key words】：the diabetic foot;the percutaneous tra
luminal angioplasty (PTA);stent implantation therapy

　　糖尿病患者隨著病程延長(zhǎng)，常伴有周圍血管病變，而糖尿病足是中老年DM患者常見的周圍血管病變并發(fā)癥，其主要原因是膝下中小動(dòng)脈不同程度的狹窄與閉塞，引起足部潰瘍、壞死、感染不易控制等慢性缺血改變，增加了其截肢的危險(xiǎn)因素。下肢動(dòng)脈硬化閉塞癥(PAD)是糖尿病晚期的嚴(yán)重并發(fā)癥之一，嚴(yán)重影響糖尿病患者的生存質(zhì)量，輕者出現(xiàn)間歇性跛行、靜息痛，重者出現(xiàn)糖尿病足壞疽，甚至危及生命。糖尿病合并下肢動(dòng)脈硬化閉塞癥造成的肢端缺血壞死，依靠單純的內(nèi)科藥物治療，如擴(kuò)張血管、改善微循環(huán)等有一定療效，但由于下肢大血管病變問題未能解決，許多患者因嚴(yán)重的肢端缺血壞死而導(dǎo)致截肢。在各種非外傷性截肢中，糖尿病足導(dǎo)致的截肢占**，而因大血管病變?nèi)缦轮珓?dòng)脈硬化閉塞癥導(dǎo)致的干性壞疽又是糖尿病足截肢的主要原因。所以，如何治療糖尿病患者下肢動(dòng)脈硬化閉塞癥，從而改善下肢動(dòng)脈的血供，減少或避免肢端缺血壞死的發(fā)生，避免截肢或降低截肢平面，是臨床亟需解決的問題，也是目前臨床上治療的難點(diǎn)。傳統(tǒng)的內(nèi)科保守治療和外科手術(shù)治療效果都不理想。介入治療即經(jīng)皮血管成形術(shù)(PTA)聯(lián)合支架植入術(shù)，是目前糖尿病足治療有效方法之一。本組血管腔內(nèi)聯(lián)合介入治療糖尿病足60例，近期取得了較好的臨床效果。現(xiàn)報(bào)道如下：

　　1 資料與方法

　　1.1 選擇我院年2月至年3月收治的60例糖尿病足動(dòng)脈病變患者，共78條肢體，F(xiàn)ontaine分期Ⅰ­—Ⅱ期3例，Ⅱ—Ⅲ期35例，Ⅲ—Ⅳ期22例，其中男44例，女16例;平均年齡(73±14)歲;所有患者術(shù)前均經(jīng)磁共振血管造影(MRA)或CT血管造影(CTA)及雙下肢血管超聲檢查證實(shí)存在髂總動(dòng)脈、股淺動(dòng)脈、特別是腘動(dòng)脈以下三支主要?jiǎng)用}(脛前、脛后、腓動(dòng)脈)為主的狹窄或閉塞性病變，病變范圍在1.0—31.5 cm不等，平均(16±14)cm; 肱指數(shù)(ABI)：ABI在0～0.4的有28條肢

　　體，ABI在0.41～0.6的有33條肢體，ABI在0.61～0.9的有14條肢體，AB1>1.3的有3條肢體;所有病例均符合糖尿病、下肢動(dòng)脈硬化閉塞癥和糖尿病足壞疽的診斷標(biāo)準(zhǔn)。

　　1.2 治療方法局麻下采用Seldinger經(jīng)皮穿刺技術(shù)，順行穿刺患側(cè)股動(dòng)脈進(jìn)行血管內(nèi)介入治療;如果術(shù)前經(jīng)MRI血管造影證實(shí)股深、股淺動(dòng)脈分叉處有明確的狹窄及斑塊或術(shù)前查體股動(dòng)脈搏動(dòng)未觸及者，估計(jì)術(shù)中順行穿刺有困難或易造成斑塊脫落等不良后果者，則采取對(duì)側(cè)股動(dòng)脈逆行穿刺“翻山”治療。穿刺成功后置人6F動(dòng)脈鞘管于股淺動(dòng)脈，鞘管內(nèi)注入肝素鈉U進(jìn)行全身肝素化。隨后用優(yōu)維顯300造影劑對(duì)患肢動(dòng)脈采用”步進(jìn)”方法進(jìn)行常規(guī)造影，進(jìn)一步了解病變情況。造影后在0.014超滑導(dǎo)絲引導(dǎo)下送入球囊對(duì)狹窄的病變部位分段進(jìn)行球囊擴(kuò)張(膝下動(dòng)脈常采用2～3/80～120 mm 的Deep球囊，膝關(guān)節(jié)處狹窄采用Sailor球囊，股淺動(dòng)脈狹窄閉塞采用Submarine球囊)。對(duì)球囊擴(kuò)張不滿意的病例，術(shù)中測(cè)量狹窄血管的內(nèi)徑及長(zhǎng)度，選擇合適的自膨支架置入。介入術(shù)后對(duì)術(shù)中有血管痙攣者或病變部位斑塊堵塞嚴(yán)重者，保留動(dòng)脈鞘管1～3d，或留置5F直頭導(dǎo)管持續(xù)動(dòng)脈內(nèi)泵入罌粟堿、凱時(shí)、尿激酶、肝素鈉等解痙、擴(kuò)管、溶栓、抗凝藥物，進(jìn)一步鞏固手術(shù)治療效果。對(duì)于不保留動(dòng)脈鞘管或直頭導(dǎo)管者，術(shù)后予低分子肝素～u，皮下注射3～5d，預(yù)防血栓形成。如無(wú)禁忌，長(zhǎng)期口服阿司匹林腸溶片100mg，1次/d，術(shù)后半年內(nèi)口服氯吡格雷 75 mg，1次/d。對(duì)于糖尿病足壞疽的治療，在介入治療術(shù)后傷口血液供應(yīng)得以改善的情況下，盡快(術(shù)后3～14d內(nèi))對(duì)傷口創(chuàng)面進(jìn)行處理 術(shù)后1、3、6個(gè)月進(jìn)行隨訪。

　　1.3 觀察指標(biāo)

　　1.3.1 手術(shù)成功率：也指技術(shù)治療成功率，定義為術(shù)中閉塞的動(dòng)脈再通，或術(shù)中至少開通膝以下3支血管中的1支閉塞血管，或術(shù)后血管狹窄