1、血管成形术血管成形术及支架植入术1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、支架成形术血管成形术及支架植入术2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 fi
2、stula,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.血管成形术及支架植入术3第一节 血管成形术基本概念 Atherosclerosis is an arterial disease that is prevalent in indus
3、trialized 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 auto
4、immune 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.血管成形术及支架植入术4第一节 血管成形术基本概念 Risk Factor for Atherosclerosis Genetic predispositionSmoking DietDiabetesChronic renal failure
5、HypertensionHomocysteinuriaAdvanced ageHyperlipidemiaObesity Elevated lipoprotein(a)Atheromatous plaque.Eccentric atheroma 血管成形术及支架植入术5第一节 血管成形术基本概念血管成形术及支架植入术6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 plaq
6、ue in the SFA 血管成形术及支架植入术7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 recon
7、stitution of distal vessels.血管成形术及支架植入术8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
8、 Stents,suture material,catheters Abnormal flow Arterialization of veins,turbulence血管成形术及支架植入术9 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
9、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血管成形术及支架植入术10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。血管成形术及支架植入术11第一节 血管成形术基本概念二、PTA的发展简史 1964年，
10、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 血管成形术及支架植入术12The 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,Coaxi
11、al catheter.c血管成形术及支架植入术13Pre-PTA Post-PTA血管成形术及支架植入术14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。血管成形术及支架植入术15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。血管成形术及支架植入术16PTA-Balloon(percutaneous transluminal angioplasty)血
12、管成形术及支架植入术17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。血管成形术及支架植入术18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。血管成形术及支架植入术19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。血管成形术及支架植入术20 Schematic of the
13、 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 ball
14、oon 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 remodele
15、d,redistributed,or vaporized by the balloon.血管成形术及支架植入术21 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 are
16、as 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
17、and requires no further intervention unless it is flow-limiting.A B血管成形术及支架植入术22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 血管成形术及支架植入术23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。血管
18、成形术及支架植入术24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、动脉夹层血管成形术及支架植入术25 balloon rupture vessel rupture 血管成形术及支架植入术26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、晚期再狭窄血管成形术及支架植入术27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：PTA后立即或不久产 生的血管狭窄或闭塞。原因：、血管痉挛 、血管壁的弹性回缩 、血管壁剥离，夹层形成 血管成形术及支架植入术28第一节 血管成形
19、术基本概念七、PTA后再狭窄机制 2、早期再狭窄：PTA后1-2个月至1年内 发生的再狭窄，是最常见的再狭窄类型；主要原因：、PTA后血管壁损伤处的内皮细 胞的过度增生。、病变血管壁的弹性回缩。血管成形术及支架植入术29第一节 血管成形术基本概念七、PTA后再狭窄机制 3、晚期再狭窄：PTA后1年以上发生 的再狭窄 原因：、PTA后血管壁损伤处的内皮 细胞的过度增生。、原有病变的加重或发展。血管成形术及支架植入术30第一节 血管成形术基本概念七、PTA后再狭窄机制 4、再狭窄的预防 、药物：抗凝、抗血小板聚集。、改进方法：减少血管损伤。、stent 置入。血管成形术及支架植入术31第二节 支架
20、成形术基本概念一、支架成形术（Stent Angioplasty）血管内支架（Endovascular Stent，ES）是预防PTA后再狭窄的重要的手段，已广泛应用于临床，是介入放射学发展史上一个新的里程碑(milestone)。二、stent的含义及来源 stent:支撑器，通常指金属支架。“stent”一词来源一位口腔科医生“charles stent”的名字。为纪念发明的一种支撑皮肤移植物的装置，将这种支撑器称为stent。血管成形术及支架植入术32第二节 支架成形术基本概念 金属支架：现在通常所说的支架多为（stent），是一种用于支撑管道的器材，释放后对管壁有永久的支撑力。内涵管：
21、临床上实际运用的尚有一种塑料支架，为了区别起见，将其称为内涵管。支架移植物（stent-graft):在支架上覆盖特种塑料的薄膜，对已扩张的瘤腔起隔绝作用。血管成形术及支架植入术33血管成形术及支架植入术34第二节 支架成形术基本概念 三、支架发展简史1964年血管成形术支付Dotter及Jukins预言血管内支撑物可以成形内膜化1969年成功地在猪的腘动脉进行了动物实验1982年发明了不锈钢丝编织支架Wallstent1983年Dotter、Cragg报道了鎳鈦记忆合金的支架动物实验结果以后，各种支架开始不断出现1985年Palmaz报道了球囊扩张式支架，Wright报道了不锈钢“z”型自膨
22、式支架1987-1989年，Sigwart、Rousseau、Strecker、Robkin等相继报道了一些新的支架血管成形术及支架植入术35第二节 支架成形术基本概念 四、支架分类1、按膨胀方式分为：自膨式支架（self-expandable stent)球囊膨胀式支架 （balloon-expandable stent)血管成形术及支架植入术36第二节 支架成形术基本概念四、支架分类 2、按支架结构分为：编织焊接支架：国产支架、wallstent、symphony 激光切割支架：smart、zilver、palmaz、saxx-stent、lumingnexx 螺旋状支架：IntraCoi
23、l、EndoCoil 血管成形术及支架植入术37 血管成形术及支架植入术38第二节 支架成形术基本概念四、支架分类 3、按支架表面情况分为：裸支架(Bare stent)覆膜支架（Covered stent)血管成形术及支架植入术39第二节 支架成形术基本概念 五、支架 置入步骤血管成形术及支架植入术40血管成形术及支架植入术41血管成形术及支架植入术42第二节 支架成形术基本概念 Stents provide an intravascular scaffold for the vessel lumen.The mechanism of action of stents is very dif
24、ferent from angioplasty,as the plaque and vessel wall are literally pushed aside by the stent to enlarge the lumen血管成形术及支架植入术43 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,F
25、racturing,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
26、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.血管成形术及支架植入术44第二节 支架成形术基本概念 六、适应症 1、PTA术后并发症或疗效不佳者 2、狭窄性病变累及主动脉壁或粥样硬化明显者 3、颈部及颅内具有血流动力学意义的狭窄 4、腔静脉和较大静脉分支的狭窄或闭塞 5
27、、重建血管通道 6、支架移植物用于动脉瘤及主动脉夹层的治疗 7、其他血管成形术及支架植入术45 Indications for stent placement ArterialRecanalization of chronic occlusionOcclusive or flow-limiting dissection following angioplastyElastic or recurrent stenosisLesion suspected as source of distal emboliInflow lesion prior to distal surgical bypass
28、procedureOstial lesion(especially renal artery)Thoracic aortic coarctation/pulmonary artery stenosis(pediatric)VenousRecanalization of chronic occlusionExtrinsic compression by malignancyElastic,fibrotic,or recurrent stenosisOtherBridging mouth of aneurysm prior to coil placementReinforce stent-graf
29、t血管成形术及支架植入术46第二节 支架成形术基本概念 七、禁忌症1、严重的心肺肾功能不全2、大动脉炎活动期3、肢体广泛的动脉病变4、生长发育未成熟者5、其他 血管成形术及支架植入术47第二节 支架成形术基本概念 八、并发症与预防1、支架移位或血管壁破裂2、血管损伤：血管壁穿通、动脉破裂、3、支架内急性血栓形成或远端血管栓塞4、支架感染5、其他：spasm、分支血管阻塞血管成形术及支架植入术48complications Unique to Sent Placement ComplicationStent loose on balloon during deliveryStent emboli
30、zation after deploymentStent will not expand lesionStent kinks in lesion after deployment EtiologyLoose crimpUndersized stentNondilatable or fibrotic lesionAngled vessel PreventionTight crimp,correct balloon size,slight positive pressure in balloon after mountingOversize stent5-10%in diameterTest with angioplasty balloon before deploying stent;use stent with high hoop strengthUse flexible self-expanding stent 血管成形术及支架植入术49血管成形术及支架植入术50
