血管外科疾病Vascular+Disease課件

1、Vascular Diseases血管外科疾病ZHAO JICHUN （趙紀春） M.D. & Ph. D. Vascular Surgery, West China Hospital, Sichuan UniversityContentPart I The overview of vascular disease 血管外科疾病總論Symptoms and signs 癥狀和體征Part II Common vascular diseases (artery and vein disease) 血管外科常見疾病The overview of vascular diseaseSymptoms a

2、nd signs血管外科疾病概述Part I IntroductionArterial and venous circulationVascular : cardiovascular cerebrovascular(intracranial) peripheral vascularIntroductionPeripheral vascular diseases:comprise disorders of the arteries and veins, but exclude cardiovascular and cerebrovascular.除心血管及腦血管系統(tǒng)之外的所有循環(huán)系統(tǒng)疾病Clas

3、sification分類CharacteristicsArterial diseaseVenous diseaseMixed disease ShapeStenosis 狹窄Rupture 破裂 Occlusion 閉塞 Dilation 擴張 Arterial Disease: Aneurysm（動脈瘤）Stenosis（動脈狹窄）Occlusion（動脈閉塞）Rupture（動脈瘤破裂）Venous Disease： Varicose vein（靜脈曲張）Venous thrombosis（靜脈血栓形成）Mixed DiseaseArteriovenous fistula（動靜脈瘺）Abd

4、ominal aortic aneurysm,AAA腹主動脈瘤Internal Carotid aneurysm頸內動脈瘤 1892年，加拿大、美國等國的基督教會在成都創(chuàng)辦仁濟、存仁醫(yī)院 歷史沿革 1892年，加拿大、美國等國的基督教會在成都創(chuàng)辦仁濟、存仁醫(yī)院 歷史沿革 Renal artery stenosisAortoiliac Occlusion主髂動脈閉塞Varicose Vein靜脈曲張14Acute Deep Venous Thrombosis(DVT)深靜脈血栓形成Clinical manifestation臨床表現(xiàn)HeartOrgans and tissuesarteryvei

5、nischemiaCongestionArterial blood carry oxygen and nutritional materials from heart to organs or tissues of the whole body.Arterial stenosis and occlusion will cause ischaemia of organ and tissue, which will present the symptoms and signs of arterial insufficiency, such as lower limb ischaemia. ARTE

6、RY： VEIN: Transfer metabolic products from organs and tissues to heart and evacuate them via lung and kidney. The blood flow in vein is on one direction forward heart which depend on: muscle contraction （肌肉收縮力） negative pressure during inhaling of lung and diastole of heart （心肺的“抽吸作用”） vein valves（靜

7、脈瓣）Clinical manifestation臨床表現(xiàn)Sensation 感覺Color 顏色Shape 形態(tài)Nutrition 營養(yǎng)性變化Sensation abnormality感覺異常Pain 疼痛Intermittent pain 間歇性疼痛Intermittent claudication 間歇性跛行Position pain 體位性疼痛Temperature pain 溫度性疼痛Position pain體位性疼痛HeartOrgans and tissuesarteryveinIschemia缺血Congestion腫脹LimbLimbdifficultaggravatere

8、lieveeasyTemperature pain溫度性疼痛Ischemia缺血Congestion腫脹WarmExpand vessel血管擴張-+ColdContract vessel血管收縮+-Sensation abnormality感覺異常PainPersistent pain(rest pain):ischemia,inflammation,necrosis持續(xù)性疼痛（靜息痛）：缺血，炎癥，壞死Artery rest pain 2. Vein rest painSensation abnormality感覺異常Skin temperature 皮膚溫度Artery stenosis

9、 or occlusion : decreasedVein occlusion: increasedNumbness and paralysis 麻木和麻痹Early stage（早期）: numbness 麻木Later stage（晚期）: paralysis 麻痹Color abnormality皮膚顏色異常Arterial disease動脈疾病Venous disease靜脈疾病ColorPallor 蒼白Flare 紅腫Pressure testDelayed return of capillary blushExercise testPallor +Flare +Position

10、 testElevate: pallor +Drop back induce returnElevate: Flare -+:aggravate -: relieveShape abnormality形態(tài)異常Atrophy萎縮: arterial occlusionSwollen腫脹: venous diseaseAbnormal growth生長異常: venous diseaseLocal nodule局部結節(jié):varicose veinsConstruction abnormality營養(yǎng)性障礙Necrosis or gangrene壞死或壞疽 : arterial ischemiaUl

11、cer潰瘍: venous diseaseOthers manifestationPulselessness 無脈: arterial occlusionFemoral APopliteal ADorsalis pedis Aposterior tibial APulse: absent, decreased, or normal-Comparing a pulse with that in the contralateral extremity can demonstrate changes indicative of proximal stenosis or occlusionOthers

12、 manifestationPulsating mass: arterial aneurysm 搏動性包塊：動脈瘤Murmur or tremor: A-V fistula 震顫：動靜脈瘺arteryveinVEINStenosis狹窄 Obstruction閉塞Valve function insufficiency靜脈瓣膜功能不全 varicose veinstagnationswellingIschaemiaClinical ManifestationVEIN?ARTERY?Acute? or Chronic?HISTORY IN PATIENTS WITH ARTERIAL DISEA

13、SEacute arterial occlusion急性動脈閉塞chronic arterial insufficiency慢性動脈缺血6 Ps sign 6P征: pain 疼痛Paresthesias 感覺異常 Paralysis 麻痹poikilothermy (change with temperature, cool extremity) 變溫性 Pallor 蒼白Pulselessness 無脈chronic or long-standing symptoms and encompasses a spectrum of symptoms, beginning with effort

14、 discomfort (claudication) and progressing to pain at rest and tissue loss. （間歇性跛行 靜息痛）HISTORY IN PATIENTS WITH VENOUS DISEASchronic venous occlusion or valvular incompetence with venous reflux慢性靜脈閉塞/靜脈功能不全acute venous thrombosis急性靜脈血栓形成 pain or discomfort and swelling of the extremity（疼痛，不適或肢體腫脹）ve

15、nous hypertension and edema（靜脈性高壓及靜脈水腫）venous stasis ulcers（靜脈性潰瘍）Common vascular diseases (artery and vein disease)血管外科常見疾病Part II 35Thromboangiitis Obliterans（Buergers Disease）血栓閉塞性脈管炎 Pathogenesis The definitive etiology :At present unknownSmoking plays a crucial role.吸煙是主要誘因60-95% have the histo

16、ry of smoking60-95%吸煙史 It has been suggested:Buergers disease is an autoimmune disorder（自身免疫性疾?。㏕he autoimmune response may cause dysfunction of the endothelial cells with increased propensity to thrombosis and vasoconstriction （免疫反應導致內膜損傷 血栓形成/血管痙攣）PathogenesisMain PathologyBuergers disease is an i

17、nflammatory nonatherosclerotic disease of the small to medium-sized arteries and veins 炎性反應主要累及中小血管Clinical manifestationClinical picture is dominated by signs of skin ischemia ranging from Raynauds phenomenon（雷諾現(xiàn)象） to signs of local critical ischemia and eventual gangrene.Symptoms and signs Includi

18、ng:young man(aged:18-50),heavy smoker 青年男性 吸煙史 Pain: most at fingers or toes 肢端疼痛 Abnormality in colour and temperature 皮膚顏色及溫度異常 Migratory superficial phlebitis 游走性淺靜脈炎 Pulselessness 無脈 Ulcer and gangrene 潰瘍和壞疽Figure 7-11 Schematic representation of symptoms and signs in Buergers disease 吸煙 Smoking

19、 Inflammatory Young men 青年男性 disease medium to small size 炎癥反應累及中小血管 Arteries Veins Skin Muscle Phlebitis migrans 淺靜脈炎Raynaudss Ulcers 潰瘍 Gangrene壞疽 Claudication 間歇性跛行 attacks 雷諾現(xiàn)象 Infection 感染Clinical Stages 臨床分期：Stage1：Intermittent claudication 間歇性跛行 Stage2：Persistent Pain(rest pain) 靜息痛Stage3：Ulc

20、er and gangrene 潰瘍和壞疽Physical examination: Skin Temperature, Sensation, Pulse of arterySpecial examination： Dopplor Ultrasound: blood flow, patency and lesion site Noninvasive examination: Blood pressure , ABI Arteriography圖1 左側股淺動脈下段圖2 左側股淺動脈下段圖3 右側脛前動脈頻譜圖4 右側足背動脈頻譜Femoral artery occludedDifferenti

21、al Diagnosis 鑒別診斷 Atherosclerosis occlusion( ASO)動脈粥樣硬化閉塞: older age(50 years old) 老年患者hyperlipidemia 高脂血癥hypercholesterolemia 高膽固醇血癥hypertension 高血壓diabetes 糖尿病 Embolic occlusive disease 動脈栓塞(Five “P”signs 5P征: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis)Aortoiliac Occlusion主髂動脈閉塞Femoral a

22、rtery occluded 股動脈閉塞Figure 7-14 Principles of treatment of Buergers disease血栓閉塞性脈管炎的治療原則Stop SmokingAlpha blocking Cure local agents infectiona受體阻斷劑Calcium Relief of Amputationantagonists ischemia 截肢鈣離子拮抗劑Iloprost Bypass前列素類藥物 Sympathectomy surgery Surgery(1) Sympathectomy （交感神經切除術）: Stage 1 or 2.Lu

23、mbar sympathetic ganglionectomy and trunk resection which based on the evidence that the skin and muscle vessels and the collaterals were supplied by sympathetic vasoconstrictor nerves(2) Bypass surgery（搭橋手術）: Stage 2 or 3Femoropopliteal Bypass股動脈膝上膕動脈搭橋Infrapopliteal Bypass膝上膝下膕動脈搭橋Femoropopliteal

24、BypassArterial anastomosisIn Situ Saphenous Vein Arterial BypassEndovascular TherapyPercutaneous Transluminal Angioplasty, (PTA)經皮腔內血管成形術Balloon and Stent Placement 球囊擴張和支架置入Abdominal Aortic Aneurysm腹主動脈瘤Albert Einstein 死于腹主動脈瘤 一種血管擴張性疾病Abdominal Aortic Aneurysm （AAA） 腹主動脈瘤正常主動脈腹主動脈瘤1Definition: Ane

25、urysms are defined as focal dilatations at least 50% larger than the expected normal arterial diameter腹主動脈局限性異常擴張，與正常血管相比，局部血管直徑永久性增大超過1.5倍A practical working definition: Abdominal Aortic Aneurysm 3 cmCommon Iliac Aneurysm 1.8 cm腹主動脈的直徑超過3cm，可以診斷為腹主動脈瘤髂總動脈的直徑超過1.8cm，可以診斷為髂總動脈瘤The Normal Aortic Diame

26、ter gradually decreases Thorax (28 mm in men) Infrarenal location (20 mm in men).Womenman 2mm男性主動脈直徑在各個層面比女性大2mmNearly all AAAs involve the infrarenal aorta, Only about 5% to 15% of AAAs undergoing surgical repair also involve the suprarenal aorta 絕大部分腹主動脈瘤為腎動脈下型Rupture! 腹主動脈瘤未能得到及時診斷和治療,就有可能發(fā)生破裂死亡E

27、pidemology Of AAAsIncidence of AAAs of the Wolrd： 3-117 / 100,000/yrs60歲以上男性AAA發(fā)病率： 4-8%人口老齡化 AAAs的發(fā)病率美國就有約 200 萬名 AAA 患者，每年的新發(fā)病人在 20 萬例以上RAAAs：15th leading cause of death overall 10th leading cause of death in men older than 55y大多數(shù)AAAS沒有臨床癥狀，難以發(fā)現(xiàn)和及時就診無聲的殺手美國一年有大約 15,000 名患者死于AAAs，死亡率和艾滋病相當Evaluatio

28、n of Risk for Rupture(Annual) 破裂風險的評估 (每年)4.0-5.4 cm0.6%5.5-6.4 cm10%6.5-6.9 cm19%7.0-7.9 cm35%8.0 cm51%Evaluation of Increasing Speed(Annual) 瘤體增大速度的評估 (每年) 5 cm 0.3-0.7 cm動脈瘤直徑破裂風險瘤體增大速度Incidence of Rupture(AAAs)Early Diagnosis and Treatment for AAAs82% of RAAAs DieMotality of RAAA after arriving

29、hospital: 50% 破裂腹主動脈瘤患者被送到醫(yī)院：死亡率為50%Motality of RAAAs for operation：30-70% 破裂腹主動脈瘤的手術死亡率：30-70%Motality of AAAs for Elective Surgery: 2-7% 腹主動脈瘤的擇期手術死亡率僅為 2-7%AAA can be detected by UltrasoundRisk Factors for AAAs腹主動脈瘤的危險因素Old Age 65yMale Family History 一級男性親屬: 20%Past History既往史Aneurysm Atheroscler

30、osisHypertension COPDInfection/InflammationSmoking 篩查患者的一級男性親屬！篩查患有動脈粥樣硬化的吸煙老年男性Diagnosis for AAAsSymptoms:Most of AAAs are Asymptomatic 多數(shù)腹主動脈瘤患者沒有癥狀 通常因慢性后背疼痛或腎結石行CT或超聲檢查而偶然發(fā)現(xiàn)Symptomatic AAAs shows possibility of rupture 有癥狀的腹主動脈瘤（后背-脅部-腹部疼痛 ）提示近期破裂可能Diagnosis for AAAsPhysical Examination:Pulsatil

31、e Mass 腹正中搏動性包塊Continuous Vascular Murmur : Aortic-Vena Cava Fistula 聞及持續(xù)性血管雜音提示主動脈腔靜脈漏Sensibility and Specificity: Low 敏感性 和 特異性低：80%漏診Ultrasound: Most effective for diagnosis超聲篩查能夠避免 70% AAA破裂導致的死亡 Advantages of Ultrasound: Sensibility and Specificity: High 敏感性高： 82-99% Noninvasive 64-81歲男性AAA篩查研究

32、 Cheap36Further Diagnosis for AAAsCTA：Golden StandardAdvantage: 薄層掃描 3mm快速：15-30秒， 單次屏氣空間分辨率高，精確可以進行三維重建受操作醫(yī)師/技師判斷影響小Disadvantages: Radiation Exposure; Contrast nephropathyMRA DSA 用于動脈瘤長度的測量，無法測量動脈瘤的直徑，不能替代CT或者MRIPrinciple for Treatment of AAAs國際上遵循以下原則Diameter of AAAPrinciple5cmSymptomatic Annual G

33、rowth Rate1cmOpen Surgery or EVER血管腔內修復術 （EVAR）Treatment of AAAs開腹手術（Open Surgery）Open SurgeryAdvantages:1st Open Surgery(1951 Dubost)50 years of clincal experience Long-term Effect: Good!Disadvantages:Huge Incision3090min for clamping Time for Surgery: LongSlow RecoveryICU 12d住院714d完全恢復46wOpen Surg

34、eryContraindication:High Risk of Anesthesia 麻醉風險高Cardiac/Respiratory Dysfunction 心肺功能異常Past Surgical History of Abdomen 既往腹部手術史Complication:Pseduoaneurysm 假性動脈瘤 (3%)Sexual Dysfunction 性功能障礙 (25%) Aortoenteric Fistula 主動脈腸瘺 (1-2%)Graft Thrombosis 移植物血栓形成 (2%)Graft Infection 移植物感染 (1-2%)腹主動脈瘤腔內修復治療（EV

35、AR）Advantages:Minimal Invasive 微創(chuàng)Femoral Artery Approach 股動脈入路，無需開腹Low Mortality 死亡率低Short Time for Surgey 手術時間短腹主動脈瘤腔內修復治療（EVAR）Advantages:Quick Recovery 術后恢復快No ICULength of Hospital Stay: DecreaseQuality of Life: High 術后生活質量高PainIncidence of paralysisSexual DysfunctionStent for AAAs腎上錨定通用型接口外傾和逐漸

36、變細的支架延長段鎳鈦合金材料：可行MRI檢查中間的C-bar結構兼具支撐力和柔韌性牢固可靠的聚酯覆膜+腹主動脈瘤腔內修復治療（Endovascular Repair for AAA)腔內修復治療（EVAR）Anatomy Condition 解剖條件合適Vacular Access 血管通路Length and Tortuosity of Neck 主動脈瘤頸長度和扭曲程度Calcification of Vessels 血管鈣化Accurate Calculation 測量精確3mm CT 薄層掃描Devices 良好的顯影成像設備Follow up 強烈建議患者術后每年隨訪復查TRIALE

37、VAROPENP值EVAR I (#)*54353930天死亡率1.7 %4.7 %0.04二次干預6.9 %2.4 %0.0001DREAM (#)*17117430天死亡率1.2 %4.6 %0.1 手術死亡率和嚴重并發(fā)癥4.7 %9.8 %0.1隨機對照研究證實 EVAR 相對于開放手術的優(yōu)越性Comparision of EVAR and Open SurgeryNote: * Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1)

38、: randomized controlled trial Lancet Vol 365 June 25, 2005*A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms the NEJM Vol 351 Oct. 14, 2004Preoperative Evaluation CTAPRIMARY VARICOSE VEIN OF LOWER EXTREMITY下肢靜脈曲張Introduction Varicose veins are dilated, t

39、ortuous and prominent superficial veins in the lower limb下肢淺表靜脈的迂曲，擴張2% of the population has varicose vein, the incidence of varicose vein increase with ageLong saphenous vein 大隱靜脈 Tributaries sapheno-femoral junction-femoral vein, no artery accompanied and muscle support Short saphenous vein 小隱靜脈

40、popliteal veinSuperficial Veins1.Anatomy and physiology2.Deep Veins 深靜脈：anterior tibial veinposterior tibial veincommon femoral veincommon iliac veininferior vena cavapopliteal veinSuperficial femoral veinDeep femoral vein3. Communicating vein 交通靜脈4. Valve 靜脈瓣5.Dynamics： The blood flow in vein is on

41、 one direction forward heart which depend on: muscle contraction 肌肉收縮力 negative pressure during inhaling of lung and diastole of heart 心肺“抽吸作用”vein valves prevent retrograde flow of blood in a proximal-to-distal direction靜脈瓣防止倒流Cause of diseaseGenetic factor 遺傳因素Acquired factor: increased vein gravi

42、ty 靜脈壓力增加long standing work 長期站立heavy physical labor 負重Pregnacy 懷孕 Clinical manifestation臨床表現(xiàn)Early stage（早期）: Vein dilated and tortuous 靜脈迂曲，擴張Middle stage（中期）: Swollen, itch 下肢腫脹，皮膚瘙癢Late stage（晚期）: Pigementation,Ulcer 皮膚色素沉著，皮膚潰瘍Ulcer Development:(a)Pressure and stasis(b)Arteriovenous shunts(c)The

43、 fibrin diffusion block(d)White cell trapping and activation Physical ExaminationThe Trendlenburg Test 大隱靜脈瓣膜功能試驗To assess the direction of blood flow and the refilling of the superficial veins Perthes Test 深靜脈通暢試驗To assess if the deep vein were competent and unobstructedDifferential Diagnosis 鑒別診斷1

44、.Chronic venous insufficiency 慢性靜脈功能不全2.Congenital venous abnormality 先天性靜脈畸形3.Post-thrombotic syndrome 深靜脈血栓后遺癥4. Ateriovenous fistulae 動靜脈瘺 TREATMENTMain objectives1.Satisfactory cosmesis 美容效果2.Relief of symptoms 減輕癥狀3.Treatment of complications 治療并發(fā)癥4.Prevention of complications 預防并發(fā)癥5.Prevention

45、 of recurrence 防止復發(fā)General treatmentExternal elastic compression: 靜脈彈力襪 support stockings: relieving symptomsSclerotherapy: 硬化劑注射 obliteration of varicose veins and connections between the superficial and deep veinsSurgical treatment of varicose veins1.High ligation and division of the long saphenou

46、s vein and its tributaries at the sapheno-femoral junction 大隱靜脈高位結扎2.Stripping the long saphenous vein 大隱靜脈剝離3.Avulsion,ligation or excision of varicose vein 曲張靜脈剝脫術Deep Venous Thrombosis下肢深靜脈血栓形成 IntroductionDeep Venous Thrombosis(DVT) is ablood clotthat forms in a vein deep in the body. 靜脈血栓是多種原因導致人體靜脈血管內血栓形成的疾 病，被視為第三大常見血管疾病 Most deep vein clots occur in the lower leg or thigh 最常見的靜脈血栓是下肢深靜脈血栓 Incidence of DVT(Annual）:1.45/1000Risk Factors for DVT 深靜脈血栓形成的危險因素1.Vessels Injury 各種原因引起血管壁損傷2.Abnormality of Blood Flow 血流異常（如血流緩慢或淤積）3.Hypercoagulative Sta