Right SFA stenting

以溶栓導管治療腹主動脈馬鞍型血管栓塞

病患原本是右側股動脈阻塞造成間歇性跛行

經過血管支架治療二個月後
在腹主動脈分叉處又新形成了一個馬鞍型血管栓塞( saddle thrombus )
間歇性跛行的症狀又出現了

我們於腹主動脈置入兩條溶栓導管治療血管阻塞 ( X-configuration CDT )

結果血栓大部分都被我們溶解掉了
病人的跛行症狀獲得完全的改善!!

saddle thrombus CDT

aortic bifurcation saddle thrombus status post type A dissection operation (2)

aortic bifurcation saddle thrombus status post type A dissection operation (1)

right CFA saddle thrombus status post type A dissection operation (2)

right CFA saddle thrombus status post type A dissection operation (1)

TIMI

TIMI stands for 'Thrombolysis In Myocardial Infarction'

'TIMI Grade Flow' is a widely adopted scoring system from 0-3 referring to levels of coronary blood flow assessed during percutaneous coronary angioplasty:

• TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion.
• TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed.
• TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory.
• TIMI 3 flow (complete perfusion) is normal flow which fills the distal coronary bed completely

Fontaine classification

Stage I – Asymptomatic. Of note: Fontaine stage I does in fact describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and non-specific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of “subclinical” peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses.

Stage II – Intermittent claudication. This stage takes into account the fact that patients usually have a very constant distance at which they have pain:

• Stage IIa – Intermittent claudication after more than 200 meters of pain free walking.

• Stage IIb – Intermittent claudication after less than 200 meters of walking

Stage III – Rest pain. Rest pain is especially troubling for patients during the night. The reason for this is twofold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night the lack of sensory stimuli allow patients to focus on their legs.

Stave IV – Ischemic ulcers or gangrene (which may be dry or humid).

Rutherford classification

Stage 0 – Asymptomatic

Stage 1 – Mild claudication

Stage 2 – Moderate claudication – The distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

Stage 3 – Severe claudication

Stage 4 – Rest pain

Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot

Stage 6 – Severe ischemic ulcers or frank gangrene

右側髂動脈到股動脈完全阻塞

這位老先生的右側總髂動脈到淺股動脈完全阻塞了!

因為血管阻塞,已經造成他長期的右側腰部以至於大腿和腳部的疼痛和無力感

怎麼辦呢?血管腔內治療似乎沒辦法解決他的問題. 我們只好用外科的血管繞道手術來解決了!

上臂動脈阻塞

上肢的動脈血管阻塞問題臨床上較少見,不像下肢動脈阻塞那麼常見,不過有這個問題的病人卻是非常的困擾,這個病人因為左手的血流量根本不夠,完全無法正常的生活,左手只要稍微活動一下,立刻因為組織缺乏血流而感到酸麻及疼痛,就算放著不動,他的左手也和屍體一樣摸起來冰冰涼涼的!!

從影像中我們可以看出,他的臂動脈到肱骨的中間就斷掉了,難怪造成他左手這麼嚴重的症狀! 如果要積極的治療這位病患,可能得要擷取他自己大腿上的大隱靜脈來做繞道手術!

雙側前脛動脈狹窄

這個北盃的兩側ATA(前脛動脈)都狹窄成虛線/點點狀了,併有腳趾慢性傷口
謹記學長的教誨:
血管腔內治療(endovascular therapy) ---> target ATA
傳統繞道手術(bypass surgery) ---> target PTA

淺談週邊動脈血管疾病

                                            新北市慈濟醫院血管外科

    隨著醫學科技的進步,人類整體的平均壽命延長了,伴隨而來的,則是許多慢性病的照顧, 像是糖尿病、高血壓、心臟病, 退化性關節炎, 老年癡呆症等等, 人口老化的問題, 世界上大部分的國家都正在面對它。

    而在其中, 伴隨著糖尿病/高血壓/高血脂,以及老化現象, 週邊動脈血管疾病(一般簡稱PAD或是PAOD) 的病患,在醫院的門診及住院病人中,也有逐漸增加的趨勢。週邊動脈血管疾病的發生,常源自於動脈粥樣硬化或一些炎性反應過程,逐漸導致動脈血管的狹窄, 或是因急性血栓掉落而導致急性阻塞,病患隨著阻塞部位嚴重的程度, 伴隨而來的下肢冰冷/疼痛,是最主要的症狀。

    圖為血管外科醫學會時, 週邊血管相關治療器材的卡通圖, 他們的表達方式, 與醫界前輩和病患解釋時的比諭不謀而合, 所以特別放在這裡與大家分享。筆者的前輩常常會淺顯易懂的跟病患解釋: 「該逼(即腹股溝附近)洗台北, 膝蓋洗台中, 而腳踝/腳底板就像高雄和屏東；現在國道一號中山高速公路塞車了(狹窄、阻塞), 我們要嘛就是要把中山高拓寬,把四線車道拓寬成六線道(就像是血管氣球撐開術,或是支架置放), 還是無法疏通的話, 我們就要再開一條國道三號/北二高(就像是血管繞道手術), 來解決這個塞車(血流不通)的問題。」

    週邊動脈血管疾病,常發生於糖尿病和高血壓的病人身上,尤其是糖尿病足。它的臨床表現主要分為四級: 初級僅為輕微的肢體麻木感或是末梢肢體溫度較低, 第二級醫學上稱為間歇性跛行, 講白話一點就是因為血液循環不良,路走不遠,每走一段路程,腳就會因為缺血性疼痛,而不得不停下來休息一下；第三級則是連不走路的時候腳都會有不舒服及疼痛感, 最嚴重的第四級,因為肢體末梢的組織已經承受不住缺血, 開始產生傷口/潰瘍壞死。

    血管外科現在在手術室中,透過先進的設備, 像是透視床、血管攝影機 (angio C-arm)等, 已經與世界其他先進國家的潮流一致, 走向精緻微創手術(minimal invasive procedure) 的時代, 優先使用血管腔內治療,像是氣球成型術、溶栓治療、血管支架等 (像是高速公路拓寬工程), 若效果仍不盡理想, 再考慮用繞道手術 (加開一條國道三號), 以增加末梢血液循環。

 一旦截肢,不只影響病患的生活品質,整個家庭也都要耗費更多的資源來照顧行動不便的家人,以及長期臥床的可能併發症(如褥瘡,肺炎,泌尿道感染等),所以下肢缺血病變和糖尿病足的病人,應該在血管外科醫師檢查及治療後,非不得已,才行清瘡或截肢手術,以期降低對家庭的負擔和整個社會的照護成本。