腔内微创时代下的急性下肢缺血诊疗进展

Advances in the Diagnosis and Treatment of Acute Limb Ischemia in the Era of Intracavitary Minimally Invasive Techniques

摘要: 急性下肢缺血(acute lower limb ischemia, ALLI)是指由各种原因导致下肢血供骤然减少，动脉血流灌注不足，出现一系列缺血症状，从而严重威胁肢体存活的一类突发急性病症，对于ALLI的治疗一直是临床医生所关注的焦点，近年来随着技术水平的不断发展，对于ALLI的治疗手段也不断更新，目前主流的治疗手段主要包括经典的切开取栓术、迅速发展的腔内取栓溶栓术、以及相互结合的杂交手术方式。切开取栓对病人一般情况要求相对较高，Fogarty取栓相对成熟，但存在内膜反应性增生的争议。腔内技术中接触性导管溶栓(CDT)技术对于I及IIa型下肢缺血具有不错的临床效果，目前已发展出多侧孔及超声溶栓技术，在保证一定再灌注效果的前提下，具有相对较低的术后缺血再灌注风险，但是其术后的出血并发症需要得到广大临床工作者的高度重视。经皮穿刺血栓抽吸术(PAE)以其简单、经济、高效的技术特点，得到广泛开展，减少远端栓塞是该技术接下来的发展方向。经皮机械取栓细分技术多样，可根据不同病人情况选择不同的手术方式，但是该技术花费相对较高，且快速开通血运后的缺血再灌注损伤需要密切关注，术后常规给予消肿等对症治疗。各技术不存在绝对优势，技术间相互取长补短，目前ALLI的治疗技术多样，选择性较高，虽然对于现阶段的复杂病情具有较全面的应对方案，但是腔内技术仍然是需要各位临床工作者的重点研究方向。

Abstract: Acute lower limb ischemia (ALLI) refers to a sudden acute disease that causes a sudden decrease in blood supply to the lower limbs, insufficient arterial blood perfusion, and a series of ischemic symptoms, which seriously threatens the survival of the limbs. At present, the mainstream treatment methods mainly include classical incision and thrombectomy, the rapidly developing endovascular thrombectomy and thrombolysis, and hybrid surgery. Incision and thrombectomy are relatively demanding on the general condition of patients, and Fogarty thrombectomy is relatively mature, but there is controversy about intimal reactive hyperplasia. Among the endovascular techniques, CDT technology has a good clinical effect on type I and IIa lower limb ischemia, and multi-lateral foramen and ultrasound thrombolysis technology have been developed, which have a relatively low risk of postoperative ischemia and reperfusion under the premise of ensuring a certain reperfusion effect, but its postoperative bleeding complications need to be highly valued by the majority of clinicians. PAE has been widely developed due to its simple, economical and efficient technical characteristics, and reducing distal embolization is the next development direction of this technology. Percutaneous mechanical thrombectomy has a variety of subdivision techniques, and different surgical methods can be selected according to different patients’ conditions, but the cost of this technique is relatively high, and the ischemia and reperfusion injury after rapid vascularization requires close attention, and symptomatic treatment such as swelling reduction is routinely given after surgery. At present, the treatment techniques of ALLI are diverse and selective, although there is a more comprehensive response plan for complex diseases at this stage, endovascular technology is still the key research direction that needs to be done by clinicians.