切换至 "中华医学电子期刊资源库"

中华普通外科学文献(电子版) ›› 2016, Vol. 10 ›› Issue (01) : 1 -18. doi: 10.3877/cma.j.issn.1674-0793.2016.01.001

所属专题: 指南与规范 文献 指南共识

指南

下肢动脉硬化闭塞症诊治指南
中华医学会外科学分会血管外科学组   
  • 收稿日期:2015-05-04 出版日期:2016-02-01

Diagnosis and treatment guidelines for lower limb ar ter iosclerosis obliteran

Vascular Surgery Group of Chinese Society For General Surgery   

  • Received:2015-05-04 Published:2016-02-01
引用本文:

中华医学会外科学分会血管外科学组. 下肢动脉硬化闭塞症诊治指南[J]. 中华普通外科学文献(电子版), 2016, 10(01): 1-18.

Vascular Surgery Group of Chinese Society For General Surgery. Diagnosis and treatment guidelines for lower limb ar ter iosclerosis obliteran[J]. Chinese Archives of General Surgery(Electronic Edition), 2016, 10(01): 1-18.

表1 间歇性跛行的鉴别诊断
症状/疾病 疼痛或不适的部位 不适的性质 症状与运动的关系 休息的影响 体位的影响 其他特点
间歇性跛行(小腿) 小腿肌群 痉挛性疼痛 相同程度的运动后发生 很快缓解 重复性
慢性骨筋膜室综合征 小腿肌群 突发紧痛 一定程度运动后(如慢跑)发生 缓解很慢 抬高肢体可快速缓解症状 常见于肌肉发达的运动员
静脉性间跛 全下肢,但大腿及腹股沟的症状通常更重 突发紧痛 步行后发生 缓解慢 抬高肢体可快速缓解症状 髂股深静脉血栓形成史,静脉淤血及水肿征象
神经根的压迫(如椎间盘突出) 沿患肢向下的放射性疼痛,常位于后方 尖锐的针刺样痛 立即或很短时间内发生 不能很快缓解(休息过程中也常出现) 调整后背位置可能有助于缓解症状 有背部疾病史
症状性腘窝囊肿 膝关节后方沿小腿向下的疼痛 肿胀、酸痛、压痛 运动时发生 休息过程仍有症状 无间歇性跛行
间歇性跛行(髋部、大腿、臀部) 髋部、大腿、臀部 疼痛不适及无力感 相同程度的运动后发生 很快缓解 重复性
髋关节炎 髋部、大腿、臀部 疼痛不适 不同程度的运动后发生 不能很快缓解(休息时也常出现) 采用下肢获支撑的坐姿较为舒适 多变,可能与活动量和天气变化有关
脊髓压迫症 髋部、大腿、臀部(相应皮节) 无力感多于疼痛感 行走或站立相同时间后发生 仅体位改变可缓解症状 可通过坐或前屈改变腰椎屈曲压力以缓解症状 频繁发作背部疾病史,腹内压增高可诱发症状
间歇性跛行(足) 足、脚弓 严重的深部疼痛和麻木感 相同程度的运动后发生 很快缓解 重复性
关节炎、炎症反应 足、脚弓 酸痛 不同程度的运动后发生 不能很快缓解(休息时也常出现) 可能通过不承重而缓解 多变,可能与活动量有关
表2 神经性溃疡与缺血性溃疡的症状体征比较
表3 急性肢体缺血的症状和体征
表4 Fontaine和Rutherford关于下肢ASO的分级和分类
表5 主髂动脉闭塞病变的TASC Ⅱ分型
表6 股腘动脉病变的TASCⅡ分型
图1 下肢ASO诊断流程
图2 间歇性跛行的治疗流程
图3 CLI的治疗流程
图4 ALI的诊治流程
表7 ALI分级
1
Collins R,Armitage J,Parish S, et al. Heart Protection Study Col-laborative G. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a ran-domised placebo-controlled trial[J]. Lancet, 2003, 361(9374): 2005-2016.
2
Graham I,Atar D,Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiolo-gy and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts)[J]. Eur J Cardiovasc Prev Rehabil, 2007, 14(Suppl 2): S1-113.
3
Catapano AL,Reiner Z,De Backer G, et al. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiol-ogy (ESC) and the European Atherosclerosis Society (EAS)[J]. Atherosclerosis, 2011, 217(1): 3-46.
4
Rubins HB,Robins SJ,Collins D, et al. Gemfibrozil for the sec-ondary prevention of coronary heart disease in men with low lev-els of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group[J]. N Engl J Med, 1999, 341(6): 410-418.
5
Messerli FH,Bangalore S,Ram VS. Telmisartan, ramipril, or both in patients at high risk of vascular events[J]. N Engl J Med, 2008, 359: 426-427.
6
Hirsch AT,Haskal ZJ,Hertzer NR, et al. ACC/AHA 2005 Prac-tice Guidelines for the management of patients with peripheral ar-terial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardio-vascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Com-mittee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American As-sociation of Cardiovascular and Pulmonary Rehabilitation; Nation-al Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation[J]. Circulation, 2006, 113(11): e463-e654.
7
Mancia G,Laurent S,Agabiti-Rosei E, et al. Reappraisal of Eu-ropean guidelines on hypertension management: a European Soci-ety of Hypertension Task Force document[J]. J Hypertens, 2009, 27(11): 2121-2158.
8
Yusuf S,Sleight P,Pogue J, et al. Effects of an angiotensin-con-verting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators[J]. N Engl J Med, 2000, 342(3): 145-153.
9
Hoeks SE,Poldermans D. European Society of Cardiology 2009 guidelines for preoperative cardiac risk assessment and periopera-tive cardiac management in noncardiac surgery: key messages for clinical practice[J]. Pol Arch Med Wewn, 2010, 120(7-8): 294-299.
10
Zisser H,Gong P,Kelley CM, et al. Exercise and diabetes[J]. Int J Clin Pract Suppl, 2011, 170: 71-75.
11
American Diabetes Association. Standards of medical care for pa-tients with diabetes mellitus[J]. Diabetes Care, 2003, 26: S33-S50.
12
Donohoe ME,Fletton JA,Hook A, et al. Improving foot care for people with diabetes mellitus—a randomized controlled trial of an integrated care approach[J]. Diabet Med, 2000, 17(8): 581-587.
13
Fowler B,Jamrozik K,Norman P, et al. Prevalence of peripheral arterial disease: persistence of excess risk in former smokers[J]. Aust N Z J Public Health, 2002, 26(3): 219-224.
14
Hobbs SD,Bradbury AW. Smoking cessation strategies in pa-tients with peripheral arterial disease: an evidence-based ap-proach[J]. Eur J Vasc Endovasc Surg, 2003, 26(4): 341-347.
15
Hennrikus D,Joseph AM,Lando HA, et al. Effectiveness of a smoking cessation program for peripheral artery disease patients: a randomized controlled trial[J]. J Am Coll Cardiol, 2010, 56(25): 2105-2112.
16
Knight C,Howard P,Baker CL, et al. The cost-effectiveness of an extended course (12+12 weeks) of varenicline compared with other available smoking cessation strategies in the United States: an extension and update to the BENESCO model[J]. Value Health, 2010, 13(2): 209-214.
17
Jorenby DE,Leischow SJ,Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smok-ing cessation[J].N Engl J Med, 1999, 340(9): 685-691.
18
Antithrombotic Trialists' (ATT) Collaboration,Baigent C,Black-well L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual partic-ipant data from randomised trials[J]. Lancet, 2009, 373(9678): 1849-1860.
19
Committee CS. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee[J]. Lancet, 1996, 348(9038): 1329-1339.
20
Bhatt DL,Fox KA,Hacke W, et al. Clopidogrel and aspirin ver-sus aspirin alone for the prevention of atherothrombotic events[J]. N Engl J Med, 2006, 354(16): 1706-1717.
21
Cacoub PP,Bhatt DL,Steg PG, et al. Patients with peripheral ar-terial disease in the CHARISMA trial[J]. Eur Heart J, 2009, 30(2): 192-201.
22
Bendermacher BL,Willigendael EM,Teijink JA, et al. Super-vised exercise therapy versus non-supervised exercise therapy for intermittent claudication[J]. Cochrane Database Syst Rev, 2006: CD005263.
23
Watson L,Ellis B,Leng GC. Exercise for intermittent claudica-tion[J]. Cochrane Database Syst Rev, 2008: CD000990.
24
Hiatt WR,Wolfel EE,Meier RH, et al. Superiority of treadmill walking exercise versus strength training for patients with periph-eral arterial disease. Implications for the mechanism of the train-ing response[J]. Circulation, 1994, 90(4): 1866-1874.
25
Roddy SP,Abdelnoor M,Stranden E, et al. The Oslo Balloon An-gioplasty versus Conservative Treatment Study (OBACT)—the 2-years results of a single centre, prospective, randomised study in patients with intermittent claudication[J]. Eur J Vasc Endovasc Surg, 2007, 33(1): 3-12.
26
European Stroke Organisation,Tendera M,Aboyans V, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracrani-al carotid and vertebral, mesenteric, renal, upper and lower ex-tremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiolo-gy (ESC) [J]. Eur Heart J, 2011, 32(22): 2851-2906.
27
Pande RL,Hiatt WR,Zhang P, et al. A pooled analysis of the du-rability and predictors of treatment response of cilostazol in pa-tients with intermittent claudication[J]. Vasc Med, 2010, 15(3): 181-188.
28
Momsen AH,Jensen MB,Norager CB, et al. Drug therapy for im-proving walking distance in intermittent claudication: a systemat-ic review and meta-analysis of robust randomised controlled stud-ies[J]. Eur J Vasc Endovasc Surg, 2009, 38(4): 463-474.
29
O'Donnell ME,Badger SA,Sharif MA, et al. The vascular and biochemical effects of cilostazol in patients with peripheral arteri-al disease[J]. J Vasc Surg, 2009, 49(5): 1226-1234.
30
Spronk S,Bosch JL,den Hoed PT, et al. Intermittent claudica-tion: clinical effectiveness of endovascular revascularization ver-sus supervised hospital-based exercise training--randomized controlled trial[J]. Radiology, 2009, 250(2): 586-595.
31
Bradbury AW,Adam DJ,Bell J, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival predic-tion model to facilitate clinical decision making[J]. J Vasc Surg, 2010, 5195 Suppl): 52S-68S.
32
Adam DJ,Beard JD,Cleveland T, et al. Bypass versus angioplas-ty in severe ischaemia of the leg (BASIL): multicentre, ran-domised controlled trial[J]. Lancet, 2005, 366(9501): 1925-1934.
33
Tetteroo E,van der Graaf Y,Bosch JL, et al. Randomised com-parison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Dutch Iliac Stent Trial Study Group[J]. Lancet, 1998, 351(9110): 1153-1159.
34
Schillinger M,Sabeti S,Dick P, et al. Sustained benefit at 2 years of primary femoropopliteal stenting compared with balloon angioplasty with optional stenting[J]. Circulation, 2007, 115(21): 2745-2749.
35
Dick P,Wallner H,Sabeti S, et al. Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial fem-oral artery lesions[J]. Catheter Cardiovasc Interv, 2009, 74(7): 1090-1095.
36
Laird JR,Katzen BT,Scheinert D, et al. Nitinol stent implanta-tion versus balloon angioplasty for lesions in the superficial femo-ral artery and proximal popliteal artery: twelve-month results from the RESILIENT randomized trial[J]. Circ Cardiovasc Interv, 2010, 3(3): 267-276.
37
Hirsch AT,Haskal ZJ,Hertzer NR, et al. ACC/AHA 2005 guide-lines for the management of patients with peripheral arterial dis-ease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American As-sociation for Vascular Surgery/Society for Vascular Surgery, Soci-ety for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiolo-gy, and the ACC/AHA Task Force on Practice Guidelines (Writ-ing Committee to Develop Guidelines for the Management of Pa-tients With Peripheral Arterial Disease) endorsed by the Ameri-can Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation[J]. J Am Coll Cardiol, 2006, 47(6): 1239-1312.
38
Brogneaux C,Sprynger M,Magnee M, et al. 2011 ESC guidelines on the diagnosis and treatment of peripheral artery diseases[J]. Rev Med Liege, 2012, 67(11): 560-565.
39
Tepe G,Zeller T,Albrecht T, et al. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg[J]. N Engl J Med, 2008, 358(7): 689-699.
40
Ferraresi R,Centola M,Ferlini M, et al. Long-term outcomes af-ter angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia[J]. Eur J Vasc Endovasc Surg, 2009, 37(3): 336-342.
41
Conrad MF,Kang J,Cambria RP, et al. Infrapopliteal balloon an-gioplasty for the treatment of chronic occlusive disease[J]. J Vasc Surg, 2009, 50(4): 799-805.
42
Siablis D,Karnabatidis D,Katsanos K, et al. Infrapopliteal appli-cation of sirolimus-eluting versus bare metal stents for critical limb ischemia: analysis of long-term angiographic and clinical outcome[J]. J Vasc Interv Radiol, 2009, 20(9): 1141-1150.
43
Olsen PS,Gustafsen J,Rasmussen L, et al. Long-term results af-ter arterial surgery for arteriosclerosis of the lower limbs in young adults[J]. Eur J Vasc Surg, 1988, 2(1): 15-18.
44
Reed AB,Conte MS,Donaldson MC, et al. The impact of patient age and aortic size on the results of aortobifemoral bypass grafting[J]. J Vasc Surg, 2003, 37(6): 1219-1225.
45
Eagle KA,Berger PB,Calkins H, et al. ACC/AHA guideline up-date for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Periop-erative Cardiovascular Evaluation for Noncardiac Surgery) [J]. Circulation, 2002, 105(10): 1257-1267.
46
Twine CP,McLain AD. Graft type for femoro-popliteal bypass surgery[J]. Cochrane Database Syst Rev, 2010: CD001487.
47
Chiu KW,Davies RS,Nightingale PG, et al. Review of direct ana-tomical open surgical management of atherosclerotic aorto-iliac occlusive disease[J]. Eur J Vasc Endovasc Surg, 2010, 39(4): 460-471.
48
Rooke TW,Hirsch AT,Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with pe-ripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in col-laboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery[J]. Catheter Cardiovasc Interv, 2012, 79(4): 501-531.
49
Griffiths GD,Nagy J,Black D, et al. Randomized clinical trial of distal anastomotic interposition vein cuff in infrainguinal polytet-rafluoroethylene bypass grafting[J]. Br J Surg, 2004, 91(5): 560-562.
50
SCAMICOS. PTFE bypass to below-knee arteries: distal vein col-lar or not? A prospective randomised multicentre study[J]. Eur J Vasc Endovasc Surg, 2010, 39(6): 747-754.
51
Johnson WC,Lee KK. A comparative evaluation of polytetrafluo-roethylene, umbilical vein, and saphenous vein bypass grafts for femoral-popliteal above-knee revascularization: a prospective randomized Department of Veterans Affairs cooperative study[J]. J Vasc Surg, 2000, 32(2): 268-277.
52
Brumberg RS,Back MR,Armstrong PA, et al. The relative impor-tance of graft surveillance and warfarin therapy in infrainguinal prosthetic bypass failure[J]. J Vasc Surg, 2007, 46(6): 1160-1166.
53
Bandyk DF. Surveillance after lower extremity arterial bypass[J]. Perspect Vasc Surg Endovasc Ther, 2007, 19(4): 376-383.
54
Davies AH,Hawdon AJ,Sydes MR, et al. Is duplex surveillance of value after leg vein bypass grafting? Principal results of the Vein Graft Surveillance Randomised Trial (VGST) [J]. Circula-tion, 2005, 112(13): 1985-1991.
55
Brown J,Lethaby A,Maxwell H, et al. Antiplatelet agents for pre-venting thrombosis after peripheral arterial bypass surgery[J]. Co-chrane Database Syst Rev, 2008: CD000535.
56
Anand SS. Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery (the Dutch Bypass Oral antico-agulants or Aspirin study) [J]. Lancet, 2000, 355(9201): 346-351.
57
Johnson WC,Williford WO, Department of Veterans Affairs Co-operative Study. Benefits, morbidity, and mortality associated with long-term administration of oral anticoagulant therapy to pa-tients with peripheral arterial bypass procedures: a prospective randomized study[J]. J Vasc Surg, 2002, 35(3): 413-421.
58
Dick F,Diehm N,Galimanis A, et al.Surgical or endovascular re-vascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome[J]. J Vasc Surg, 2007, 45(4): 751-761.
59
Wolfe JH,Wyatt MG. Critical and subcritical ischaemia[J]. Eur J Vasc Endovasc Surg, 1997, 13(6): 578-582.
60
Heart Protection Study Collaborative Group. Randomized trial of the effects of cholesterol-lowering with simvastatin on peripheral vascular and other major vascular outcomes in 20,536 people with peripheral arterial disease and other high-risk conditions[J]. J Vasc Surg, 2007, 45(4): 645-654.
61
Norgren L,Hiatt WR,Dormandy JA, et al. Inter-Society Consen-sus for the Management of Peripheral Arterial Disease (TASC II) [J]. J Vasc Surg, 2007, 45(Suppl S): S5-S67.
62
Mamode N,Scott RN. Graft type for femoro-popliteal bypass sur-gery[J]. Cochrane Database Syst Rev, 2000: CD001487.
63
Critical Leg Ischaemia Prevention Study (CLIPS) Group, Catalano M,Born G, et al. Prevention of serious vascular events by aspirin amongst patients with peripheral arterial disease: randomized, double-blind trial[J]. J Intern Med, 2007, 261(3): 276-284.
64
Dormandy JA. Prostanoid drug therapy for peripheral arterial oc-clusive disease—the European experience[J]. Vasc Med, 1996, 1(2): 155-158.
65
Creutzig A,Lehmacher W,Elze M. Meta-analysis of randomised controlled prostaglandin E1 studies in peripheral arterial occlu-sive disease stages III and IV[J]. Vasa, 2004, 33(3): 137-144.
66
Bradbury AW, BASIL trial Investigators and Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial in perspective[J]. J Vasc Surg, 2010, 51(5 Suppl): 1S-4S.
67
Green RM,Abbott WM,Matsumoto T, et al. Prosthetic above-knee femoropopliteal bypass grafting: five-year results of a ran-domized trial[J]. J Vasc Surg, 2000, 31(3): 417-425.
68
AbuRahma AF,Robinson PA,Holt SM. Prospective controlled study of polytetrafluoroethylene versus saphenous vein in claudi-cant patients with bilateral above knee femoropopliteal bypasses[J]. Surgery, 1999, 126(4): 594-601.
69
Pomposelli FB Jr,Marcaccio EJ,Gibbons GW, et al. Dorsalis pe-dis arterial bypass: durable limb salvage for foot ischemia in pa-tients with diabetes mellitus[J]. J Vasc Surg, 1995, 21(3): 375-384.
70
Archie JPJr. Femoropopliteal bypass with either adequate ipsilat-eral reversed saphenous vein or obligatory polytetrafluoroethylene[J]. Ann Vasc Surg, 1994, 8(5): 475-484.
71
Bernstein EF,Rhodes GA,Stuart SH, et al. Toe pulse reappear-ance time in prediction of aortofemoral bypass success[J]. Ann Surg, 1981, 193(2): 201-205.
72
Hamdan AD,Rayan SS,Hook SC, et al. Bypasses to tibial vessels using polytetrafluoroethylene as the solo conduit in a predomi-nantly diabetic population[J]. Vasc Endovascular Surg, 2002, 36(1): 59-63.
73
Henke PK,Blackburn S,Proctor MC, et al. Patients undergoing infrainguinal bypass to treat atherosclerotic vascular disease are underprescribed cardioprotective medications: effect on graft pa-tency, limb salvage, and mortality[J]. J Vasc Surg, 2004, 39(2): 357-365.
74
Diehm N,Schillinger M,Minar E, et al. TASC II section E3 on the treatment of acute limb ischemia: commentary from European interventionists[J]. J Endovasc Ther, 2008, 15(1): 126-128.
75
Sobel M,Verhaeghe R, American College of Chest Physicians, et al. Antithrombotic therapy for peripheral artery occlusive disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) [J]. Chest, 2008, 133(6 Suppl): 815S-843S.
76
Ouriel K,Shortell CK,DeWeese JA, et al. A comparison of throm-bolytic therapy with operative revascularization in the initial treat-ment of acute peripheral arterial ischemia[J]. J Vasc Surg, 1994, 19(6): 1021-1030.
77
Results of a prospective randomized trial evaluating surgery ver-sus thrombolysis for ischemia of the lower extremity. The STILE trial[J]. Ann Surg, 1994, 220(3): 251-266.
78
Ouriel K,Veith FJ,Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arte-rial occlusion of the legs. Thrombolysis or Peripheral Arterial Sur-gery (TOPAS) Investigators[J]. N Engl J Med, 1998, 338(16): 1105-1111.
No related articles found!
阅读次数
全文


摘要