The Effects, Influencing Factors And Interventions About Systemic Treatment Of Diabetic Arteriosclerosis Obliterans

ObjectiveTo explore the efficacy and influencing factors of "complex procedures"(embole-ctomy+balloon dilatation+stent implantation, Intimectomy+balloon dilatation+stent implantation) treatment of complex diabetes lower extremity arteriosclerosis obliterans (DLASO).Methods1. From August2007to August2010,338hospitalized patients in Baoding Second Hos-pital Vascular Surgery with lower extremity arterial occlusive disease were Chosen and randomly divided into two groups. There are198patients with diabetes lowerext-remity arteriosclerosis obliterans (DLASO)(61cases of bilateral lesions) of259limbs, and120cases non-diabetic lower extremity atherosclerotic occlusive disease (LEAOD)(41cases with bilateral lesions) of161limbs. According to the preoperative CTA (CT angiography) results, we can make treatment strategies. Some patients that preoperative CTA has prompted lesions vascular with thrombosis should take thrombectomy first and others that superficial femoral artery stenosis or occlusion should adopt local endarterectomy first, by intraoperative angiography to determine lesions vascular stenosis location, then intracavitary interention. Major steps:Through the ipsilateral or contralateral femoral artery anterograde puncturing under local anesthesia, angiography can confirme the site and degree of lesion. Select the appropriate godet, if necessary, Cooperating to use the godet and catheter, the godet can through the stenosis or occlusion of the lesion. According to the location and length of the lesion,the appropriate balloon are selected (which is producted by Italian-British tektronix company:Balloon Diameter2.50mm,3.00mm,4.00mm,6.00mm,7.00mm, length of40mm,60mm,80mm,120mm) the appropriate balloon are selected for expansion at the standard pressure pump.The standard pressure is6-12atm and1-3min of each expansion, if necessary, repeat1or2times.5000U-7000U of heparin though artery should be intraoperative given. In case of intraoperative dissection or poorly expansion effect,tweezers alloy titanium stents (Johnson&Johnson) should be implantanted. End of surgery Urokinase200000U was given by arterial. If appears spasm,0.1-0.2mg of nitroglycerin may be given by artery. For patients with poor outflow tract, limb arterial indwelling epidural catheter with continuous infusion of Lipo20ug, safflower20ml and physiological saline200ml treatment1to2weeks. Subcutaneous injection of low molecular weight heparin5000U/8h each time after operation,, contin uously used for5d, and oral intake of aspirin100mg/d life-long. Followed up6to36months through the return visit and telephone contact of discharged patients. Patients were observed limp symptoms, rest pain changes, and measured of the stage pressure and Doppler blood flow; given CTA, if necessary. To judgement the patency of blood vessels and to investigate the daily life habits, medication and all of regularly biochemical test results. All data entered by Excel, SPSS10.0statistical analysis software.2. There are160patients with lowerext-remity arteriosclerosis obliterans were accepted the cavity forming therapy. There are68patients with lowerext-remity arteriosclerosis obliterans were accepted the artificial blood vessel bypass graft treatment else.We investigated the efficacy of treatment, respectively. We recorded daily life habits of two groups such as smoking, hypertension, high cholesterol, poor blood glucose control at the same time. The data were analyzed to observe the factors influencing efficacy.3.24New Zealand white rabbits were randomly divided into for group:normal control group,fat model group, balloon-injured modle group, atorvastatin treated group. The control group was fed with ordinary diet,other groups were fed on cholesterol-rich diet, followed an injured by dilated balloon on abdominal artery at the end of the5th week. Blood samples were collected at the end of the first and9th week for Examination of serum lipid levels,TNF-a levels and IL-6levels. The abdominal arteries were harvested for histomorphometic analysis the pathogenic features of the arterial wall were showed by HE stain assay.Immunohistochemistry was employed to detect the expression of PDGFR-β.4.118patients with lower extremity arterial occlusive disease were accepted "complex procedures" treatment and randomly divided into two groups(60cases in the control group/58cases in the Observation group). Both groups were treated with aspirin100mg daily. Observation group were treated with atorvastatin20mg daily addition. Patients were observed vascular patency rate, CRP, lipids and IMT before treatment and after treatment for4weeks,12weeks,24weeks. We observeded effects of atorvastatin on the patency rate of vascular lesions.Results1. First Patency rate for the DLASO, LEAOD with the treatment of complex procedures:The initial treatment success rates in318patients were, DLAOD90%of the primary vessels,92%of the secondary vessels, LEAOD91%of the primary vessels,94%of the secondary vessels respectively. Followed up for6to36months, the patients should be rechecked CTA when they return visit, to observe the patency of lower limb vascular. First Patency rate of the two groups reduces with longer follow-up time, DLAOD group is significantly evident. After24months of follow-up, the secondary vascular patency rate was significantly lower than LEAOD (P<0.05).2. DLASO, LEAOD with complex procedures treatment of complex cumulative secondary patency rate:Followed up6to36months, cumulative secondary patency rate of primary vascular is93%and of subprime vascular is73%in DLASO. The results show that primary vascular patency rate in DLASO is inferior to LEAOD, which have no statistical significance; DLASO and LEAOD patients with restenosis or occlusion should be given repeated endovascular treatment, and the results were satisfactory. 3. The rate of stenosis after implantation DLASO or LEAOD stent were compared:The rate of stenosis in DLASO or LEAOD group was significantly lower than only balloon dilatation(P<0.05). However, in Simple balloon dilatation with stent implant, the rate of stenosis DLASO group was higher than LEAOD group, but it is not statistically significant. In all, DLASO or LEAOD group with stent implant can effectively reduce the recurrence of stenosis.4. Clinical effects of "complex procedures" treatment with DLASO and LEAOD:The results show that Secondary treatment success rates in LDLASO Patients was higher than in DLASO Patients. Amputation rate in patients with DLASO was higher than patients with DLASO. They have no statistical significance.5. The relationship between the recurrence rate after DLASO and associated factors:This is no difference on the primary patency rate in the bypass graft treatment group and endovascular treatment group.The related factors about the recurrence rate after DLASO was analysed in a simple linear regression analysis. The result showed that smoking, hypertension, hype-rcholesterolemia and uncontrol blood glucose were the influential factors for the rec-urrence rate in the model, which were introduced into the logistic regression analys-is and in the level of the multivariate factors screen factors associated with recuren-ce rate. The result showed that smoking, hypertension and uncontrol blood glucosea-re associated with the recurrence rate after DLASO.6. Animal experiment:Compared with the control group, the serum total cholesterol levels of rabbits fed with high cholesterol diet were higher(P<0.01),Treatment with atovastatin lowed serum lipid levels(P<0.05). The serum levels of IL-6and TNF-a increased in fat model group, and balloon-injured modle group(P<0.05). The serum levels of IL-6and TNF-a lowed in atorvastatin treated group(P<0.05). The intima thickness in atovastatin treated group were much more decreased than injured modle group(P<0.01). Fat model group and balloon-injured modle group had higher level of expression of PDGFR-β compared with control group and atorvastatin treated group. 7. Intervention role of Atorvastatin in LEAOD patients with restenosis:Two patency rate of vascular lesions were decreased to varying degrees With the follow-up time.We have not seen the same change in the observation group. Followed up for24weeks, the patency rate of the control group was significantly lower than the observation group(P<0.05). Atorvastatin may have a Intervention role in patients with restenosis.Conclusion1. The "complex procedures" method has a wide range of indications for Treatment arteriosclerosis obliterans and can also be used to treat complex patients who are untreated with the traditional method. The surgical procedures are under local anesthesia that materially minimizes the risk of complications which are caused by anesthesia, reduces the danger of excess injury for patients by traditional surgery and relatively shortens the time of treatment, besides, it can be repeated and it is undoubtedly about its effect.2. Primary patency rate was not significantly different in the people who were accepted cavity forming therapy or artificial blood vessel bypass graft treatment. Three factors including smoking, hypertension and uncontrol blood glucose are related to the repeated LASO. The efficacious prognosis of patients who had arterial occlusive disease can be improved in control of these related factors. Further research about intervention endovascular treatment for resist restenosis is needed.3. Atorvastatin can inhibit vascular stenosis in high cholesterol diet plus balloon injured rabbit modle by reducing serum lipids, inflammatory factors. The media thickess were increased in abdominal artery after balloon injury, atorvastatin can protect the abdomal artery from this injury, the expression of PDGFR-β in arterial walls in atorvastatin treated group may contributed to this protective effect.4. Atorvastatin can restrain the hyperplasia of vascular endothelial, it can prevent the disease process of atherosclerosis at the same time. Atorvastatin can prevent restenosis after systemic treatment of diabetic arteriosclerosis obliterans. Patency rate was increased by atorvastatin...