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#137
10.08.2014, 11:13
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Год назад я писал про новые отечественные рекомендации
Цитата:
Тезисно по американским консенсусам (я пропускал очевидные бесспорные положения). Аорто-подвздошный сегмент. - For Type “D” lesions, surgical bypass is the preferred treatment modality for revascularization. However, with improved operator techniques and newer re-entry devices/catheters, experienced endovascular specialists are able to approach TASC C and D lesions with an endovascular strategy. Hybrid surgical-endovascular approaches have also been developed for patients with aorto-iliac and lower extremity occlusive disease.....Operator and institutional expertise should also be considered in the treatment algorithm, particularly for patients with extensive and complex aorto-iliac disease (TASC C and D lesions).......Overall, aorto-iliac occlusive disease is more commonly being treated with an endovascularfirst approach, using open surgery as a secondary option. - Occasionally, intervention is necessary in asymptomatic patients to facilitate delivery of large sheaths (endovascular aneurysm repair, transcatheter aortic valve replacement), hemodynamic support devices, or to facilitate percutaneous coronary intervention. - Appropriate care - Internal iliac artery (IIA) with moderate to severe symptoms of buttock or hip claudication or major tissue loss (RC 2–6) with >50% stenosis and/or resting mean translesional gradient >5 mmHg. - May be appropriate care - IIA >50% stenosis with vasculogenic impotence. - The preferred site for arterial access depends on several factors including: ……… 7) availability (доступность, пригодность) of radial or brachial artery access. - Initial arterial access via the radial artery or brachial artery is also an attractive option for some patients, but lesion location and equipment length should be taken into account during treatment planning. - Primary stent placement may minimize vessel recoil and prevent abrupt occlusion, but there is debate over the relative benefit of primary stenting vs. provisional stenting for reducing restenosis in this vascular territory. The current 2011 ACC/AHA guideline document supports primary stenting of the common and external iliac arteries with a Class I recommendation (Level of Evidence B). - Either balloon expandable or self-expanding stents can be used for the treatment of aorto-iliac lesions. Overall, no clinically available stent has been demonstrated as superior to any other in the aorto-iliac distribution. - One option is to perform a hybrid procedure with open femoral endarterectomy (with or without profundoplasty) followed iliac stenting. - Following aorto-iliac intervention, it is important to perform a post intervention arterial run-off angiogram to rule out DE. DE has been reported in most studies of iliac interventions; the incidence ranges from 0.4 to 9%. - Pain during balloon inflation is a warning sign of impending rupture. Perforations can be stabilized with immediate balloon inflation proximal to the tear to tamponade the bleeding. Продолжение следует... 
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#138
10.08.2014, 11:24
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Бедренно-подколенный сегмент.
- Contemporary clinical trials data and experience in the treatment of FP disease supports an endovascular-first approach, with the reservation of open surgery for selected individuals. - However, there are selected patients who are considered poor candidates for CFA endarterectomy and may be amenable to endovascular treatments. These include patients with severe medical comorbidities or scarred groins from previous operations or infections. - Although there is no evidence of clinical benefit for dual antiplatelet therapy to support endovascular treatment of FP disease, it is common practice, following intervention, to add a thienopyridine (typically clopidogrel) for 1–3 months to a daily aspirin. - There is no evidence that cryoplasty or cutting balloon atherotomy have any objective benefit over conventional, less-expensive therapies in treating FP disease. - However, comparative data are lacking regarding the effectiveness of newer stent designs, such as the interwoven Supera stent and whether newer designs translate into improved clinical value. - The Viabahn stent graft is approved for treatment of SFA lesions; however, head to head comparative studies with bare metal stents in complex TASC C and D have not shown an advantage. - There are no objective or controlled data that any of these devices (Atherectomy) have any favorable impact on long-term patency compared with conventional devices. - In several randomized clinical trials, DCBs have been shown to reduce the rate of FP restenosis compared with conventional PTA. DCBs have not yet been approved for use in the United States. ВТК сегмент - Ambulatory patients who are acceptable surgical candidates, expected to survive more than two years with a patent IP artery that provides direct flow to the foot (considered to be a good distal target), and an adequate autologous venous conduit should be considered for surgical bypass. Patients with significant medical comorbidities that limit life expectancy, those at increased risk for surgery, those without an adequate distal target for bypass, or with poor venous conduit should be considered for an endovascular-first approach. - Procedural success is defined as the re-establishment direct “in-line” pulsatile flow to the foot through at least one IP artery. It is currently unknown whether healing rates are improved when in-line flow to the foot is established through more than one IP artery, but maximizing blood flow through more than one artery is particularly attractive in patients with inadequate collaterals, plantar arch vessels, or limb-threatening ischemia. - Furthermore, revascularization of the angiosome (a three-dimensional vascular territory supplied by specific source artery), has been shown to improve healing rates, using either endovascular or surgical therapies, when compared to revascularization of the non-angiosome territory. However, realistically the angiosomebased revascularization strategy may be limited by the length and/or complexity of disease, the extent of collateralization, and the anatomic variability among patients, including anatomic anomalies. - Cutting balloon angioplasty (Boston Scientific, Natick, MA) may be appropriate for lesions resistant to plain balloon angioplasty that are fibrous or calcified, but the added cost, and lack of comparative evidence, makes these balloons not ideal for routine use. - This promising technology (Drug-coated balloons) is not yet approved for use in the United States. (очень они дипломатично о лекарственных баллонах написали  )- Currently, there is no comparative evidence to support the use of any atherectomy devices in the IP arteries to improve clinical outcomes. - Consequently, the use of stents in the IP arteries is still under scrutiny and is felt to be most effective in focal, proximal lesions that fail primary therapy with balloon angioplasty. Furthermore, the patency advantage of stenting may be more applicable to Rutherford 3 and 4 than Rutherford 5 and 6 where stenting has not been consistently shown to affect limb salvage rates. - However, until these results are available, given the increased costs of other modalities (e.g., cutting balloons, cryoplasty, laser, orbital, rotational, and directional atherectomy catheters), and the lack of comparative data to support their efficacy, balloon angioplasty should remain the initial endovascular therapy for most IP disease. Продолжение следует ......
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#139
10.08.2014, 11:47
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Подытоживая, можно сказать, что эти рекомендации не рекомендуют лечить в очень очевидных ситуациях. Стенозы менее 50%, стенозы и окклюзии с незначительными симптомами, выраженную ПХ с однососудистым поражением на голени.
О многих положениях пишут в контексте пока еще слабых доказательств. Позволяют достаточную свободу выбора для хирургов. При слабых финансовых возможностях вполне допустимо использование доброй старой баллонной ангиопластики в общем-то на всех уровнях. Допускают возможность использования различных техник, девайсов и доступов. И самое главное. Я еще раз перечитал главы отечественных рекомендаций, касающиеся вопросов реваскуляризации н/к. И снова готов с удовольствием заключить, что почти все положения не противоречат, а часто совпадают с новыми американскими консенсусами. Это тем более приятно, что отчизна переживает трудные времена и всякий в любой момент готов сказать, что все наше - все плохое. А вы как думаете? Про рекомендации, про консенсусы.
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#140
11.08.2014, 20:41
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Цитата:
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#141
12.08.2014, 06:56
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Цитата:
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#143
21.08.2014, 06:47
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Да, сомнений нет, учить нужно и тому, и другому. Иначе получается перекос....
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#144
21.08.2014, 07:45
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Да уж, лучше им вообще-то учиться у нас. Мы их научим всяким доступам с помощью всяких ухищрений. А также научим как делать ангиопластики использованными инструментами или когда раходки вообще мало и не та. Научим работать, не показываясь на учебах. Научим делать одно, говорить другое, а читать третье. Научим работать на любых аппаратах при любом руководстве.
Они забудут про парадоксы.
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#146
21.08.2014, 18:18
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Алексей просто зажигает последнее время на форуме! Ну я даже не смотрю там, например, новости в интернете. Война и санкции во все дырки...
 Прихожу вечером и читаю от доктора Мизина в разных разделах массу интересного, поучительного и философского. Пишу это искренне, чтобы выразить свое восхищение нестандартному мышлению этого классного доктора как в клинических случаях так и по жизни.
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#147
22.08.2014, 08:25
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Цитата:
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#148
22.08.2014, 11:32
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#Вопрос, кстати, достаточно актуальный: учить одновременно обоим доступам или последовательно... И если последнее, чему вначале?#
Роман Сергеевич! Я думаю надо последовательно, сначала классический бедренный, потом уже ухищрения - лучевой, локтевой, плечевой и пр. Это по аналогии с хирургией - вначале классика - большой разрез, полостные операции, потом лапароскопические. Иначе будет примерно так: молодой хирург-лапароскопист делает операцию(холецистэктомия, например), идет не так, требуется конверсия, он не умеет - вызывает опытного хирурга (ему лапароскопически оперировать не дают - поздно учиться), тот говорит - ты хирург, вот и оперируй.
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#150
22.08.2014, 14:28
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Цитата:
 Поэтому учить будем, я так думаю.
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Линейный вид
