庞鹤学术思想与临床经验总结及益气活血解毒法对下肢动脉硬化闭塞症动脉腔内成形术后的治疗作用

发布时间：2018-05-21 18:32

本文选题：经验继承 + 下肢动脉硬化闭塞症　；参考：《北京中医药大学》2016年博士论文

【摘要】：背景：下肢动脉硬化闭塞症(ASO)是一种高发病率、高致残率的疾病、严重影响患者生活治疗质量。药物治疗现代医学的药物、手术疗法均有各自的局限性。单一的药物治疗能够在一定程度上缓解临床症状,但不能针对病因根本上治愈,因而治愈率较低。传统的血管外科开放性手术由于适应症的选择,大部分患者不可能采用手术治疗。近年来,血管腔内技术不断发展,血管腔内治疗能有效改善下肢血供,但术后再狭窄的高发生率,造成血管通畅率降低而直接影响着患者的预后。因此,降低介入治疗后再狭窄,提高通畅率已成为亟需解决的课题。中药对下肢动脉硬化闭塞症治疗具有自身优势,其作用机理多为降低血脂、血液粘稠度,抗血小板、抗血栓,改善微循环,促进侧枝循环等作用。然而,中药对介入治疗后再狭窄治疗的研究报道极少,个别报道是以活血化瘀治疗为主,也没有相对严格的随机对照研究和明确的药物作用时间靶点和疗程,因此,有必要加强此方面研究。在ASO治疗中,将发生动脉硬化性闭塞的肢体血管通过动脉腔内治疗技术使血管开通,从而改善肢体的远端供血,患者的临床缺血症状和指标得到改善。但其原发病动脉粥样硬化的进程并没有停止,由于肢体动脉硬化的继续发展,从而造成治疗靶血管及其近远端或其他部位再发狭窄或闭塞。庞鹤教授在继承陈淑长教授“血瘀证”辨证思路基础上,提出下肢动脉硬化闭塞症主要病机为“正虚瘀浊化毒阻络”,以益气活血解毒法治疗ASO,对下肢动脉腔内治疗术后再狭窄、闭塞取得良好临床疗效。其次,现代研究表明血管腔内介入术后再狭窄主要因素可能为血管内膜增生和血管重塑所致。很多研究表明中药对抑制血管内皮增生和血管重塑具有干预作用。如：破瘀药物能水蛭提取物可使内皮细胞跨膜受体VEGFR2表达明显减少,从而抑制血管内膜生成。再者,血管腔内治疗球囊及支架对内膜刺激损伤后导致血管内膜增生的原因可能为支架刺激切割血管内膜,由此引发炎症和免疫反应,近年来,众多学者认为动脉内膜损伤导致的炎症是动脉硬化形成的初始动因,即“炎症-损伤-反应”学说。因此,对动脉腔内成形后血管损伤引起的血管内皮炎症的干预治疗,保护血管内膜细胞结构和功能完整性,对提高ASO介入术后的通畅率至关重要。清热解毒类中药具有明确的抗炎作用,对提高下肢动脉腔内治疗术后通畅率具有治疗意义。下肢动脉硬化闭塞症介入术后早期患者无缺血症状,患者往往不会进行中药治疗,早期应用中药提高动脉腔内治疗后血管通畅率成为必要的研究课题。因此,有必要进行益气活血解毒中药对血管腔内成形术后疗效研究,对提高动脉腔内治疗术后通畅率,避免再狭窄反复手术及因此而造成的下肢缺血加重具有重要意义。目的：益气活血解毒中药应用下肢动脉硬化闭塞症动脉腔内成形术后患者,观察通畅率及临床疗效(包括踝肱指数、经皮氧分压)。为益气活血解毒中药治疗下肢动脉硬化闭塞症下肢动脉腔内成形术后再狭窄及闭塞提供临床依据。并为中药干预下肢动脉硬化闭塞症的治疗时机探索新途径和提供一种新的研究思路和方法。方法：依据统计学估算所需病例数,按脱落率20%计算,选择2013年2月至2015年3月我院下肢动脉硬化闭塞症介入治疗患者100名,将入选病例随机分为A组(治疗组)和B组(对照组),治疗90天。观察入组后3个月、6个月肢体ABI、TcPO2、下肢动脉彩超血管通畅情况等指标。结果：共完成病例观察88例,两组患者6个月下肢动脉腔内成形术后血管通畅率比较差异显著,有统计学意义,治疗组高于对照组；A组治疗前后经皮氧分压比较差异显著,治疗后优于治疗前。A组出现血管再狭窄、闭塞的患者治疗前后TcP02比较差异无统计学意义。结论：早期应用益气活血解毒中药可以提高动脉腔内成形术后的血管通畅率,同时可以促进侧枝循环的建立,提高局部经皮氧分压,改善局部循环。当血管出现再狭窄、闭塞时,可以缓解缺血症状,提高局部供血,对提高患者生活质量有重要意义。
[Abstract]:Background: lower extremity arteriosclerosis obliterans (ASO) is a disease with high morbidity and high disability, which seriously affects the quality of life and treatment of patients. Drug treatment of modern medicine has its own limitations. A single drug treatment can relieve clinical symptoms to a certain extent, but it can not be fundamentally cured for the cause of the disease. The cure rate is low. In the traditional open surgery of vascular surgery, because of the choice of indications, most patients can not be treated with surgical treatment. In recent years, endovascular technology is developing continuously. Endovascular treatment can effectively improve the blood supply of the lower extremities. However, the high incidence of restenosis after operation leads to the decrease of vascular patency and direct influence on the patient. Therefore, it has become an urgent task to reduce restenosis after interventional therapy and improve the patency rate. Traditional Chinese medicine has its own advantages for the treatment of arteriosclerosis obliterans of the lower extremities. Its mechanism is mainly to reduce blood lipid, blood viscosity, anti platelet, antithrombotic, improve microcirculation, and promote collateral circulation. However, interventional therapy is used in Chinese medicine. There are few reports on the treatment of restenosis. There are few reports on the treatment of blood circulation and blood stasis, and there is no relatively strict randomized controlled study and definite time target and course of drug action. Therefore, it is necessary to strengthen this research. In the treatment of ASO, the artery intracavitary blood vessels of the arteriosclerosis obliterans are treated through the endovascular technique. The operation makes the blood vessels open, thus improving the distal blood supply of the limbs, and the clinical ischemic symptoms and indicators of the patients are improved. However, the process of atherosclerosis has not stopped, because the arteriosclerosis of the limbs continues to develop, resulting in the restenosis or occlusion of the target vessel and its near distal or other parts. On the basis of Professor Chen Shuchang's syndrome differentiation of blood stasis syndrome, the main pathogenesis of arteriosclerosis obliterans of the lower extremities is "positive asthenia and turbidity toxic obstructing collaterals", and the treatment of ASO with the method of Invigorating Qi and activating blood and detoxification, and obtaining good clinical curative effect for restenosis after endovascular treatment in the lower extremity. The narrow main factors may be caused by vascular intima hyperplasia and vascular remodeling. Many studies have shown that traditional Chinese medicine can interfere with the inhibition of vascular endothelial proliferation and vascular remodeling. For example, the extract of leech can reduce the expression of transmembrane receptor VEGFR2 in endothelial cells and inhibit the formation of vascular intima. The causes of intimal hyperplasia that lead to intimal injury in the capsule and stent may be caused by the stent stimulation of the vascular intima, which leads to inflammation and immune response. In recent years, many scholars believe that the inflammation caused by arterial intimal injury is the initial cause of arteriosclerosis, that is, the "inflammation injury reaction" theory. The intervention treatment of vascular endothelial inflammation caused by vascular injury after forming, protecting the structure and functional integrity of the vascular intima cells, is very important to improve the patency rate after ASO intervention. The antipyretic drugs of clearing heat and detoxification have definite anti inflammatory effects and have the therapeutic significance for improving the patency rate after the treatment of the lower extremity arterial endovascular treatment. Early patients without ischemic symptoms after interventional therapy are often not treated with traditional Chinese medicine. Early application of traditional Chinese medicine to improve the vascular patency after endovascular treatment is a necessary research topic. Therefore, it is necessary to study the therapeutic effect of the Chinese medicine of Yiqi Huoxue detoxification after endovascular endovascular therapy and to improve the patency rate after endovascular treatment. Objective: To observe the patency rate and clinical effect (including the ankle brachial index and percutaneous oxygen partial pressure) for the patients with arteriosclerosis obliterans of lower extremity after internal arteriosclerosis of lower extremity arteriosclerosis obliterans. To provide clinical basis for restenosis and occlusion of lower extremity arterial cavity after arteriosclerosis obliterans, and to explore new ways and provide a new way of thinking and methods for the treatment of arteriosclerosis obliterans of lower extremities by Chinese medicine. Methods: the number of cases required by statistics is estimated according to the number of cases required, and 20% to March 2015 from February 2013 to March 2015. 100 patients with arteriosclerosis obliterans were randomly divided into group A (treatment group) and group B (control group), and the treatment was treated for 90 days. The limb ABI, TcPO2, artery patency of lower extremity arteries were observed for 3 months and 6 months. Results: a total of 88 cases were observed, and the two groups were formed in the lower extremity for 6 months. The postoperative vascular patency rate was significantly different, with statistical significance, the treatment group was higher than the control group, A group before and after treatment of percutaneous oxygen pressure difference was significant, after treatment was better than before the treatment group.A restenosis, the patients with occlusion of TcP02 before and after treatment had no statistically significant difference. Conclusion: early application of Qi enriching and activating blood to detoxify Chinese medicine can be used. In order to improve the vascular patency after internal angioplasty, it can also promote the establishment of collateral circulation, improve partial percutaneous oxygen pressure and improve the local circulation. When the blood vessels are restenosis and occlusion, it can relieve the symptoms of ischemia and improve the local blood supply. It is of great significance to improve the quality of life of the patients.
【学位授予单位】：北京中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R259

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