本文選題：經(jīng)驗(yàn)繼承 + 下肢動(dòng)脈硬化閉塞癥��； 參考：《北京中醫(yī)藥大學(xué)》2016年博士論文

【摘要】：背景：下肢動(dòng)脈硬化閉塞癥(ASO)是一種高發(fā)病率、高致殘率的疾病、嚴(yán)重影響患者生活治療質(zhì)量。藥物治療現(xiàn)代醫(yī)學(xué)的藥物、手術(shù)療法均有各自的局限性。單一的藥物治療能夠在一定程度上緩解臨床癥狀,但不能針對(duì)病因根本上治愈,因而治愈率較低。傳統(tǒng)的血管外科開放性手術(shù)由于適應(yīng)癥的選擇,大部分患者不可能采用手術(shù)治療。近年來,血管腔內(nèi)技術(shù)不斷發(fā)展,血管腔內(nèi)治療能有效改善下肢血供,但術(shù)后再狹窄的高發(fā)生率,造成血管通暢率降低而直接影響著患者的預(yù)后。因此,降低介入治療后再狹窄,提高通暢率已成為亟需解決的課題。中藥對(duì)下肢動(dòng)脈硬化閉塞癥治療具有自身優(yōu)勢,其作用機(jī)理多為降低血脂、血液粘稠度,抗血小板、抗血栓,改善微循環(huán),促進(jìn)側(cè)枝循環(huán)等作用。然而,中藥對(duì)介入治療后再狹窄治療的研究報(bào)道極少,個(gè)別報(bào)道是以活血化瘀治療為主,也沒有相對(duì)嚴(yán)格的隨機(jī)對(duì)照研究和明確的藥物作用時(shí)間靶點(diǎn)和療程,因此,有必要加強(qiáng)此方面研究。在ASO治療中,將發(fā)生動(dòng)脈硬化性閉塞的肢體血管通過動(dòng)脈腔內(nèi)治療技術(shù)使血管開通,從而改善肢體的遠(yuǎn)端供血,患者的臨床缺血癥狀和指標(biāo)得到改善。但其原發(fā)病動(dòng)脈粥樣硬化的進(jìn)程并沒有停止,由于肢體動(dòng)脈硬化的繼續(xù)發(fā)展,從而造成治療靶血管及其近遠(yuǎn)端或其他部位再發(fā)狹窄或閉塞。龐鶴教授在繼承陳淑長教授“血瘀證”辨證思路基礎(chǔ)上,提出下肢動(dòng)脈硬化閉塞癥主要病機(jī)為“正虛瘀濁化毒阻絡(luò)”,以益氣活血解毒法治療ASO,對(duì)下肢動(dòng)脈腔內(nèi)治療術(shù)后再狹窄、閉塞取得良好臨床療效。其次,現(xiàn)代研究表明血管腔內(nèi)介入術(shù)后再狹窄主要因素可能為血管內(nèi)膜增生和血管重塑所致。很多研究表明中藥對(duì)抑制血管內(nèi)皮增生和血管重塑具有干預(yù)作用。如：破瘀藥物能水蛭提取物可使內(nèi)皮細(xì)胞跨膜受體VEGFR2表達(dá)明顯減少,從而抑制血管內(nèi)膜生成。再者,血管腔內(nèi)治療球囊及支架對(duì)內(nèi)膜刺激損傷后導(dǎo)致血管內(nèi)膜增生的原因可能為支架刺激切割血管內(nèi)膜,由此引發(fā)炎癥和免疫反應(yīng),近年來,眾多學(xué)者認(rèn)為動(dòng)脈內(nèi)膜損傷導(dǎo)致的炎癥是動(dòng)脈硬化形成的初始動(dòng)因,即“炎癥-損傷-反應(yīng)”學(xué)說。因此,對(duì)動(dòng)脈腔內(nèi)成形后血管損傷引起的血管內(nèi)皮炎癥的干預(yù)治療,保護(hù)血管內(nèi)膜細(xì)胞結(jié)構(gòu)和功能完整性,對(duì)提高ASO介入術(shù)后的通暢率至關(guān)重要。清熱解毒類中藥具有明確的抗炎作用,對(duì)提高下肢動(dòng)脈腔內(nèi)治療術(shù)后通暢率具有治療意義。下肢動(dòng)脈硬化閉塞癥介入術(shù)后早期患者無缺血癥狀,患者往往不會(huì)進(jìn)行中藥治療,早期應(yīng)用中藥提高動(dòng)脈腔內(nèi)治療后血管通暢率成為必要的研究課題。因此,有必要進(jìn)行益氣活血解毒中藥對(duì)血管腔內(nèi)成形術(shù)后療效研究,對(duì)提高動(dòng)脈腔內(nèi)治療術(shù)后通暢率,避免再狹窄反復(fù)手術(shù)及因此而造成的下肢缺血加重具有重要意義。目的：益氣活血解毒中藥應(yīng)用下肢動(dòng)脈硬化閉塞癥動(dòng)脈腔內(nèi)成形術(shù)后患者,觀察通暢率及臨床療效(包括踝肱指數(shù)、經(jīng)皮氧分壓)。為益氣活血解毒中藥治療下肢動(dòng)脈硬化閉塞癥下肢動(dòng)脈腔內(nèi)成形術(shù)后再狹窄及閉塞提供臨床依據(jù)。并為中藥干預(yù)下肢動(dòng)脈硬化閉塞癥的治療時(shí)機(jī)探索新途徑和提供一種新的研究思路和方法。方法：依據(jù)統(tǒng)計(jì)學(xué)估算所需病例數(shù),按脫落率20%計(jì)算,選擇2013年2月至2015年3月我院下肢動(dòng)脈硬化閉塞癥介入治療患者100名,將入選病例隨機(jī)分為A組(治療組)和B組(對(duì)照組),治療90天。觀察入組后3個(gè)月、6個(gè)月肢體ABI、TcPO2、下肢動(dòng)脈彩超血管通暢情況等指標(biāo)。結(jié)果：共完成病例觀察88例,兩組患者6個(gè)月下肢動(dòng)脈腔內(nèi)成形術(shù)后血管通暢率比較差異顯著,有統(tǒng)計(jì)學(xué)意義,治療組高于對(duì)照組；A組治療前后經(jīng)皮氧分壓比較差異顯著,治療后優(yōu)于治療前。A組出現(xiàn)血管再狹窄、閉塞的患者治療前后TcP02比較差異無統(tǒng)計(jì)學(xué)意義。結(jié)論：早期應(yīng)用益氣活血解毒中藥可以提高動(dòng)脈腔內(nèi)成形術(shù)后的血管通暢率,同時(shí)可以促進(jìn)側(cè)枝循環(huán)的建立,提高局部經(jīng)皮氧分壓,改善局部循環(huán)。當(dāng)血管出現(xiàn)再狹窄、閉塞時(shí),可以緩解缺血癥狀,提高局部供血,對(duì)提高患者生活質(zhì)量有重要意義。
[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.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R249;R259

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5 黃t，

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