Advances in the Assessment, Prevention, and Treatment of Postoperative Dissection after Percutaneous Transluminal Angioplasty for Lower Extremity Arteriosclerosis Obliterans

目的：了解下肢动脉硬化闭塞症(ASO)行经皮腔内血管成形术(PTA)后夹层评估、预防和治疗的新近研究进展，为减少严重夹层的发生寻找新的突破点。方法：遵循PRISMA 2020指南系统检索PubMed、Web of Science、Embase等数据库(2000年~2024年)，筛选PTA后夹层评估、预防及治疗相关文献进行综述。结果：目前文献报道夹层的评估主要依赖数字减影血管造影(DSA)、血管内超声(IVUS)和光学相干断层扫描(OCT)等影像学技术，但DSA因二维成像局限可能低估夹层，IVUS与OCT虽精准但普及受限。夹层分级系统如NHLBI、Kobayashi、iDissection和DISFORM等提供了评估和治疗的依据，但仍缺乏统一标准。文献报道长病变、窄管腔和软斑块可能是严重夹层的预测因素，而通过避免偏心导丝路径、使用长球囊、增加球囊扩张时间，或是进行减容治疗等方式，可以减少严重夹层发生。针对PTA后夹层的治疗主要为补救性的支架置入，而Tack血管装置作为一种新兴的治疗方法，有望在未来血管夹层治疗中发挥更大作用。结论：PTA后严重夹层的预防和治疗是必要的，夹层的评估、预防和治疗是连续、复杂且动态的过程。应根据最新的研究进展和患者的具体情况，制定个性化方案，尽可能减少严重夹层形成，促进血管长期通畅。Objective: To understand recent research progress in the assessment, prevention, and treatment of postoperative dissection after percutaneous transluminal angioplasty (PTA) for lower extremity arteriosclerosis obliterans (ASO), and to find new breakthroughs in reducing severe dissection events. Methods: A systematic search was conducted following the PRISMA 2020 guidelines across databases including PubMed, Web of Science, and Embase (2000~2024) to screen and review relevant literature on the assessment, prevention, and treatment of post-PTA dissection. Results: Dissection assessment mainly depends on DSA, IVUS, and OCT, but DSA has limitations and the clinical use of IVUS and OCT is limited. Classification systems like NHLBI, Kobayashi, iDissection, and DISFORM offer assessment and treatment references but lack unified standards. Literature shows long lesions, narrow lumens, and soft plaques may predict severe dissection. Severe dissection can be reduced by avoiding eccentric wire paths, using long balloons, increasing balloon expansion time, or atherectomy. Post-PTA dissection treatment is mainly salvage stenting. The Tack vascular device, a new method, is expected to play a bigger role in future dissection treatment. Conclusion: Preventing and treating severe post-PTA dissection is crucial. Its assessment, prevention, and treatment are continuous, complex, and dynamic. Personalized plans based on the latest research and patient-specific conditions should be developed to minimize severe dissection and ensure long-term vascular patency.