发表一个常见话题,互相学习也让本版活跃起来吧。周围动脉疾病的手术转流和介入xx现在应该开展的很多了,好象术后的用药并没有一个规范,即便是血管科最常规的抗血小板和抗凝xx,在此提出一些疑问,希望听听大家的见解,更希望大家的答案有循症医学的证据:
1.动脉PTA及支架置入术后抗血小板xx是否需要加强,加强多久?
2.膝下段动脉Deep球囊扩张以后有没有必要给予抗凝溶栓xx？毕竟术后小动脉很容易继发血栓
3.人工血管旁路转流术后是否需要抗凝xx，xx多久？其间又分很多情况，腹主动脉瘤切除术后需要否？股股转流术后需要否？静脉的转流如布加的转流手术？
4.静脉支架的植入如布加.髂静脉受压综合症术后是否需要抗凝xx，xx多久？
先提出这些问题吧，互相补充，互相解答，体现出网络的互助，呵呵。
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xx的数据和推荐方案，建议大家参考AHA/ASA、TASC等的指南，都有详细的论述。个人经验也多少反映了国外指南的意见，简单回答一下：
1、您提到的“加强”是什么含义？对介入围手术期的抗血小板xx好像没有这个概念，只有急诊手术前加量的紧急术前准备方案，即波利维300mg顿服，一般的术前准备都是波利维75mg qd、加/不加阿司匹林75~225mg qd至少3天，术后同样，但3~6个月后波利维可以停掉。
2、膝下血管介入xx后，指南中没有特殊要求，和上述方案一样。小动脉容易血栓形成，是您的经验还是推测？至少我们没碰到过膝下动脉硬化闭塞症Deep球囊扩张后血栓形成的。术后短期的抗凝（低分子肝素）相信在国内的医生是普遍应用的，但并没有具体的根据。
3、人工血管旁路转流术后，腹主动脉瘤切除术后基本不需要、或者单纯阿司匹林足够；股腘转流术后也不推荐，2004年的J Vasc Surg曾有一篇大样本的对照，结论是仅有膝下人工血管旁路术后采用华法林抗凝是获益的。布加的转流个人没有经验，相信是应该抗凝xx的。
4、布加的支架植入，我们开展不多，李晓强教授的常规做法是抗凝3~6个月，我想应该不是担心下腔静脉支架会堵塞，更多的原因是担心局部小血栓造成肺栓塞的风险；髂静脉支架我们目前xx于DVT溶栓术后的左髂静脉狭窄，当然是抗凝了。
也说说自己的看法（有些东西还是缺乏证据的）:
1.同意mingshengdai1979，PTA及支架置入后，应该服用波立维75mg qd ,三至六个月；拜阿司匹林100mg qd 终身；
2.曾经做过几例膝下动脉闭塞的膝下段动脉Deep球囊扩张，还是开通了膝下动脉，术后效果不佳，也没有立即复查，血栓形成是有想当然的因素，但觉得也是一种合理的解释。这个做的人还是不少的，想听听大家意见。
3.人工血管旁路转流术后有人讲到膝下的转流要用，大动脉就不用了，我想无非是血流速度的问题，血流快不易血栓，单临床上还是看到股股转流术后血栓形成乃至闭塞的，曾经一病例腘动脉瘤切除原位重建术后吻合口部位血栓形成的，也困惑。个人认为是否结合术后血流速度，血流动力学的因素（个人感觉了）考虑一下个体化了，虽然不规范，但也是一种探索吧。
静脉的转流应该血栓形成的高风险，因该是用的，还有个问题，人工血管植入后能够内皮细胞覆盖管腔内皮化吗？可能这个问题的答案能够回答抗凝药要用多久。
4.是想只道静脉血栓是否会引起局部血栓，这种危险因素会持续多久。个人对此所知甚少。
mingshengdai1979提到了抗凝xx，但华发林的使用建议参阅一下《2003年美国心脏协会／美国心脏病学会华法林xx指南》
ACCP 2008相关内容，请参阅
1.0 Chronic Limb Ischemia and
Intermittent Claudication
1.1.1.1. In peripheral artery occlusive disease
patients with clinically manifest coronary or
cerebrovascular disease, we recommend lifelong
antiplatelet therapy in comparison to no
antiplatelet therapy (Grade 1A).
1.1.1.2. In those without clinically manifest coronary
or cerebrovascular disease, we suggest aspirin
(75–100 mg/d) over clopidogrel (Grade 2. In
patients who are aspirin intolerant, we recommend
clopidogrel over ticlopidine (Grade 1.
Underlying values and preferences: This recommendation
places a relatively high value on avoiding large
expenditures to achieve uncertain, small reductions in
vascular events.
1.1.2. In patients with peripheral artery occlusive
disease and intermittent claudication, we
recommend against the use of anticoagulants to
prevent vascular mortality or cardiovascular
events (Grade 1A).
1.1.4. For patients with moderate-to-severe disabling
intermittent claudication who do not
respond to exercise therapy, and who are not
candidates for surgical or catheter-based intervention,
we recommend cilostazol (Grade 1A).
We suggest that clinicians not use cilostazol in
those with less disabling claudication (Grade
2A). We recommend against the use of pentoxifylline
(Grade 2.
Underlying values and preferences: Because of the
cost of cilostazol therapy, and the safety and efficacy
of an exercise program, we recommend cilostazol
treatment be reserved for patients with moderateto-
severe claudication who have tried and failed an
exercise program, and are not candidates for vascular
surgical or endovascular procedures.
1.1.5. For patients with intermittent claudication,
we recommend against the use of anticoagulants
(Grade 1A).
1.1.6. For patients with limb ischemia, we
suggest clinicians do not use prostaglandins
(Grade 2.
2.1. In patients who suffer from acute arterial
emboli or thrombosis, we recommend immediate
systemic anticoagulation with UFH, over no
anticoagulation (Grade 1C). In patients undergoing
embolectomy, we suggest following systemic
anticoagulation with UFH with long-term
anticoagulation with VKA (Grade 2C).
2.2. In patients with short-term (< 14 days)
thrombotic or embolic disease, we suggest intraarterial
thrombolytic therapy (Grade 2, provided
patients are at low risk of myonecrosis and
ischemic nerve damage developing during the
time to achieve revascularization by this method.
Underlying values and preferences: This recommendation
places relatively little value on small reductions
in the need for surgical intervention and relatively
high value on avoiding large expenditures and
possible major hemorrhagic complications.
3.1. For patients undergoing major vascular
reconstructive procedures, we recommend IV
UFH, prior to the application of vascular cross
clamps (Grade 1A).
3.2. For all patients undergoing infrainguinal
arterial reconstruction, we recommend aspirin
(75–100 mg, begun preoperatively) [Grade 1A].
We recommend against the routine use of perioperative
dextran, heparin, or long-term anticoagulation
with VKA for all extremity reconstructions
(Grade 1.
3.3. For patients receiving routine autogenous
vein infrainguinal bypass, we recommend aspirin
(75–100 mg, begun preoperatively) [Grade
1A]. We suggest that VKA not be used routinely
in patients undergoing infrainguinal vein bypass
(Grade 2. For those at high risk of bypass
occlusion and limb loss, we suggest VKA plus
aspirin (Grade 2.
Underlying values and preferences: These recommendations
place relatively little value on small
increases in long-term patency that may be statistically
uncertain, and a relatively high value on avoiding
hemorrhagic complications.
3.4. For patients receiving routine prosthetic
infrainguinal bypass, we recommend aspirin
(75–100 mg, begun preoperatively) [Grade 1A].
We suggest that VKA not be used routinely in
patients undergoing prosthetic infrainguinal
bypass (Grade 2A).
Underlying values and preferences: These recommendations
place relatively little value on small
increases in long-term patency that may be statistically
uncertain, and a relatively high value on avoiding
hemorrhagic complications.
4.0. In patients undergoing carotid endarterectomy,
we recommend that aspirin, 75–100 mg,
preoperatively to prevent perioperative ischemic
neurologic events. We recommend lifelong postoperative
aspirin (75–100 mg/d) [Grade 1A].
5.0. In nonoperative patients with asymptomatic
carotid stenosis (primary or recurrent), we recommend
lifelong aspirin, 75–100 mg/d (Grade 1C).
In this patient group, we recommend against dual
antiplatelet therapy with aspirin and clopidogrel
(Grade 1.
6.0. For patients undergoing lower-extremity balloon
angioplasty (with or without stenting), we
recommend long-term aspirin (75–100 mg/d)
[Grade 1C]. For patients undergoing lowerextremity
balloon angioplasty (with or without
stenting), we recommend against anticoagulation
with heparin or VKA (Grade 1A).