韓濟(jì)南 侯艷秋
【摘要】 目的 比較開腹手術(shù)和腔內(nèi)隔絕術(shù)治療破裂腹主動(dòng)脈瘤的手術(shù)效果。方法 32例破裂腹主動(dòng)脈瘤患者, 其中23 例行腹動(dòng)脈瘤切除、人工血管移植術(shù)治療(開腹組), 9 例行覆膜支架腔內(nèi)隔絕術(shù)治療(腔內(nèi)隔絕組)。對(duì)兩組患者術(shù)后圍手術(shù)期死亡率進(jìn)行比較, 對(duì)發(fā)病至手術(shù)開始各時(shí)間段患者死亡率進(jìn)行比較。結(jié)果 兩組死亡率比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);但發(fā)病至手術(shù)各時(shí)間段患者死亡率比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 早期診斷是提高患者生存率的主要因素, 正確評(píng)估破裂腹主動(dòng)脈瘤是及時(shí)準(zhǔn)確選擇外科術(shù)式的前提。
【關(guān)鍵詞】 破裂腹主動(dòng)脈瘤;腔內(nèi)隔絕術(shù);開腹手術(shù)
破裂腹主動(dòng)脈瘤是血管外科死亡率最高疾病之一, 未經(jīng)治療, 患者死亡率高達(dá)100%, 手術(shù)死亡率為40%~60%[1-4]。本科對(duì)2005年3 月~2014 年7 月就診的32例破裂腹主動(dòng)脈瘤患者分別行覆膜支架腔內(nèi)隔絕和開腹手術(shù)治療, 現(xiàn)比較分析兩種方法療效。
1 資料與方法
1. 1 一般資料 本組男29例, 女3 例;年齡 53~88歲, 平均年齡65歲。其中23例患者入院時(shí)有低血壓或休克表現(xiàn), 5例既往患有該病病史?;颊呔?jīng)超聲或計(jì)算機(jī)斷層攝影血管造影(computed tomographic angiography , CTA)以及手術(shù)探查確診。9 例患者入院時(shí)生命體征平穩(wěn), 行CTA檢查示血管解剖條件良好, 符合腔內(nèi)覆膜支架植入條件, 故行腔內(nèi)隔絕術(shù)治療(腔內(nèi)隔絕組);余 23例行開腹腹主動(dòng)脈瘤切除、人工血管移植術(shù)治療(開腹組)。兩組患者術(shù)前健康狀況見表1, 術(shù)前合并癥組間比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05 ), 具有可比性。
1. 2 手術(shù)方法 開腹組:均采用劍突下至恥骨聯(lián)合腹部正中切口。13例患者瘤頸距離腎動(dòng)脈開口較遠(yuǎn), 且易于顯露, 直接于腎動(dòng)脈下鉗夾阻斷;9例患者因腹膜后巨大血腫, 顯露腎下腹主動(dòng)脈較困難, 故先阻斷膈下腹主動(dòng)脈后, 分離腎動(dòng)脈下腹主動(dòng)脈, 快速將膈下腹主動(dòng)脈阻斷鉗移至腎動(dòng)脈下腹主動(dòng)脈阻斷, 以減少腎上阻斷時(shí)間;1例患者行腔內(nèi)治療時(shí), 術(shù)中突發(fā)血壓下降, 出現(xiàn)休克癥狀, 立即給予輸血補(bǔ)液等, 行開腹手術(shù)。本組5例采用直型人工血管, 18例采用分叉型人工血管, 使人工血管與雙側(cè)髂總動(dòng)脈行端端吻合;4例因動(dòng)脈瘤延續(xù)至一側(cè)髂內(nèi)動(dòng)脈或髂總動(dòng)脈, 故將同側(cè)人工血管與對(duì)應(yīng)髂外動(dòng)脈行端端吻合, 同時(shí)結(jié)扎髂內(nèi)動(dòng)脈, 對(duì)側(cè)與髂總動(dòng)脈端端吻合。腔內(nèi)隔絕組:本組 9 例患者在全身麻醉下行腔內(nèi)隔絕術(shù), 植入戈?duì)柟痉植嫘透怪鲃?dòng)脈覆膜支架;其中 3 例應(yīng)用彈簧栓栓塞髂內(nèi)動(dòng)脈, 然后植入覆膜支架。術(shù)后兩組患者進(jìn)入重癥監(jiān)護(hù)病房進(jìn)行治療, 其中開腹組2~20 d, 平均7 d;而腔內(nèi)隔絕組 2~7 d, 平均3 d。
1. 3 統(tǒng)計(jì)學(xué)方法 采用SPSS17.0統(tǒng)計(jì)軟件包進(jìn)行分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差( x-±s)表示, 采用t檢驗(yàn);計(jì)數(shù)資料采用χ2檢驗(yàn)。P<0.05為差異具有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
開腹組在術(shù)后24 h內(nèi)有3例患者死亡, 而30 d內(nèi)8例死亡。12例患者存活, 密切隨訪6~48個(gè)月, 平均18個(gè)月?;颊叱霈F(xiàn)與移植物不相關(guān)并發(fā)癥18例(30例次), 如傷口感染、心肺功能衰竭、腎功能衰竭、消化道出血及多器官功能衰竭等, 未見與移植物相關(guān)并發(fā)癥。腔內(nèi)隔絕組術(shù)后24 h內(nèi)無(wú)死亡病例發(fā)生, 30 d內(nèi)3例患者死亡, 6例存活, 密切隨訪3~35個(gè)月, 平均14個(gè)月。9例患者中6例出現(xiàn)術(shù)后并發(fā)癥, 其中3例次出現(xiàn)移植物相關(guān)并發(fā)癥, 出血1例次, 內(nèi)漏2例次。兩組術(shù)后死亡率比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);而各發(fā)病至手術(shù)時(shí)間段比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表2、3。
3 討論
1951年Dubost 等[5]第一次成功為1例患者施行腹主動(dòng)脈瘤切除、人工血管移植術(shù)。1966 年Creech[6]報(bào)道了動(dòng)脈瘤內(nèi)縫扎腰動(dòng)脈, 腔內(nèi)人工血管移植術(shù), 該術(shù)式成為目前腹主動(dòng)脈瘤治療的標(biāo)準(zhǔn)術(shù)式;近年來(lái)腹主動(dòng)脈瘤腔內(nèi)隔絕術(shù)成為一種重要手術(shù)選擇。研究表明腹主動(dòng)脈瘤腔內(nèi)隔絕可明顯降低腹主動(dòng)脈瘤患者患病早期的死亡率及并發(fā)癥[7], 其具有創(chuàng)傷小、出血少、手術(shù)持續(xù)時(shí)間短等優(yōu)點(diǎn), 故受到越來(lái)越多外科醫(yī)生的重視。
Peppelenbosch等[8]比較應(yīng)用腔內(nèi)隔絕技術(shù)與開放手術(shù)治療破裂腹主動(dòng)脈瘤, 結(jié)果顯示, 腔內(nèi)隔絕術(shù)治療可明顯減少輸血量, 并能降低患者術(shù)后1個(gè)月內(nèi)的死亡率。但破裂腹主動(dòng)脈瘤患者并不均適合腔內(nèi)治療, 破裂腹主動(dòng)脈瘤常伴休克或血壓不穩(wěn)定者, 如行腔內(nèi)治療, 術(shù)前準(zhǔn)備復(fù)雜, 時(shí)間長(zhǎng), 增加患者突發(fā)死亡風(fēng)險(xiǎn)。且腔內(nèi)治療對(duì)醫(yī)院的條件要求較高, 除專業(yè)設(shè)備外, 還需具有經(jīng)驗(yàn)豐富的醫(yī)生。而開腹手術(shù)對(duì)設(shè)備要求較低, 且經(jīng)驗(yàn)豐富的醫(yī)生, 經(jīng)過(guò)專業(yè)培訓(xùn), 多能掌握, 故目前對(duì)大多數(shù)醫(yī)療單位來(lái)說(shuō)破裂腹主動(dòng)脈瘤的搶救方法仍是常規(guī)開腹手術(shù)。
破裂腹主動(dòng)脈瘤預(yù)后影響因素很多, 其中包括患者自身因素, 所屬醫(yī)院等級(jí), 手術(shù)醫(yī)師經(jīng)驗(yàn)等。研究表明, 高齡、術(shù)前合并心臟病、腎功能不全、慢性阻塞性肺疾病可能是導(dǎo)致腹主動(dòng)脈瘤破裂死亡率增加的危險(xiǎn)因素[9, 10]。而醫(yī)院等級(jí)同樣影響患者生存率, Lo等[11]研究表明, 全因死亡率, 英國(guó)小醫(yī)院和大醫(yī)院分別為82.56%和61.89%, 美國(guó)兩類醫(yī)院分別為75.86%和43.82%。而我國(guó)基層醫(yī)院與區(qū)域中心醫(yī)院的水平差距大, 優(yōu)勢(shì)醫(yī)療資源有限且集中, 故破裂腹主動(dòng)脈瘤救治成功率差距將更大。本研究結(jié)果顯示, 兩種手術(shù)方式治療腹主動(dòng)脈瘤破裂患者死亡率比較差異無(wú)統(tǒng)計(jì)學(xué)意義, 但發(fā)病至手術(shù)各時(shí)間段患者死亡率差異具有統(tǒng)計(jì)學(xué)意義(P<0.05), 早期診斷及手術(shù)患者圍手術(shù)期死亡率顯著低于晚就診患者。
綜上所述, 腹主動(dòng)脈瘤破裂腔內(nèi)隔絕術(shù)對(duì)血管解剖條件好, 可以承擔(dān)手術(shù)相應(yīng)費(fèi)用, 且就診在有條件的醫(yī)院, 是一種切實(shí)可行的方法, 其減少手術(shù)時(shí)間, 減少在重癥監(jiān)護(hù)室時(shí)間, 縮短患者住院時(shí)間。且隨著腔內(nèi)技術(shù)的逐漸成熟以及新型覆膜支架材料的應(yīng)用, 腔內(nèi)隔絕術(shù)將會(huì)更多應(yīng)用于腹主動(dòng)脈瘤破裂患者的治療。而動(dòng)脈瘤切除手術(shù)對(duì)一些不具備腔內(nèi)治療條件的患者及醫(yī)院同樣是挽救患者生命的一種有效手段, 而非過(guò)度強(qiáng)調(diào)轉(zhuǎn)診而浪費(fèi)寶貴的搶救時(shí)間。破裂腹主動(dòng)脈動(dòng)脈瘤治療, 早期診斷是提高患者生存率的主要因素, 正確評(píng)估破裂腹主動(dòng)脈瘤是及時(shí)準(zhǔn)確選擇外科術(shù)式的前提。
參考文獻(xiàn)
[1] Holt PJ, Poloniecki JD, Gerrard D, et al. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg, 2007, 4(8):395-403.
[2] Qureshi NA, Rehman A, Slater N, et al. Abdominal aortic aneurysm surgery in a district general hospital: a 15-year experience. Ann Vasc Surg, 2007, 21(6):749-753.
[3] Wanhainen A, Bylund N, Bj?rck M. Outcome after abdominal aortic aneurysm repair in Sweden 1994-2005. Br J Surg, 2008, 95(5): 564-570.
[4] Huber TS, Wang JG, Derrow AE, et al. Experience in the United States with intact abdominal aortic aneurysm repair. J Vasc Surg, 2001, 33(2):304-310.
[5] Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg, 1952, 64(3):405-408.
[6] Creech O Jr. Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg, 1966, 164(6):935-946.
[7] Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet, 2004, 364(9437):843-848.
[8] Peppelenbosch N, Yilmaz N, van Marrewijk C, et al. Emergency treatment of aucute symptomatic or ruptueed abdominal aortic aneursm. Outcome of a prospective intenttotreat by EVAR protocol. Eur J Vasc Endovasc Surg, 2003, 26(3):303-310.
[9] Dueck AD, Johnston KW, Alter D, et al. Predictors of repair and eff ect of gender on treatment of ruptured abdominal aortic aneurysm. J Vasc Surg, 2004, 39(4):784-787.
[10] Acosta S, Lindblad B, Zdanowski Z. Predictors for outcome after open and endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg, 2007, 33(3):277-284.
[11] Lo A, Adams D. Ruptured abdominal aortic aneurysms: risk factors for mortality after emergency repair. N Z Med J, 2004, 117(1203): U1100.
[收稿日期:2014-09-29]
參考文獻(xiàn)
[1] Holt PJ, Poloniecki JD, Gerrard D, et al. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg, 2007, 4(8):395-403.
[2] Qureshi NA, Rehman A, Slater N, et al. Abdominal aortic aneurysm surgery in a district general hospital: a 15-year experience. Ann Vasc Surg, 2007, 21(6):749-753.
[3] Wanhainen A, Bylund N, Bj?rck M. Outcome after abdominal aortic aneurysm repair in Sweden 1994-2005. Br J Surg, 2008, 95(5): 564-570.
[4] Huber TS, Wang JG, Derrow AE, et al. Experience in the United States with intact abdominal aortic aneurysm repair. J Vasc Surg, 2001, 33(2):304-310.
[5] Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg, 1952, 64(3):405-408.
[6] Creech O Jr. Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg, 1966, 164(6):935-946.
[7] Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet, 2004, 364(9437):843-848.
[8] Peppelenbosch N, Yilmaz N, van Marrewijk C, et al. Emergency treatment of aucute symptomatic or ruptueed abdominal aortic aneursm. Outcome of a prospective intenttotreat by EVAR protocol. Eur J Vasc Endovasc Surg, 2003, 26(3):303-310.
[9] Dueck AD, Johnston KW, Alter D, et al. Predictors of repair and eff ect of gender on treatment of ruptured abdominal aortic aneurysm. J Vasc Surg, 2004, 39(4):784-787.
[10] Acosta S, Lindblad B, Zdanowski Z. Predictors for outcome after open and endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg, 2007, 33(3):277-284.
[11] Lo A, Adams D. Ruptured abdominal aortic aneurysms: risk factors for mortality after emergency repair. N Z Med J, 2004, 117(1203): U1100.
[收稿日期:2014-09-29]
參考文獻(xiàn)
[1] Holt PJ, Poloniecki JD, Gerrard D, et al. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg, 2007, 4(8):395-403.
[2] Qureshi NA, Rehman A, Slater N, et al. Abdominal aortic aneurysm surgery in a district general hospital: a 15-year experience. Ann Vasc Surg, 2007, 21(6):749-753.
[3] Wanhainen A, Bylund N, Bj?rck M. Outcome after abdominal aortic aneurysm repair in Sweden 1994-2005. Br J Surg, 2008, 95(5): 564-570.
[4] Huber TS, Wang JG, Derrow AE, et al. Experience in the United States with intact abdominal aortic aneurysm repair. J Vasc Surg, 2001, 33(2):304-310.
[5] Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg, 1952, 64(3):405-408.
[6] Creech O Jr. Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg, 1966, 164(6):935-946.
[7] Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet, 2004, 364(9437):843-848.
[8] Peppelenbosch N, Yilmaz N, van Marrewijk C, et al. Emergency treatment of aucute symptomatic or ruptueed abdominal aortic aneursm. Outcome of a prospective intenttotreat by EVAR protocol. Eur J Vasc Endovasc Surg, 2003, 26(3):303-310.
[9] Dueck AD, Johnston KW, Alter D, et al. Predictors of repair and eff ect of gender on treatment of ruptured abdominal aortic aneurysm. J Vasc Surg, 2004, 39(4):784-787.
[10] Acosta S, Lindblad B, Zdanowski Z. Predictors for outcome after open and endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg, 2007, 33(3):277-284.
[11] Lo A, Adams D. Ruptured abdominal aortic aneurysms: risk factors for mortality after emergency repair. N Z Med J, 2004, 117(1203): U1100.
[收稿日期:2014-09-29]