姚佐懿，羅菲菲，周翔宇，王 芳

(1.西南醫(yī)科大學(xué)第一附屬醫(yī)院血管外科,四川瀘州 646000；2.四川省成都市第五人民醫(yī)院血管外科 611130)

論著·臨床研究 doi:10.3969/j.issn.1671-8348.2017.04.006

超聲引導(dǎo)下經(jīng)皮凝血酶注射對(duì)醫(yī)源性股動(dòng)脈復(fù)雜假性動(dòng)脈瘤的應(yīng)用研究*

姚佐懿1,2，羅菲菲2，周翔宇1Δ，王 芳1

(1.西南醫(yī)科大學(xué)第一附屬醫(yī)院血管外科,四川瀘州 646000；2.四川省成都市第五人民醫(yī)院血管外科 611130)

[摘要] 目的 彩超引導(dǎo)下醫(yī)源性股動(dòng)脈復(fù)雜假性動(dòng)脈瘤(IFACP)腔內(nèi)經(jīng)皮凝血酶注射治療(UGTI)方法學(xué)及可行性評(píng)價(jià)。方法 回顧性分析32例經(jīng)股動(dòng)脈徑路進(jìn)行介入操作術(shù)后并發(fā)IFACP患者接受經(jīng)皮凝血酶注射治療。假性動(dòng)脈瘤瘤腔數(shù)目為2腔23例，3腔8例，4腔1例；局部麻醉后彩超持續(xù)引導(dǎo)下動(dòng)脈穿刺針依次進(jìn)入各瘤腔進(jìn)行凝血酶注射，動(dòng)態(tài)觀察瘤腔內(nèi)血栓形成完成封堵，24 h，7 d后分別彩超隨訪。結(jié)果 23例2腔全部一次性成功，2例3腔24 h后復(fù)查部分再通，再次行UGTI封堵失敗，1例4腔封堵失敗，均無(wú)血栓形成、栓塞、感染、過(guò)敏等并發(fā)癥。結(jié)論 彩超引導(dǎo)下UGTI是治療股IFACP首選術(shù)式，精準(zhǔn)定位穿刺可提高復(fù)雜假性動(dòng)脈瘤治療成功率，避免嚴(yán)重并發(fā)癥。

動(dòng)脈瘤,假性；股動(dòng)脈；凝血酶；超聲檢查,多普勒,彩色

醫(yī)源性股動(dòng)脈復(fù)雜假性動(dòng)脈瘤(iarogenic femoral arterial complexity pseudoaneurysms,IFACP)是經(jīng)股動(dòng)脈入路進(jìn)行介入相關(guān)診療后的并發(fā)癥，因經(jīng)反復(fù)穿刺后形成多腔，各個(gè)腔隙相通或不相通，與股動(dòng)脈直接或間接相通，解剖結(jié)構(gòu)復(fù)雜，臨床診治困難。本研究針對(duì)IFACP進(jìn)行彩超引導(dǎo)下凝血酶注射治療(ultrasound-guided thrombin injection,UGTI),探討UGTI對(duì)IFACP的正確操作方法、臨床療效及可行性評(píng)價(jià)。

1 資料與方法

1.1 一般資料 2012年9月至2015年7月，32例IFACP(瘤腔2腔以上)患者接受了UGTI治療，其中男19例，女13例，年齡59～81歲，平均(68.7±4.9)歲。瘤腔個(gè)數(shù)2～4腔，平均(2.31±0.53)腔，載瘤動(dòng)脈直徑1.1～3.6 mm，平均(1.9±0.7)mm。所有患者均經(jīng)過(guò)至少2次股動(dòng)脈穿刺及鞘管放置，IFACP發(fā)生在術(shù)后3 d以內(nèi)。所有患者均簽署相關(guān)知情同意書(shū)后接受UGTI。

1.2 超聲評(píng)估 臨床上超聲影響評(píng)估部分假性動(dòng)脈瘤無(wú)任何臨床癥狀及體征，一旦發(fā)現(xiàn)臨床癥狀或體征應(yīng)立即超聲評(píng)估，精準(zhǔn)定位以下指標(biāo)：(1)瘤腔數(shù)目;(2)載瘤動(dòng)脈直徑(mm)，載瘤動(dòng)脈直徑可作為評(píng)估是否具有UGTI指征的獨(dú)立因素;(3)瘤腔距體表距離、瘤腔之間的關(guān)系、瘤腔與股動(dòng)脈的關(guān)系,評(píng)估操作方法及風(fēng)險(xiǎn);(4)評(píng)估股淺、股深動(dòng)脈及髂外動(dòng)脈，觸摸患肢足背動(dòng)脈、脛后動(dòng)脈、腘動(dòng)脈搏動(dòng)。

1.3 方法 取2 mL注射器將凝血酶1支(500 U)與2 mL生理鹽水相溶，將凝血酶稀釋為250 U/mL，50 U/0.2 mL，注射器接三通管，分別與另一已抽吸2 mL生理鹽水的5 mL注射器及22號(hào)動(dòng)脈穿刺針(長(zhǎng)150 mm)連接。腹股溝區(qū)皮膚碘伏消毒，鋪巾，超聲傳感器套塑料無(wú)菌套，超聲定位瘤腔位置及進(jìn)針?lè)较?，回? mL注射器見(jiàn)搏動(dòng)性回血確定進(jìn)入瘤腔后，盡量遠(yuǎn)離瘤頸部注入凝血酶0.2 mL(50 U)，每次注射時(shí),針尖部位會(huì)出現(xiàn)“閃屏”現(xiàn)象(bursts to color),2～3 s血栓即可形成，動(dòng)態(tài)監(jiān)測(cè)腔內(nèi)血栓形成狀況，以每次50 U依次推注凝血酶直至瘤腔內(nèi)血流完全消失，凝血酶最大劑量應(yīng)少于1 000 U。當(dāng)遠(yuǎn)端瘤腔封堵后，部分近端瘤腔可逐漸自行封堵。UGTI后加壓包扎2 h，臨床觀察：(1)局部有無(wú)炎癥;(2)下肢是否缺血或淤血;(3)有無(wú)全身過(guò)敏反應(yīng)。UGTI后24 h、7 d分別復(fù)查彩超評(píng)估：(1)瘤腔有無(wú)再通;(2)載瘤動(dòng)脈血流情況;(3)有無(wú)新發(fā)瘤腔。

2 結(jié) 果

2.1 封堵效果 29例成功封堵，2例3腔24 h后復(fù)查部分再通，再次行UGTI封堵失敗，1例4腔封堵失敗，有效封堵率90.6%(29/32)。均未有正常動(dòng)脈血栓形成、栓塞及全身或局部感染、過(guò)敏等并發(fā)癥。

2.2 瘤腔封堵效果影響因素 載瘤動(dòng)脈直徑和瘤腔數(shù)目是影響封堵成功率的因素，直徑越大，成功率越低，同脈瘤腔數(shù)目越多，封堵成功率越低；瘤腔數(shù)目越多、載瘤動(dòng)脈直徑越大，凝血酶劑量越多。多因素分析結(jié)果見(jiàn)表1。

表1 瘤腔封堵效果描述性分析

2.3 典型病例 患者女，63歲，冠狀動(dòng)脈造影術(shù)后左腹股溝區(qū)腫塊。彩超提示左側(cè)股淺動(dòng)脈外側(cè)分別約45 mm×20 mm×39 mm和10 mm×5 mm假性動(dòng)脈瘤，二者相通，股淺動(dòng)脈破口直徑1.3 mm，載瘤動(dòng)脈長(zhǎng)23 mm。急診行UGTI后，瘤腔內(nèi)血栓成功完成封堵。見(jiàn)圖1。

A:左側(cè)股動(dòng)脈假性動(dòng)脈瘤；B：左側(cè)股動(dòng)脈假性動(dòng)脈瘤破口；C：左側(cè)股動(dòng)脈假性動(dòng)脈瘤(治療中)；D：左側(cè)股動(dòng)脈假性動(dòng)脈瘤(治療后)。

3 討 論

目前臨床治療IFACP有5種方式：據(jù)解剖位置人工壓迫，超聲引導(dǎo)下人工壓迫(US-guided compression,UGC)，超聲引導(dǎo)下UGTI，超聲引導(dǎo)下生理鹽水[1]或膠原蛋白[2]注射封堵，外科手術(shù)。據(jù)解剖位置人工壓迫因不能精準(zhǔn)定位破口，無(wú)法進(jìn)行有效壓迫。UGC可準(zhǔn)確定位破口，是比較安全有效的方法，但耗時(shí)長(zhǎng)，長(zhǎng)時(shí)間局部用力壓迫引起患者不適[3]，并增加相關(guān)鎮(zhèn)靜和鎮(zhèn)痛藥物所致風(fēng)險(xiǎn)，且長(zhǎng)期接受抗凝治療患者純粹壓迫治愈率低。ElMahdy等[1]、Hamraoui 等[2]分別報(bào)道超聲引導(dǎo)下生理鹽水及膠原蛋白注射封堵均有成功案件，但相關(guān)文獻(xiàn)報(bào)道少。外科手術(shù)難度大，術(shù)后可能并發(fā)吻合口破裂，再次形成IFCAP，切口感染，外科手術(shù)后切口永久性神經(jīng)痛達(dá)32%[1,4]，術(shù)后淋巴漏可達(dá)40%[1,4]，Lumsden等[5]報(bào)道外科手術(shù)修復(fù)后并發(fā)癥率和病死率分別為 21%和2.1%，外科手術(shù)不是治療IFACP首選方案。UGTI則避免了外科手術(shù)后的一系列并發(fā)癥，是一種安全、快速、有效、經(jīng)濟(jì)的方法，一次性成功率達(dá)91.0%[6]或92.7%[7]，住院周期短，已成為治療IFACP金標(biāo)準(zhǔn)[8-9]。

UGTI對(duì)IFACP的治療成功率與載瘤動(dòng)脈直徑、瘤腔數(shù)目及外科醫(yī)師穿刺技巧、彩超醫(yī)師的經(jīng)驗(yàn)有關(guān)。本研究中采用從最遠(yuǎn)端瘤腔開(kāi)始，依次進(jìn)行封堵，可以盡量減少血流沖擊對(duì)凝血酶的干擾；穿刺時(shí)盡量使穿刺針尾部與傳感器保持平行，以便動(dòng)態(tài)監(jiān)測(cè)穿刺針位置，及時(shí)調(diào)整進(jìn)針角度及深度，準(zhǔn)確進(jìn)入瘤腔；盡量靠近瘤腔底部注射、小劑量開(kāi)始注射以減少并發(fā)癥。本研究統(tǒng)計(jì)分析顯示載瘤動(dòng)脈直徑和瘤腔數(shù)目是決定UGTI成功率高低的相關(guān)因素。載瘤動(dòng)脈直徑越大、瘤腔數(shù)目越多，封堵成功率越低。Pezzullo等[10]發(fā)現(xiàn)封堵是否成功是由操作醫(yī)師經(jīng)驗(yàn)而不是瘤腔大小決定，凝血酶的用量和成功率與體積無(wú)關(guān)。在最近一項(xiàng)德國(guó)的大樣本研究中，影響凝血酶劑量的因素不是瘤體的尺寸，是股動(dòng)脈壁的受損方式和程度決定的[11]。本研究中有1例失敗，因?yàn)榱銮粩?shù)目過(guò)多，位置隱蔽，穿刺針無(wú)法進(jìn)入瘤腔所致；2例部分再通分析原因與長(zhǎng)期服用兩聯(lián)抗血小板藥物相關(guān)。

UGTI相關(guān)并發(fā)癥發(fā)生率可達(dá)2%[12-13]，這些并發(fā)癥包括：股動(dòng)脈血栓形成(凝血酶通過(guò)載瘤動(dòng)脈進(jìn)入股動(dòng)脈導(dǎo)致血栓形成概率低于0.5～2.0%)[14]、股動(dòng)脈急性栓塞、下肢深靜脈血栓、肺栓塞(發(fā)生率0.28%)，假性動(dòng)脈瘤腔內(nèi)感染、過(guò)敏反應(yīng)。甚至有報(bào)道稱UGTI可與冠狀動(dòng)脈支架血栓形成有關(guān)[15]。注射劑量的大小是是否引起股動(dòng)脈栓塞的關(guān)鍵因素[16]。瘤腔與股動(dòng)脈之間的載瘤動(dòng)脈長(zhǎng)度與并發(fā)癥是呈負(fù)相關(guān)，反復(fù)穿刺操作與并發(fā)癥率呈正相關(guān)，載瘤動(dòng)脈長(zhǎng)度小于2 mm明顯降低并發(fā)癥率[17]。

在需要進(jìn)行UGTI操作時(shí)，做到以下幾點(diǎn)可提高成功率：(1)精準(zhǔn)完成UGTI操作前評(píng)估；(2)從最遠(yuǎn)端瘤腔開(kāi)始，依次進(jìn)行封堵；(3)穿刺時(shí)盡量使穿刺針尾部與傳感器保持平行；(4)靠近瘤腔底部注射；(5)從小劑量開(kāi)始注射；(6)注射完成后仍有少量殘余血流時(shí)，可按壓數(shù)分鐘幫助瘤腔封閉。本例研究，樣本量少，導(dǎo)致統(tǒng)計(jì)分析中P值無(wú)意義。但本研究中UGTI治療IFACP成功率高，無(wú)并發(fā)癥，UGTI可作為IFACP治療的首選方案。

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The applied research of ultrasound-guided percutaneous thrombin injection for the treatment of Iarogenic femoral arterial complexity pseudoaneurysms*

YaoZuoyi1,2,LuoFeifei2,ZhouXiangyu1△,WangFang1

(1.DepartmentofVascularSurgery,theFirstAffiliatedHospitalofSichuanMedicalUniversity,LuzhouSichuan646000,China；2.DepartmentofGastrointestinalSurgery,theFifthPeople′sHospitalofChengdu,Chengdu,Sichuan611130,China)

[Abstract] Objective The aim to assess the methodology and feasibility of ultrasound-guided percutaneous thrombin injection(UGTI) for the treatment of Iarogenic Femoral Arterial Complexity Pseudoaneurysms(IFACP).Methods Thirty-two iarogenic femoral arterial complexity pseudoaneurysms patients following femoral arerial puncture for arterial angiography were treated with UGTI.Twenty-three IFACP with 2 lobes,8 IFACP with 3 lobes,1 IFACP with 4 lobes.Under local anesthesia the lobe was penetrated by artery needle successively and thrombin jection was performed slowely into distal lobe with US guide precise localization.Dynamical observation was performed for the status of thrombogenesis and cavity plugging.US follow-up examination were performed after 24 h and 7 d.Results Reperfusion occurred in IFACP with 3 lobes after 24 h and UGTI failure.IFACPs with 4 lobes failure.Nothromboembolic,infectious,allergic complication soccurred.Conclusion UGTI is the first mothed for the treatment of IFACP.Precise localization and percutaneous can enhance the ratio of treatment of IFACPs and avoid the severe complications.

aneurysm,false;femoral artery;thrombin;ultrasonography,doppler,color

2014年四川省衛(wèi)生和計(jì)劃生育委員會(huì)科研課題(140035)。 作者簡(jiǎn)介：姚佐懿(1983-)，主治醫(yī)師，本科，主要從事血管外科研究?！?/p>

，E-mail:Xiangyuzhou971@126.com。

R543

A

1671-8348(2017)04-0450-03

2016-09-21

2016-10-19)