腹主動(dòng)脈瘤開(kāi)腹手術(shù)與腔內(nèi)修復(fù)術(shù)的對(duì)照研究

朱鋒 戈小虎

·論 著·(腹部血管外科和上消化道出血專題)

腹主動(dòng)脈瘤開(kāi)腹手術(shù)與腔內(nèi)修復(fù)術(shù)的對(duì)照研究

朱鋒 戈小虎

目的對(duì)比分析腹主動(dòng)脈瘤病人開(kāi)放手術(shù)與腔內(nèi)修復(fù)術(shù)的治療效果。方法收集新疆維吾爾自治區(qū)人民醫(yī)院血管外科2012年7月至2017年6月收治的腹主動(dòng)脈瘤病人，對(duì)比開(kāi)放手術(shù)與腔內(nèi)治療病人的一般情況、住院情況、術(shù)后及隨訪期間并發(fā)癥情況。結(jié)果176例接受手術(shù)的腹主動(dòng)脈瘤病人均獲成功，其中腔內(nèi)修復(fù)術(shù)(endovascular aneurysm repair, EVAR)156例，開(kāi)放手術(shù)(open surgery, OS)20例，平均年齡(68.8±9.9)歲，平均隨訪時(shí)間(25.9±16.2)個(gè)月。OS 組住院期間輸注紅細(xì)胞量、輸注血漿量、術(shù)后重癥監(jiān)護(hù)室治療時(shí)間、住院時(shí)間明顯多于EVAR 組(P<0.05)。EVAR 術(shù)后髂支閉塞、支架感染等問(wèn)題值得重視。結(jié)論盡管腔內(nèi)治療效果優(yōu)于開(kāi)放手術(shù)的循證資料十分有限，EVAR仍然是一個(gè)令血管外科醫(yī)生及病人容易接受的手術(shù)方式。

腹主動(dòng)脈瘤； 開(kāi)放手術(shù)； 腔內(nèi)修復(fù)術(shù)

腹主動(dòng)脈瘤(abdominal aortic aneurysm)是腹主動(dòng)脈局限性永久性擴(kuò)張(大于正常主動(dòng)脈管徑的50%)，年齡、性別、動(dòng)脈粥樣硬化、吸煙和高血壓等均與其發(fā)病相關(guān)[1-2]。在美國(guó)，每年有15 000人死于腹主動(dòng)脈瘤，破裂的死亡率高(80%～90%)，圍手術(shù)期的死亡率高(40%～50%)[3-5]。

早期的研究認(rèn)為：腔內(nèi)治療早、中期效果優(yōu)于開(kāi)放手術(shù)。然而最近有研究報(bào)道：開(kāi)放手術(shù)與腔內(nèi)治療5年、10年、15年的生存率無(wú)顯著差異，并且腔內(nèi)治療術(shù)后再次干預(yù)的風(fēng)險(xiǎn)高于開(kāi)放手術(shù)[6]。應(yīng)對(duì)全球腹主動(dòng)脈瘤發(fā)病率逐年增高的趨勢(shì)，兩種手術(shù)方式孰優(yōu)孰劣，值得探討。本中心收集近五年的腹主動(dòng)脈瘤病人，做開(kāi)放手術(shù)與腔內(nèi)治療的對(duì)比分析，旨在進(jìn)一步提高腹主動(dòng)脈瘤的診療水平，為今后的研究提供循證資料。

資料與方法

一、一般資料

研究為回顧性研究，收集新疆維吾爾自治區(qū)人民醫(yī)院血管外科2012年7月至2017年6月收治的腹主動(dòng)脈瘤病人。納入標(biāo)準(zhǔn)：腹主動(dòng)脈計(jì)算機(jī)斷層血管造影(CTA)明確診斷的腹主動(dòng)脈瘤病人，瘤體直徑≥5.0 cm，滿足手術(shù)標(biāo)準(zhǔn)且接受手術(shù)治療。共納入研究對(duì)象176例，其中男性140例、女性36例，平均年齡(68.8±9.9)歲，平均隨訪時(shí)間(25.9±16.2)個(gè)月。分組標(biāo)準(zhǔn)以手術(shù)方式?jīng)Q定：分為開(kāi)放手術(shù)組157例與腔內(nèi)手術(shù)組20例。兩組病人一般情況差異均無(wú)統(tǒng)計(jì)學(xué)意義。(表1)

二、手術(shù)方法

1.腔內(nèi)修復(fù)術(shù)(endovascular aneurysm repair, EVAR) 采用全身麻醉，術(shù)前30 min滴注抗生素，切開(kāi)顯露或穿刺雙側(cè)股動(dòng)脈，靜脈滴注普通肝素50 mg，術(shù)中造影定位，將支架輸送系統(tǒng)送至預(yù)定點(diǎn)后再次放大圖像造影確定定位是否準(zhǔn)確，然后將支架近端釋放在腎動(dòng)脈下方。支架遠(yuǎn)端定位取決于髂動(dòng)脈條件，如合并髂總動(dòng)脈瘤或髂內(nèi)動(dòng)脈瘤，支架遠(yuǎn)端應(yīng)放置在髂外動(dòng)脈，否則盡量將髂支遠(yuǎn)端放置在髂總動(dòng)脈。支架釋放后，用球囊貼覆支架附著處，撤出超硬導(dǎo)絲，再次造影觀察支架有無(wú)位移、內(nèi)漏、髂支有無(wú)打折等。預(yù)先置入GORE 公司的Dryseal大口徑的鞘管，在釋放支架后拔出鞘管，收緊預(yù)置的血管縫合器，閉合穿刺點(diǎn)。

2.開(kāi)放手術(shù)(open surgery, OS) 采用全身麻醉，取腹部正中切口，切口上端自劍突下緣，下端至臍下5～10 cm，全身肝素化，開(kāi)腹后找到腎動(dòng)脈下方的腹主動(dòng)脈進(jìn)行阻斷，阻斷位置為腎動(dòng)脈開(kāi)口下方正常動(dòng)脈處，然后顯露出瘤體及雙側(cè)髂動(dòng)脈并阻斷。將腹主動(dòng)脈前壁切開(kāi)，從瘤腔內(nèi)縫扎腰動(dòng)脈、腸系膜下動(dòng)脈及骶中動(dòng)脈開(kāi)口，選擇能夠與病人相匹配的人工血管進(jìn)行腹主動(dòng)脈、雙髂動(dòng)脈的吻合?；謴?fù)血流后確定吻合口處無(wú)漏血，再以動(dòng)脈瘤的囊壁縫合包裹植入的人工血管。逐層縫合后結(jié)束手術(shù)。

三、參考變量

記錄病人的一般情況、住院情況、術(shù)后及隨訪期間并發(fā)癥情況。

四、統(tǒng)計(jì)學(xué)方法

結(jié) 果

一、兩組病人住院情況的對(duì)比分析

根據(jù)手術(shù)方式分組的病人住院情況對(duì)比分析見(jiàn)表2。OS組和EVAR組病人住院情況中輸注紅細(xì)胞量、輸注血漿量、術(shù)后重癥監(jiān)護(hù)室(SICU)治療時(shí)間、住院時(shí)間差異均有統(tǒng)計(jì)學(xué)意義。

二、兩組病人術(shù)后及隨訪期間并發(fā)癥的對(duì)比分析

根據(jù)手術(shù)方式分組的病人術(shù)后及隨訪期間并發(fā)癥對(duì)比分析見(jiàn)表3。下肢深靜脈血栓形成、腦血管疾病(腦梗死、腦出血)、心肌梗死、呼吸系統(tǒng)疾病(肺炎、急性呼吸窘迫綜合征)、腎功能不全、髂支閉塞、支架感染發(fā)生率在OS組和EVAR組間差異均無(wú)統(tǒng)計(jì)學(xué)意義。

表1 兩組病人基線特征

表2 兩組病人住院情況對(duì)比分析±s)

注：SICU.外科重癥監(jiān)護(hù)室

表3 兩組病人術(shù)后及隨訪期間并發(fā)癥的對(duì)比分析[例(%)]

討 論

腔內(nèi)治療因操作簡(jiǎn)單、近期效果好，已成為腹主動(dòng)脈瘤的首選治療。隨著腔內(nèi)技術(shù)的發(fā)展，開(kāi)窗技術(shù)、“煙囪”技術(shù)、分支支架技術(shù)廣泛得應(yīng)用于解剖異常、病變累及分支動(dòng)脈的腹主動(dòng)脈瘤，開(kāi)放手術(shù)已漸漸成為腔內(nèi)治療的替代方案[7]。早期的觀點(diǎn)認(rèn)為腔內(nèi)治療圍手術(shù)期的效果優(yōu)于開(kāi)放手術(shù)，如30 d的死亡率、并發(fā)癥發(fā)生率、住院時(shí)間。美國(guó)外科醫(yī)師學(xué)會(huì)的國(guó)家手術(shù)質(zhì)量改進(jìn)項(xiàng)目(National Surgical Quality Improvement Project，NSQIP)統(tǒng)計(jì)，腔內(nèi)治療約占腹主動(dòng)脈瘤擇期手術(shù)的80%、急診手術(shù)的59.8%[7]。開(kāi)腹手術(shù)圍手術(shù)期死亡率、并發(fā)癥發(fā)生率在擇期手術(shù)中是腔內(nèi)治療的4倍，在急診手術(shù)中是腔內(nèi)治療的1.6～2倍，通過(guò)校正變量，主要的危險(xiǎn)因素為：高齡、女性、腎功能不全、慢性阻塞性肺疾病等[8]。

本研究OS 組住院期間輸注紅細(xì)胞量、輸注血漿量、術(shù)后重癥監(jiān)護(hù)室治療時(shí)間、住院時(shí)間明顯高于EVAR 組。對(duì)于輸血量，腔內(nèi)治療相比開(kāi)放手術(shù)創(chuàng)傷小，通常穿刺或局部切開(kāi)，故出血的風(fēng)險(xiǎn)明顯低于開(kāi)放手術(shù)；對(duì)于術(shù)后重癥監(jiān)護(hù)室治療時(shí)間、住院時(shí)間，開(kāi)放手術(shù)創(chuàng)傷較大，手術(shù)時(shí)間長(zhǎng)，導(dǎo)致手術(shù)應(yīng)激反應(yīng)大，全麻病人術(shù)后氣管插管的拔管問(wèn)題，術(shù)后通氣、通便，術(shù)后并發(fā)癥發(fā)生，全身恢復(fù)情況，往往增加了開(kāi)放手術(shù)病人術(shù)后重癥監(jiān)護(hù)室治療時(shí)間與住院時(shí)間；這與國(guó)外相關(guān)報(bào)告所提及得EVAR較OS在術(shù)后有更好的早期效果相似[9]。

有學(xué)者通過(guò)OS與EVAR的對(duì)比研究發(fā)現(xiàn)：EVAR術(shù)后病人心、腦、肺相關(guān)并發(fā)癥的發(fā)生率明顯低于OS組[6]。本研究OS組與EVAR組術(shù)后及隨訪期間并發(fā)癥的發(fā)生率無(wú)明顯差異，這或許與本實(shí)驗(yàn)將圍手術(shù)期并發(fā)癥與隨訪期間并發(fā)癥合并在一起分析相關(guān)。有學(xué)者報(bào)道腔內(nèi)治療1年半后的遠(yuǎn)期效果與開(kāi)放手術(shù)無(wú)顯著差異(其中包括并發(fā)癥)[8]；相似的研究證實(shí)EVAR術(shù)后6年生存率(69%)無(wú)差異于開(kāi)放修復(fù)(70%)。對(duì)于破裂腹主動(dòng)脈瘤，Yildirim等[10]學(xué)者報(bào)告：腔內(nèi)治療與開(kāi)放手術(shù)除術(shù)后重癥監(jiān)護(hù)室的天數(shù)差異具有統(tǒng)計(jì)學(xué)意義，其余數(shù)據(jù)均無(wú)統(tǒng)計(jì)學(xué)意義。腔內(nèi)治療在隨機(jī)試驗(yàn)中未顯示出比開(kāi)放手術(shù)更好的長(zhǎng)期結(jié)果，在EVAR術(shù)后5年內(nèi)，有五分之一病人很有可能出現(xiàn)腔內(nèi)治療的相關(guān)并發(fā)癥[11-12]。

Deery等[13]報(bào)告：EVAR術(shù)后再次干預(yù)的比例(0.3%)高于OS手術(shù)(0%)，其中髂支閉塞的中位數(shù)高于OS組。Majd等[14]在對(duì)腹主動(dòng)脈瘤10年的隨訪研究中發(fā)現(xiàn)：EVAR術(shù)后再次手術(shù)的比例(16.7%)明顯高于OS組(6.5%)，P=0.018，原因可能是內(nèi)漏與髂支閉塞。本研究EVAR 組術(shù)后髂支閉塞病人明顯高于OS組，但差異無(wú)統(tǒng)計(jì)學(xué)意義。原因一：近5年的回顧性研究中納入的OS組病人較少，統(tǒng)計(jì)分析可能存在偏倚；原因二：本中心在2015年總結(jié)EVAR術(shù)后髂支閉塞的高危因素后，EVAR術(shù)中刻意規(guī)避了可控的危險(xiǎn)因素，從而降低了髂支閉塞的發(fā)生。有報(bào)道：髂支閉塞是EVAR術(shù)后再次入院的第三大常見(jiàn)原因，值得重視[15-16]。髂支閉塞通常發(fā)生在術(shù)后3～6個(gè)月內(nèi)，致病因素主要包括兩類：第一類是解剖因素，第二類是設(shè)備因素。解剖因素包括：髂動(dòng)脈直徑較小(特別是女性病人)、動(dòng)脈瘤角度≥60°、主動(dòng)脈分叉處成銳角、髂動(dòng)脈扭曲；設(shè)備因素包括：移植物移位，移植物直徑較小、支架徑向力低、支架連接處扭曲成角。傳統(tǒng)的觀點(diǎn)認(rèn)為：主體支架的分支交叉可能會(huì)引起髂支閉塞，但Dattani等[17]學(xué)者通過(guò)研究證實(shí)：EVAR術(shù)中主體支架的分支交叉不會(huì)增加髂支閉塞的風(fēng)險(xiǎn)，但應(yīng)當(dāng)重視術(shù)后2型內(nèi)漏的可能。雖然髂支閉塞在EVAR術(shù)后的發(fā)生率較高，但再次手術(shù)通過(guò)球囊擴(kuò)張、血栓抽吸、支架植入、直接置管溶栓等腔內(nèi)治療的方法，通常能夠達(dá)到預(yù)期效果[18-19]。

本研究EVAR 組術(shù)后支架感染病人明顯高于OS組，但差異無(wú)統(tǒng)計(jì)學(xué)意義。然而，Dakour等[20]在腹主動(dòng)脈瘤術(shù)后30 d的并發(fā)癥中報(bào)道：EVAR術(shù)后血管移植物炎癥和感染反應(yīng)的相關(guān)并發(fā)癥明顯高于OS(6.7%比4.1%；P=0.01)。支架感染是腹主動(dòng)脈瘤術(shù)后的罕見(jiàn)病，在文獻(xiàn)中通常被稱為Disastrous complications(災(zāi)難性的并發(fā)癥)，預(yù)后很差，值得重視[21]。支架感染較常見(jiàn)于EVAR術(shù)后，發(fā)生率相關(guān)系列報(bào)告為0.2%～0.9%，感染通常來(lái)源于術(shù)中無(wú)菌操作不嚴(yán)格所致的早期感染或術(shù)后闌尾炎、腎盂腎炎等感染蔓延所致的晚期感染[22]。本研究支架感染3例：其中1例拒絕手術(shù)，死于膿毒血癥；1例自動(dòng)出院，治療情況不詳；1例通過(guò)穿刺置管引流治愈，隨訪至今。穿刺引流應(yīng)用于支架感染的治療早在1990年就有學(xué)者提出，打破傳統(tǒng)的開(kāi)放手術(shù)，已漸漸應(yīng)用于支架感染、感染性腹主動(dòng)脈瘤[23]。由于支架感染的臨床資料有限，且預(yù)后較差，術(shù)前完善的評(píng)估、圍手術(shù)期抗生素的預(yù)防，術(shù)后定期復(fù)查CTA是十分必要的[22]。

內(nèi)漏在EVAR術(shù)后的發(fā)生率高(10%～40%)，其中最常見(jiàn)的是Ⅱ型內(nèi)漏[24]。而開(kāi)腹手術(shù)在直視下切開(kāi)瘤腔、縫扎分支動(dòng)脈、吻合血管，內(nèi)漏的發(fā)生率很低[25]。美國(guó)血管外科學(xué)會(huì)(Society for Vascular Surgery,SVS)建議：如瘤腔持續(xù)增大，Ⅱ型內(nèi)漏需進(jìn)一步治療[25]。歐洲血管外科學(xué)會(huì)(European Society for Vascular Surgery，ESVS)建議：Ⅱ型內(nèi)漏可通過(guò)腔內(nèi)或腹腔鏡手術(shù)進(jìn)一步處理，如未能成功，可考慮開(kāi)放手術(shù)治療(level 2b, recommendation B)[25]。早期的Ⅰ型內(nèi)漏通常在術(shù)中可以檢測(cè)到，無(wú)論是ⅠA型還是ⅠB型，均可通過(guò)腔內(nèi)的方式解決；晚期的Ⅰ型內(nèi)漏主要由于支架移位或主動(dòng)脈瘤頸進(jìn)行性擴(kuò)張，因此術(shù)后密切的隨訪是必要的。Ⅲ、Ⅳ型內(nèi)漏的發(fā)生率均小于2%，相關(guān)研究報(bào)告較少，但值得注意的是Ⅲ型內(nèi)漏的出現(xiàn)是發(fā)生支架破裂的前兆，隨訪的目標(biāo)之一就是對(duì)組件分離的診斷，以便能及時(shí)干預(yù)[26]。

腔內(nèi)技術(shù)治療腹主動(dòng)脈瘤至今已有26年的歷史，時(shí)間雖然短暫，但對(duì)血管外科領(lǐng)域有著重要的影響。盡管腔內(nèi)治療效果優(yōu)于開(kāi)放手術(shù)的循證資料十分有限，但EVAR仍然是一個(gè)令血管外科醫(yī)生及病人容易接受的手術(shù)方式。

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Comparisonofopensurgerywithendovasculartreatmentforabdominalaorticaneurysms

ZhuFeng,GeXiaohu.

DepartmentofVascularSurgery,XinjiangUygurAutonomousRegionPeople’sHospital,Wurumuqi830001,China

GeXiaohu,Email:gexiaohu_xj@163.com

ObjectiveTo comparatively analyze open surgery with endovascular treatment for abdominal aortic aneurysms.MethodsThe patients with abdominal aortic aneurysms were collected from July 2012 to June 2017 in the Department of Vascular Surgery, Xinjiang Autonomous RegionPeople'sHospital.The general condition, hospitalization andcomplications postoperation and during the follow-up period were compared between open surgery and endovascular treatment.ResultsOf 176 patients with abdominal aortic aneurysms successfully undergoing surgical operations, 26 patients were treated with endovascular therapy (EVAR) and 20 patients were treated with open surgery(OS). Of all patients, the mean age was 68.8±9.9 years, and the mean follow-up period was 25.9±16.2 months. The infusion of erythrocytes and the amount of infusion in the OS group were significantly increased as compared with those in the EVAR group (P<0.05). Theattention should be paid to iliac artery occlusion and stent infection following EVAR.ConclusionsWhether the efficacy of endovascular treatment is superior to open surgery is unclear,but EVAR is an accepted surgical procedure for vascular surgeons and patients.Early effect of endovascular treatment may be better than open surgery during hospitalization,and the long-term effect should be studied further.

Abdominal aortic aneurysm; Open surgery; Endovascular treatment

R654.3

A

10.3969/j.issn.1003-5591.2017.06.006

830001 烏魯木齊，新疆維吾爾自治區(qū)人民醫(yī)院血管外科

戈小虎，Email：gexiaohu_xj@163.com

2017-10-09)