北京大学学报(医学版) ›› 2020, Vol. 52 ›› Issue (4): 667-671. doi: 10.19723/j.issn.1671-167X.2020.04.013

• 论著 • 上一篇    下一篇

经皮肾镜去石术后出血的介入治疗

高健1,(),胡立宝1,陈尘1,郅新1,徐涛2,()   

  1. 1.北京大学人民医院 放射科,北京 100044
    2.北京大学人民医院 泌尿外科,北京 100044
  • 收稿日期:2020-04-27 出版日期:2020-08-18 发布日期:2020-08-06
  • 通讯作者: 高健,徐涛 E-mail:gao_jian@pkuph.edu.cn;xutao@pkuph.edu.cn

Interventional treatment of hemorrhage after percutaneous nephrolithotomy

Jian GAO1,(),Li-bao HU1,Chen CHEN1,Xin ZHI1,Tao XU2,()   

  1. 1. Department of Radiology, Peking University People’s Hospital, Beijing 100044, China
    2. Department of Urology, Peking University People’s Hospital, Beijing 100044, China
  • Received:2020-04-27 Online:2020-08-18 Published:2020-08-06
  • Contact: Jian GAO,Tao XU E-mail:gao_jian@pkuph.edu.cn;xutao@pkuph.edu.cn

摘要:

目的: 研究超选择性肾动脉栓塞在治疗经皮肾镜术后出血中的效果及失败原因。方法: 对65例伴有血液动力学改变的经皮肾镜术后出血患者行肾动脉造影,用微导管行超选择性插管,用微弹簧圈栓塞损伤动脉。若首次肾动脉造影无阳性发现,则采用以下措施以防止遗漏病灶:(1)腹主动脉造影;(2)重复肾动脉造影;(3)造瘘管走行区域肾动脉分支超选择造影;(4)保留穿刺通道,拔除肾造瘘管后造影。对肾动脉出血的造影表现进行总结,并对栓塞止血失败的原因进行分析。结果: 65例患者中,造影有阳性发现的60例(62个肾脏), 均经超选择性栓塞成功止血。肾动脉造影的阳性表现包括:假性动脉瘤形成、斑片状造影剂外溢、假性动脉瘤合并动静脉瘘、造影剂进入集合系统、造影剂弥散至肾被膜下。一次栓塞成功53例(55个肾脏), 成功率88.71%,两次栓塞成功率96.77%。首次栓塞失败的原因主要是遗漏病灶(4例,57.10%)和栓塞的受损血管再通(2例,28.57%)。5例患者肾动脉造影无阳性发现,经保守治疗血尿停止。所有患者介入治疗后3、6、12个月随访,均未再次出现血尿,且未发生持续、严重的肾功能损害。结论: 超选择肾动脉栓塞是治疗经皮肾镜术后出血的有效方法,肾动脉造影遗漏病灶是造成止血失败的主要原因。

关键词: 经皮肾镜取石术, 手术后并发症, 出血, 治疗性栓塞

Abstract:

Objective: To evaluate the effectiveness of super-selective renal artery embolization in treatment of post-percutaneous nephrolithotomy bleeding, and to analyse the causes of failure embolization. Methods: In the study, 65 post-percutaneous nephrolithotomy patients with severe renal bleeding and hemodynamic instability were treated by super-selective renal artery embolization. First of all, we performed selective renal arteriography. After clarifying the location of the bleeding, superselective intubation of the injured vessel with a microcatheter was carried out. Then the injured vessel was embolized with Tornado micro-coil. When complete embolization was not achieved with micro-coil, a small amount of gelatin sponge particles were added. If there was no positive finding of the beginning selective renal arteriography, the following measures could be taken to prevent missing lesions: (1) Abdominal aorta angiography was performed to determine whether there were anatomical variations, such as accessory renal arteries or multiple renal arteries; (2) Ultra-selective intubation angiography next to the nephrostomy tube path was performed; (3) Renal arteriography was repeated; (4) Renal arteriography after removing the nephrostomy tube while retaining the puncture channel. We evaluated the different angiographic findings and analysed the causes of embolization failure. Results: Bleeding was successfully controled in 60 patients (62 kidneys) whose renal arteriography was postive. Positive findings included: pseudoaneurysm formation, patchy contrast extravasation, pseudoaneurysm combined with arteriovenous fistula, contrast agent entering the collection system, extravascular perinephric leakage of contrast. After first embolization, bleeding was controled in 53 patients (55 kidneys). The success rate after the first and second embolization was 88.7% and 96.7% respectively. The second session was required because of failure to demonstrate bleeding arteries during the first session (4 patients, 57.1%) and recurrent hemorrhage of the embolized injured arteries (2 patients, 28.6%). In 5 patients with no positive findings, after conservative treatment, hematuria disappeared. All the patients were followed up for 3, 6, and 12 months after embolization, and no hematuria occurred again, and no sustained and serious renal insufficiency. Conclusion: Super-selective renal artery embolization is an effective treatment for post percutaneous nephrolithotomy bleeding. The main cause of failure is omitting of injured arteries during renal arteriography. Renal artery branch injury has various manifestations. Attention should paid to the anatomical variation of the renal artery, and patient and meticulous superselective intubation angiography is the key to avoiding missing the lesion and improving the success rate of embolization.

Key words: Nephrostomy, percutaneous, Postoperative complications, Hemorrhage, Embolization, therapeutic

中图分类号: 

  • R814.47

表1

患者资料(65例患者,67个肾脏,80次介入治疗)"

Characteristics n (%)
Gender
Male 48 (73.84)
Female 17 (26.15)
Side of interventional procedure
Left 38 (47.50)
Right 42 (52.50)
Hydronephrosis
Yes 38 (56.71)
No 29 (43.28)
Renal unit
Solitary 5 (7.69)
Not solitary 60 (92.30)
Stone burden
Single 23 (34.33)
Mulmultiple 35 (52.24)
Staghorn 9 (13.43)

图1

PCNL术后出血的肾动脉造影表现"

图2

选择性肾动脉造影未见肾动脉损伤(A);在其肾动脉开口下方,还有一支肾动脉直接起源于腹主动脉,选择性插管造影发现肾动脉损伤、造影剂外溢(箭头所示,B)"

图3

选择性肾动脉造影未发现肾动脉损伤征象(A);腹主动脉造影发现副肾动脉(箭头所示,B);选择性副肾动脉造影发现肾动脉下极分支损伤(C)"

图4

肾动脉造影未发现病变(A),6 min后再次肾动脉造影发现肾下极动脉分支造影剂外溢(箭头所示,B)"

图5

肾动脉造影未见病变(A);主动脉造影发现副肾动脉(箭头所示,B);选择性副肾动脉造影,于肾造瘘管旁发现损伤动脉(箭头所示,C)"

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