球囊阻断联合瘤腔内凝血酶注射治疗破裂腹主动脉瘤

doi:10.19723/j.issn.1671-167X.2024.06.017

摘要/Abstract

摘要：

目的: 探讨球囊阻断联合瘤腔内注射凝血酶在腹主动脉瘤腔内修复(endovascular aneurysm repair，EVAR)治疗破裂腹主动脉瘤(ruptured abdominal aortic aneurysm, rAAA)的安全性及有效性。方法: 选择2019年10月至2022年10月在北京大学第三医院应用EVAR术且术中全程球囊阻断联合瘤腔内注射凝血酶救治的16例rAAA患者的病例资料进行回顾性分析，其中男13例，女3例，年龄42~85岁，中位年龄70.5岁。记录其术前急救(到院至手术开始)时间、手术平均时间、重症监护病房(intensive care unit, ICU)停留时间、住院时间、手术救治成功率、围手术期(30 d)病死率、并发症发生率、随访期瘤体最大直径及体积变化。结果: 技术成功率100.0%(16/16)，1例术后6 h死于多器官功能衰竭，手术救治成功率93.8%(15/16)。术前急救时间平均(53.3±6.2) min，手术时间(89.9± 17.1) min，ICU停留时间(1.7±0.8) d，住院时间(7.8±1.3) d，术中球囊阻断时间27~41 min，平均(32.4±4.1) min，术后存活15例患者肾功能较术前无明显恶化。术后1例出现腹腔间隔室综合征，经CT穿刺引流好转。中位随访时间36个月，随访期间1例患者于术后第2年死于急性心肌梗死，其余14例中发生Ⅱ型内漏1例，无其他类型内漏发生。14例患者的瘤体最大直径均较术前明显减小[(44.6±8.0) mm vs.(66.0±15.5) mm，P＜0.001]，12例有完整CT血管造影(computed tomographic angiography，CTA)结果的患者中，瘤体体积均较术前明显缩小[(311.7±170.3) mm³ vs. (168.6±68.1) mm³，P＜0.05]。结论: EVAR术中全程球囊阻断联合瘤腔内注射凝血酶能降低腹腔间隔室综合征及内漏发生率，在一定程度上可提高救治成功率。

关键词: 破裂腹主动脉瘤, 球囊阻断, 凝血酶, 腔内修复术

Abstract:

Objective: To investigate the safety and effectiveness of balloon occlusion and intra-sac thrombin injection in the endovascular repair of ruptured abdominal aortic aneurysm. Methods: From October 2019 to October 2022, the clinical data of 16 patients with rAAA treated with balloon occlusion technique and intra-sac thrombin injection combined with EVAR were retrospectively analyzed, including 13 males and 3 females, aged 42-85 years, with a median age of 70.5 years. The time of preoperative first aid (from hospital arrival to operation start), average operation time, stay in intensive care unit (ICU), average hospitalization time, success rate of surgical treatment, perioperative (30 d) mortality rate, incidence of complications, the maximum diameter and volume change of the aneurysm were observed and recorded. Results: Among the 16 patients with ruptured abdominal aortic aneurysm, the technical success rate was 100.0% (16/16). One patient died of multiple organ dysfunction 6 hours after operation. The success rate of surgical treatment was 93.8% (15/16). The preoperative first aid time was (53.3±6.2) min, the average operation time was (89.9±17.1) min, the stay in the intensive care unit (ICU) was (1.7±0.8) d, and the average hospitalization time was (7.8±1.3) d. The intraoperative balloon occlusion time was (32.4±4.1) min. The postoperative renal function of all the patients had no significant deterioration compared with that preoperative. Abdominal compartment syndrome (ACS) occurred in 1 patient after operation, which improved after CT puncture and drainage. The median follow-up time was 36 months. During the follow-up period, 1 patient died of acute myocardial infarction 2 years after operation, and the remaining 14 patients survived. Among the 14 follow-up patients, 1 type Ⅱ endoleak occurred, and no other types of endoleak occurred. By the end of the follow-up, the maximum diameter of the aneurysm sac in 14 patients was significantly lower than that before operation [(44.6±8.0) mm vs.(66.0±15.5) mm, P < 0.001], and in 12 patients with CTA, the volume of the aneurysm sac was significantly shrunk than that before operation [(311.7±170.3) mm³ vs. (168.6±68.1) mm³, P < 0.05]. Conclusion: Balloon occlusion during endovascular repair is safe and effective in the treatment of ruptured abdominal aortic aneurysm; intraoperative thrombin injection of the aneurysm sac can significantly reduce the incidence of intraoperative and postoperative abdominal compartment syndrome and endoleak and, to a certain extent, improve the success rate of treatment.

Key words: Ruptured abdominal aortic aneurysm, Balloon occlusion, Thrombin, Endovascular repair

中图分类号:

R654.3

赵世录, 栾景源, 冯琦琛, 刘启佳, 杨广鑫, 贾子昌, 庄金满. 球囊阻断联合瘤腔内凝血酶注射治疗破裂腹主动脉瘤[J]. 北京大学学报（医学版）, 2024, 56(6): 1052-1057.

Shilu ZHAO, Jingyuan LUAN, Qichen FENG, Qijia LIU, Guangxin YANG, Zichang JIA, Jinman ZHUANG. Effect of balloon occlusion combined with intra-sac injection of thrombin in the treatment of ruptured abdominal aortic aneurysm[J]. Journal of Peking University (Health Sciences), 2024, 56(6): 1052-1057.

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参考文献 19

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Group	Abdominal pain/Lmbodynia, n(%)			Body temperature/℃, $\bar x \pm s$	Leucocyte/(×10⁹/L), $\bar x \pm s$	Erythrocyte/(×10⁹/L), $\bar x \pm s$	Hemoglobin/(g/L), $\bar x \pm s$	Serum creatinine/(μmol/L), $\bar x \pm s$
Group	Non remission	Partial remission	Complete remission	Body temperature/℃, $\bar x \pm s$	Leucocyte/(×10⁹/L), $\bar x \pm s$	Erythrocyte/(×10⁹/L), $\bar x \pm s$	Hemoglobin/(g/L), $\bar x \pm s$	Serum creatinine/(μmol/L), $\bar x \pm s$
Pre-operation	15 (100)	0	0	36.8±0.2	10.64±3.69	2.65±0.64	80.73±17.03	131.80±46.47
Post-operation (24 h)	5 (33)	7 (47)	3 (20)	37.8±0.6	11.11±4.28	2.96±0.49	87.20±12.77	119.60±33.62
Post-operation (48 h)	4 (27)	8 (53)	3 (20)	38.0±0.5	9.32±3.61	3.10±0.51	93.60±11.72	100.67±26.17
Post-operation (72 h)	3 (20)	7 (47)	5 (33)	37.3±0.3	8.34±3.59	3.33±0.49	101.00±3.12	93.67±17.68
Before discharge	0 (0)	0 (0)	15 (100)	36.7±0.1	7.38±1.28	3.68±0.56	114.00±8.71	77.47±13.10

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