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中华介入放射学电子杂志

中华介入放射学电子杂志 ›› 2023, Vol. 11 ›› Issue (01) : 12 -18. doi: 10.3877/cma.j.issn.2095-5782.2023.01.003

血管介入

腔内技术治疗医源性血管损伤的临床应用
贺嘉男1, 王大帅1, 张永裕1, 赵逆1, 甘海润1, 黄伟乐1, 郭辉1,†(), 庞鹏飞1   
  1. 1. 519000　广东珠海，中山大学附属第五医院介入医学中心介入血管外科
  • 收稿日期:2022-09-01 出版日期:2023-02-25
  • 通信作者: 郭辉

Application of endovascular technique in treatment of iatrogenic vascular injury

Jianan He1, Dashuai Wang1, Yongyu Zhang1, Ni Zhao1, Hairun Gan1, Weile Huang1, Hui Guo1,†(), Pengfei Pang1   

  1. 1. Department of Interventional Vascular Surgery, Interventional Medical Centre, the Fifth Affiliated Hospital of Sun Yat-sen University, Guangdong Zhuhai 519000, China
  • Received:2022-09-01 Published:2023-02-25
  • Corresponding author: Hui Guo
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贺嘉男, 王大帅, 张永裕, 赵逆, 甘海润, 黄伟乐, 郭辉, 庞鹏飞. 腔内技术治疗医源性血管损伤的临床应用[J]. 中华介入放射学电子杂志, 2023, 11(01): 12-18.

Jianan He, Dashuai Wang, Yongyu Zhang, Ni Zhao, Hairun Gan, Weile Huang, Hui Guo, Pengfei Pang. Application of endovascular technique in treatment of iatrogenic vascular injury[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2023, 11(01): 12-18.

目的

探讨腔内技术在医源性血管损伤（iatrogenic vascular injury，IVI）治疗中的应用价值。

方法

回顾性分析2018年12月至2022年6月期间因IVI于我院行腔内治疗11例患者资料，包括静脉性IVI 4例，动脉性IVI 5例，血管内异物2例。IVI治疗方法包括腔内压迫、血管破裂口填塞、经皮血管内支架植入（percutaneous intravascular stent implantation，PISI）及血管缝合器（vascular closure devices，VCDs）腔内缝合。血管内异物治疗方法为导管辅助抓捕器腔内套取。分析腔内治疗的手术方式，统计手术成功率及手术相关并发症。

结果

所有患者均顺利完成腔内治疗IVI，技术成功率100%。1例静脉性IVI患者行PISI术后3 d复查示支架内血栓形成；1例动脉性IVI患者予行股动脉腔内封堵联合假性动脉瘤腔内注射促凝血药物治疗后4 d股动脉假性动脉瘤复发，予行外科切开缝合；1例静脉性IVI患者行腔内压迫止血无效后予弹簧圈及明胶海绵栓塞治疗术后4 d死亡，但与腔内治疗髂静脉IVI未存在明确相关性。余所有病例均未出现明显手术相关并发症及围手术期死亡。手术临床成功率81.82%，手术相关并发症发病率9.09%。无手术相关严重并发症发生。

结论

腔内技术以微创方式治疗IVI，术中创伤小、术后恢复快，值得临床推广；同时，血管侵入性操作的术前评估及术后观察亦非常重要。

关键词: 腔内技术, 医源性血管损伤, 支架植入术, 血管缝合
Objective

To explore the endovascular technique in the treatment of iatrogenic vascular injury (IVI).

Methods

Medical records of 11 patients who suffered from IVI and underwent endovascular treatment at our institute from December 2018 to June 2022 were reviewed. There were 4 cases of venous IVI, 5 cases of arterial IVI and 2 case of intravascular foreign body. The treatment of IVI included intravascular compression, embolism of the vascular rupture, percutaneous intravascular stent implantation (PISI) and intravascular suture with vascular closure devices (VCDs). The intravascular foreign body was captured by using a snarer assisted with a catheter. The methods of endovascular treatment were analyzed, and the operation success and complications related to the operation were concerned.

Results

Technical success was achieved in 11 patients (100%). One patient with venous IVI underwent PISI during the process, and was detected with in-stent thrombosis at post-operative 3 days. One patient with arterial IVI was treated with intravascular compression combined with injection of procoagulant drugs for pseudoaneurysm, and the femoral artery pseudoaneurysm recurred 4 days later, then underwent surgery. One patient died 4 days after endovascular compression combined with embolization, but there was no correlation between the endovascular treatment of IVI. All the other cases had no obvious complications related to the treatment, and no death was encountered. The clinical success rate of operation was 81.82%, and the incidence of complications was 9.09%. There were no serious complications related to the operation.

Conclusions

As a minimally invasive method to treat IVI with small trauma and rapid post-operative recovery, endovascular technique is worthy of clinical promotion. Meanwhile, pre-operative evaluation and post-operative observation should also be concerned.

Key words: Endovascular technique, Iatrogenic vascular injury, Percutaneous intravascular stent implantation, Vascular suture
图1 患者男性，72岁，因急性肾功能衰竭行经右侧股静脉TDCP，术后透析导管流量较低伴血红蛋白下降，考虑导管穿出血管外1A：术前造影示TDCP导管（白色三角形）穿出髂外静脉；1B：拔出导管后，经股静脉置入球囊扩张导管（白色三角形）予腔内压迫止血；1C：腔内球囊压迫止血后造影复查，右侧髂外静脉旁仍可见造影剂溢出（白色三角形），考虑仍存在出血；1D：将微导管置入右侧髂外静脉破裂口，予明胶海绵及弹簧圈封堵（白色三角形）；1E：术后复查造影示右侧髂外静脉血流通畅，其旁未见明显造影剂溢出（白色三角形），考虑止血成功。
图2 患者女性，66岁，因慢性肾功能衰竭行经左侧颈内静脉TDCP，术中透析导管行进阻力较大，后患者出现心包填塞症状，考虑透析导管穿出血管外2A：术前造影示左侧颈内静脉导管（白色三角形）穿出无名静脉；2B：拔出导管予腔内压迫止血后复查造影，无名静脉旁仍可见造影剂溢出（白色三角形），考虑仍存在出血；2C：予覆膜支架植入后造影复查，无名静脉管腔内血流通畅，其旁未见明显造影剂溢出，考虑止血成功；2D：经左侧颈内静脉置入球囊扩张导管，对无名静脉内支架预开窗处行球囊扩张（白色三角形），以保留左侧颈内静脉血流；2E：术后复查造影示无名静脉及左侧颈内静脉（白色三角形）管腔内血流通畅。
图3 患者女性，75岁，因心功能衰竭行经右侧锁骨下静脉CVC，术后测中心静脉压显示80 mmHg（1 mmHg = 0.133 kPa），考虑CVC误穿锁骨下动脉3A：术前3D造影示CVC置管进入右侧锁骨下动脉（白色箭头）位置远离颈总动脉起始部（白色三角形）；3B：术前造影示右侧椎动脉（白色三角形）及胸廓内动脉（白色箭头）；3C：置入球囊扩张导管（白色箭头）予腔内压迫；3D：腔内球囊压迫（白色箭头）过程中行造影示，右侧颈总动脉血流通畅，右侧椎动脉及胸廓内动脉未见显示；3E：术后复查造影示，右侧锁骨下动脉、颈总动脉血流通畅，其旁未见明显造影剂外溢，右侧椎动脉及胸廓内动脉血流通畅。
图4 患者男性，56岁，因上消化道出血行经右侧锁骨下静脉CVC，术后回抽呈动脉血样，考虑CVC误穿锁骨下动脉4A：术前3D造影示CVC置管于右侧锁骨下动脉（白色箭头）起始部进入头臂；干，距离右侧颈总动脉起始部（白色三角形）较近；4B：予VCDs行血管缝合，复查造影示右侧锁骨下动脉、颈总动脉血流通畅，右侧椎动脉（白色三角形）及胸廓内动脉（白色箭头）血流通畅。
图5 患者男性，63岁，因食管癌接受化疗行左上臂PICC，术后导管断裂并脱落进入心脏及肺动脉5A：术前胸部X线检查显示心腔内PICC导管（白色箭头）；5B：经右股静脉置入Pig导管（白色三角形）并套取PICC导管（白色箭头）；5C：采用Pig导管（白色三角形）套取PICC导管（白色箭头）并拉入下腔静脉；5D：采用Pig导管（白色三角形）将PICC导管（白色箭头）拉入下腔静脉远端，经左股静脉置入抓捕器（白色星标）套取PICC导管头端并取出。
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