王春喜, 韓麗娜, 段志泉, 褚福濤, 宋清彬

(1. 解放軍總醫(yī)院外科臨床部 普通外科, 北京, 100853;

2. 中國(guó)醫(yī)科大學(xué) 第一臨床醫(yī)院 血管外科, 沈陽(yáng), 110001;

3. 解放軍總醫(yī)院南樓臨床部心血管科, 北京, 100853)

脾動(dòng)脈頭端動(dòng)脈瘤的外科治療11例報(bào)告

王春喜1,2, 韓麗娜1, 段志泉2, 褚福濤1, 宋清彬2

(1. 解放軍總醫(yī)院外科臨床部 普通外科, 北京, 100853;

2. 中國(guó)醫(yī)科大學(xué) 第一臨床醫(yī)院 血管外科, 沈陽(yáng), 110001;

3. 解放軍總醫(yī)院南樓臨床部心血管科, 北京, 100853)

摘要:目的探討脾動(dòng)脈頭端真性動(dòng)脈瘤的切除方法以及血管重建方法，總結(jié)臨床治療經(jīng)驗(yàn)。方法回顧性總結(jié)2000年1月—2013年6月作者收治的11例資料，均經(jīng)彩色超聲、CT和 血管造影檢查證實(shí)脾動(dòng)脈頭端真性動(dòng)脈瘤。肝動(dòng)脈脾臟動(dòng)脈遠(yuǎn)端自體靜脈移植1例；腎下主動(dòng)脈—脾動(dòng)脈人工血管轉(zhuǎn)流7例；動(dòng)脈瘤、脾臟切除2例，多發(fā)動(dòng)脈瘤切除、脾動(dòng)脈結(jié)扎、脾切除1例。結(jié)果手術(shù)后10～14天治愈出院，隨訪1～14年，9例存活，2例死亡，其中1例主脾轉(zhuǎn)流后2年死于急性心肌梗死，1例動(dòng)脈瘤切除、脾切除后5年死于急性腦出血。7例主脾轉(zhuǎn)流中，1例術(shù)后2年吻合口逐漸狹窄，術(shù)后6年完全閉塞，但一直無(wú)脾臟梗死，脾臟供血由胃短血管及其側(cè)枝提供；余6例主脾轉(zhuǎn)流和1例自體血管移植者未見(jiàn)吻合口狹窄或假性動(dòng)脈瘤。結(jié)論脾動(dòng)脈頭端真性動(dòng)脈瘤切除、脾動(dòng)脈血管重建是一種較好的治療方案。

關(guān)鍵詞:脾動(dòng)脈瘤; 手術(shù)

脾臟動(dòng)脈瘤是最常見(jiàn)的內(nèi)臟動(dòng)脈瘤，占內(nèi)臟動(dòng)脈的40%～60%，瘤體多位于脾動(dòng)脈中段和遠(yuǎn)端近脾門處[1-2], 而位于脾動(dòng)脈頭端的真性動(dòng)脈瘤十分罕見(jiàn)。同其他動(dòng)脈瘤一樣，瘤體破裂是人體生命的最大威脅[3-4], 因此早期診斷早期治療異常重要。2000年1月—2013年6月，作者收治11例脾動(dòng)脈頭端真性動(dòng)脈瘤，均行外科切除手術(shù)，現(xiàn)分析報(bào)道如下。

1資料與方法

1.1一般資料

11例脾動(dòng)脈頭端真性動(dòng)脈瘤，男3例，女8例，年齡48～63歲，平均53歲。上腹部隱痛6例，上腹部搏動(dòng)性腫物1例，4例無(wú)明顯自覺(jué)癥狀。臨床查體1例觸及上腹部搏動(dòng)性腫物，3例上腹部輕壓痛，余無(wú)明顯陽(yáng)性體征。7例中3例同時(shí)合并高血壓(其中1例又同時(shí)合并冠心病)，2例合并糖尿病，1例合并肝硬化門靜脈高壓癥，1例合并全身多處動(dòng)脈硬化。

1.2影像資料

超聲檢查均顯示脾動(dòng)脈頭端血管擴(kuò)張成瘤2.5～10 cm，內(nèi)見(jiàn)附壁血栓和粥樣斑塊，瘤壁廣泛鈣化，厚薄不一，其中1例頭端5.5 cm動(dòng)脈瘤同時(shí)合并脾動(dòng)脈遠(yuǎn)端擴(kuò)張和2處2 cm動(dòng)脈瘤。11例均接受增強(qiáng)CT內(nèi)臟動(dòng)脈三維重建檢查，瘤體內(nèi)部形態(tài)結(jié)構(gòu)可見(jiàn)。動(dòng)脈瘤呈類圓形或橢圓形8例，3例呈紡錘形，CT測(cè)量直徑2.5～10 cm, 長(zhǎng)2.6～10.5 cm, 瘤壁鈣化明顯；瘤體發(fā)自腹腔干末端7例，發(fā)自肝動(dòng)脈4例；1例5.7 cm真性動(dòng)脈瘤同時(shí)合并脾動(dòng)脈擴(kuò)張，多發(fā)性動(dòng)脈瘤形成，動(dòng)脈瘤將胰腺推擠移位。肝臟和脾臟大小形態(tài)正常，無(wú)占位病變。11例同時(shí)行DSA血管造影檢查，與CT結(jié)果一致, 1例顯示多發(fā)性動(dòng)脈瘤。

1.2手術(shù)情況

均在全身麻醉下行剖腹探查手術(shù)，腫物位于胰腺后方，將胰腺推向前方或前下方，呈弧形或弓弦狀橫跨動(dòng)脈瘤；動(dòng)脈瘤搏動(dòng)與脈搏跳動(dòng)一致。游離腹腔干、肝臟動(dòng)脈和主動(dòng)脈，繼而游離胰腺上下緣和胰腺后方，顯出動(dòng)脈瘤瘤體；分離瘤體和遠(yuǎn)端脾臟動(dòng)脈，分別阻斷腹腔干、肝動(dòng)脈和動(dòng)脈瘤遠(yuǎn)端脾動(dòng)脈，切開(kāi)動(dòng)脈瘤，即可看到血栓和鈣化的瘤壁，常呈蛋殼狀，切除動(dòng)脈瘤壁，嚴(yán)密止血，如發(fā)現(xiàn)與動(dòng)脈瘤交通的血管支予以縫扎，完全閉合開(kāi)口。修補(bǔ)近肝動(dòng)脈或腹腔干動(dòng)脈處的血管壁，行肝動(dòng)脈或腹腔干動(dòng)脈成型。對(duì)遠(yuǎn)端脾動(dòng)脈結(jié)構(gòu)完整、鈣化不明顯、血管壁相對(duì)正常而需要保留脾臟者，行脾動(dòng)脈重建術(shù)，包括自體血管原位移植或人工血管旁路移植，后者主要用于腹腔干或肝動(dòng)脈顯露不佳、手術(shù)野狹小、動(dòng)脈瘤周圍粘連嚴(yán)重者；對(duì)無(wú)法重建或無(wú)需重建者，行動(dòng)脈瘤切除同時(shí)脾臟切除。本組肝動(dòng)脈脾臟動(dòng)脈遠(yuǎn)端自體靜脈移植1例；腎下主動(dòng)脈—脾動(dòng)脈人工血管轉(zhuǎn)流術(shù)7例。另外本組對(duì)脾動(dòng)脈遠(yuǎn)端明顯硬化、鈣化、不規(guī)則擴(kuò)張等不適合血管重建者2例，行動(dòng)脈瘤、脾臟一并切除；1例多發(fā)性動(dòng)脈瘤行頭端動(dòng)脈瘤切除，脾臟動(dòng)脈結(jié)扎遠(yuǎn)端動(dòng)脈瘤連續(xù)縫合后脾臟切除。

2結(jié)果

11例均于手術(shù)后10～14 d治愈出院，手術(shù)后均獲1～14年隨訪，9例存活，2例死亡。隨訪1年者1例(肝動(dòng)脈成型、主動(dòng)脈脾臟動(dòng)脈轉(zhuǎn)流)，健在。隨訪2～5年者3例，其中1例動(dòng)脈瘤、脾臟切除和1例動(dòng)脈瘤切除、腹腔干脾動(dòng)脈自體靜脈移植存活，1例動(dòng)脈瘤切除主脾轉(zhuǎn)流死亡，術(shù)后2年死于急性心肌梗死。隨訪5～8年者4例，其中3例動(dòng)脈瘤切除、主脾轉(zhuǎn)流者存活，1例動(dòng)脈瘤和脾臟切除者術(shù)后5年死于急性腦出血。隨訪8年者1例，動(dòng)脈瘤切除、主脾轉(zhuǎn)流術(shù)后健在。隨訪10年以上者1例，動(dòng)脈瘤和脾臟切除手術(shù)后存活14年。7例主脾轉(zhuǎn)流者，1例術(shù)后2年逐漸出現(xiàn)狹窄，術(shù)后6年完全閉塞，但無(wú)脾臟梗死，脾臟供血由胃短血管及其側(cè)枝提供；余6例主脾轉(zhuǎn)流者和1例自體血管移植者均未見(jiàn)吻合口狹窄或假性動(dòng)脈瘤形成。

3討論

脾臟動(dòng)脈瘤常見(jiàn)病因?yàn)閯?dòng)脈粥樣硬化、肝硬化門靜脈高壓、脾動(dòng)脈先天性異常、外傷、多次妊娠等[4-5]。瘤體一般位于脾動(dòng)脈的遠(yuǎn)端及尾端近脾門處[6-7]，而脾動(dòng)脈頭端的真性動(dòng)脈瘤則十分少見(jiàn)[2,8]。通常情況下，真性動(dòng)脈瘤呈囊狀或球樣擴(kuò)張，部分呈紡錘狀，瘤體直徑一般2～5 cm, 少數(shù)10 cm以上[2,9]，脾臟動(dòng)脈瘤多孤立單發(fā)，少數(shù)多發(fā)，甚至呈串珠狀[10-11], 本組即1例多發(fā)性脾動(dòng)脈瘤。本類疾病通常無(wú)明顯自覺(jué)癥狀，多為健康查體或因其他疾病檢查時(shí)發(fā)現(xiàn)。臨床上僅少數(shù)患者存在上腹部不適、腹痛等，瘤體較大時(shí)可出現(xiàn)左側(cè)肩背部疼痛，當(dāng)壓迫腹腔神經(jīng)叢或刺激胃后壁時(shí)可出現(xiàn)惡心、嘔吐等消化道癥狀，少數(shù)病人出現(xiàn)腹部腫物。瘤體破裂可出現(xiàn)失血性休克，也是頭端動(dòng)脈瘤的最大威脅，表現(xiàn)為突發(fā)性急性腹痛，可放射至背部或肩部，血壓迅速下降，脈搏增快，很快失血性休克、甚至死亡，且其死亡率高達(dá)25%～70%[12]。

影像學(xué)檢查對(duì)脾動(dòng)脈頭端動(dòng)脈瘤的診斷價(jià)值較大[13-14], 由于多數(shù)真性脾動(dòng)脈瘤常常合并嚴(yán)重鈣化，在腹部平片胰腺水平即可見(jiàn)明顯鈣化，有時(shí)呈蛋殼狀。CT是一種相對(duì)無(wú)創(chuàng)的敏感性檢查手段，可清晰地顯示膨大的瘤體大小和形態(tài)，以及有無(wú)鈣化、附壁血栓等，瘤體多半位于胰腺后方，并將胰腺向前方或前下方推擠，三維成像可顯示不同側(cè)面的立體結(jié)構(gòu)，并清晰顯示出肝動(dòng)脈、腹腔干與瘤體的關(guān)系。MRI也可清晰顯示脾動(dòng)脈頭端動(dòng)脈瘤的形態(tài)結(jié)構(gòu)，以及血液流動(dòng)方向。腹部B超：一般來(lái)說(shuō)陽(yáng)性率不如CT和核磁共振，但可作為一種初步檢測(cè)或篩選的影像檢查方法。選擇性血管造影：可具體了解瘤體的大小、形態(tài)、部位以及與周圍器官的關(guān)系，尤其是動(dòng)態(tài)血流走行方向、與周圍血管有無(wú)交通或其他異常血流。因此結(jié)合臨床表現(xiàn)和影像學(xué)檢查，一般不難得出正確的診斷。

因動(dòng)脈瘤存在破裂之虞，頭端動(dòng)脈瘤一旦確診，與脾動(dòng)脈其他部位的動(dòng)脈瘤一樣需要積極干預(yù)[12], 尤其是瘤體直徑≥2 cm; 有癥狀的脾動(dòng)脈瘤；多發(fā)性動(dòng)脈瘤；準(zhǔn)備接受肝移植、準(zhǔn)備妊娠或妊娠期間發(fā)現(xiàn)的脾動(dòng)脈瘤。

隨著血管內(nèi)微創(chuàng)技術(shù)的發(fā)展和成熟，血管介入栓塞和帶膜支架植入能夠有效治療大多數(shù)部位的脾臟動(dòng)脈瘤，但卻不能完全替代傳統(tǒng)手術(shù)，尤其是介入失敗或無(wú)法實(shí)施微創(chuàng)者，例如巨大瘤體、特殊部位或解剖結(jié)構(gòu)的異常，均導(dǎo)致介入治療無(wú)法實(shí)施。Yadav S等[15]認(rèn)為瘤體較大(大于5 cm)、瘤頸較寬、動(dòng)脈瘤鄰近肝動(dòng)脈或腹腔干時(shí)，介入治療十分困難，且極易出現(xiàn)并發(fā)癥，傳統(tǒng)手術(shù)治療應(yīng)作為首選方法[16-17], 包括瘤體切除和血管重建，相對(duì)安全可靠。

本組資料脾臟動(dòng)脈頭端動(dòng)脈瘤緊鄰肝臟動(dòng)脈或腹腔干動(dòng)脈，瘤體較大、瘤頸較寬、瘤壁鈣化厚薄不均，同時(shí)因缺乏及時(shí)、合適的分叉型帶膜支架供應(yīng)，血管內(nèi)修復(fù)常常無(wú)法實(shí)施；介入栓塞則因瘤體較大不易完全閉塞且極易導(dǎo)致正常管徑的腹腔干動(dòng)脈、肝動(dòng)脈的阻塞，另外瘤壁較薄也極易造成瘤體破裂，另外栓塞物的脫落也容易造成脾臟的大面積梗死[18]；傳統(tǒng)開(kāi)腹手術(shù)成為動(dòng)脈瘤切除的最后手段，包括脾動(dòng)脈瘤切除、脾動(dòng)脈重建，或脾動(dòng)脈瘤和脾臟一并切除，同時(shí)處理并存的病理改變，如動(dòng)靜脈瘺、胃腸瘺等[19]。然而，脾動(dòng)脈頭端動(dòng)脈瘤的切除并非易事，手術(shù)時(shí)需要游離腹腔干，而此時(shí)的腹腔干常常為動(dòng)脈瘤遮蓋，游離十分困難。一般來(lái)說(shuō)，開(kāi)腹后可觸及搏動(dòng)性腫物，與脈搏一致，位于胰腺后方，腫瘤將胰腺推向前方或前下方，胰腺呈弧形或弓弦狀橫跨動(dòng)脈瘤；作者的體會(huì)是，手術(shù)時(shí)首先游離主動(dòng)脈和腹腔干，便于阻斷動(dòng)脈防止瘤體突然破裂大出血。完全游離胰腺上下緣和胰腺后方，將胰腺與動(dòng)脈瘤分開(kāi)，牽開(kāi)胰腺顯出動(dòng)脈瘤瘤體；小心分離腹腔干動(dòng)脈、肝臟動(dòng)脈和動(dòng)脈瘤瘤體以及遠(yuǎn)端脾動(dòng)脈，阻斷瘤體近遠(yuǎn)段動(dòng)脈血流后，切除動(dòng)脈瘤，同時(shí)進(jìn)行肝動(dòng)脈或腹腔干動(dòng)脈成型。動(dòng)脈瘤切除后脾動(dòng)脈重建方式應(yīng)據(jù)情況而定，如腹腔干和肝動(dòng)脈相對(duì)游離、瘤體較小，瘤體切除后脾動(dòng)脈與肝動(dòng)脈或腹腔干端側(cè)吻合，如張力較高切取一段自體靜脈，在脾動(dòng)脈遠(yuǎn)端與腹腔干或肝動(dòng)脈之間行間置靜脈轉(zhuǎn)流術(shù)；如操作困難也可行腎下主動(dòng)脈—脾動(dòng)脈人工血管轉(zhuǎn)流術(shù)，其顯著優(yōu)點(diǎn)是手術(shù)野比較清楚、相對(duì)寬敞，且腎下主動(dòng)脈阻斷不影響腎臟血運(yùn)，對(duì)腎臟功能起到保護(hù)作用。本組1例動(dòng)脈瘤切除、肝動(dòng)脈—脾動(dòng)脈自體靜脈轉(zhuǎn)流；6例動(dòng)脈瘤切除、腎下主動(dòng)脈—脾動(dòng)脈人工血管轉(zhuǎn)流，2例動(dòng)脈瘤切除、脾臟切除術(shù)，1例多發(fā)性動(dòng)脈瘤行頭端動(dòng)脈瘤切除，脾臟動(dòng)脈結(jié)扎遠(yuǎn)端動(dòng)脈瘤連續(xù)縫合后脾臟切除。近期均獲得臨床治愈，且遠(yuǎn)期療效也比較理想。

隨著腔鏡技術(shù)的發(fā)展，盡管已有腹腔鏡下脾臟動(dòng)脈瘤切除的報(bào)道，但因其技術(shù)條件、設(shè)備條件以及瘤體解剖條件要求較高尚未廣泛開(kāi)展，目前多為脾動(dòng)脈遠(yuǎn)端和近脾門處動(dòng)脈瘤案例報(bào)道，而脾動(dòng)脈頭端真性動(dòng)脈瘤尚無(wú)報(bào)道。資料[20]顯示，近10年來(lái)僅有1例脾動(dòng)脈近端近腹腔干處真性動(dòng)脈瘤的腹腔鏡切除的報(bào)道。手術(shù)切除以及血管重建仍然是目前治療脾動(dòng)脈頭端真性動(dòng)脈瘤的主要方法，安全可靠，且仍將在一定時(shí)期內(nèi)作為首選方法。

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Surgical treatment of 11 patients with

aneurysm at the head of splenic artery

WANG Chunxi1,2, HAN Lina1, DUAN Zhiquan2, CHU Futao1, SONG Qingbin2

(1.DepartmentofGeneralSurgery,GeneralHospitalofPLA,Beijing, 100853;

2.DepartmentoftheVascularSurgery,TheFirstClinicalHospitalofChinaMedical

University,Shenyang,Liaoning, 110001; 3.CardiovascularDepartment,

GeneralHospitalofPLA,Beijing, 100853)

ABSTRACT:ObjectiveTo investigate the resection methods of true aneurysm at the head of splenic artery and reconstruction method of blood vessels and to summarize the clinical treatment experience. MethodsThe clinical material of 11 patients with the true aneurysm from January 2000 to June 2013 at the head of splenic artery was retrospectively analyzed. All patients were definitely diagnosed by color ultrasonography, computer tomography (CT) and angiography as true aneurysm at the head of splenic artery, among which there was one case with distal autologous vein transplantation of the hepatic and splenic artery, seven cases with artificial blood vessel bypass between the infrarenal aorta and the splenic artery, 2 cases with the splenectomy and aneurysm resection, and one case with splenectomy combined with multiple aneurysm resection, splenic artery ligations and splenectomy. ResultsAll cases were cured and discharged from the hospital after 10 days to 14 days of operation. During 1 year to 14 years follow-up, 9 cases survived and 2 cases died. In these patients, 1 case with aorta splenic artery bypass operation died of acute myocardial infarction after 2 years and 1 case with post aneurysm resection and the splenectomy operation died of acute cerebral hemorrhage after 5 years. Among 7 cases with aorta splenic artery bypass, anatomosis of 1 case gradually became narrow after 2 years and completely occluded after 6 years of operation, but no splenic infarction was found and the spleen blood was supplied by the short gastric vessel and its collaterals. The other 6 cases with aorta splenic artery bypass and 1 case with autologous vascular transplantation had no stenosis or pseudoaneurysm in the stoma. ConclusionThe aneurysmectomy and vascular reconstruction of splenic artery is a better therapy for patients with aneurysm at the capitular head of the splenic artery.

KEYWORDS:splenic aneurysm; surgery

基金項(xiàng)目:吳介平醫(yī)學(xué)基金(320.6750.08180)

收稿日期:2014-10-21

中圖分類號(hào):R 733.2

文獻(xiàn)標(biāo)志碼:A

文章編號(hào):1672-2353(2015)03-053-04

DOI:10.7619/jcmp.201503015