108例创伤性动静脉瘘的介入诊疗分析

Endovascular diagnosis and therapy for traumatic arteriovenous fistulas:an analysis of 108 cases

目的分析创伤性动静脉瘘(AVF)的临床特点、造影表现、造影技术及治疗方式的选择。方法回顾性分析纽约Kings County医疗中心25年间全部确诊的108例创伤性AVF的介入相关诊疗资料。分析内容包括患者外伤种类、临床表现、损伤部位、血管造影异常特征、AVF血流动力学特征(分5个类型)、治疗方式的选择等。结果 108例患者中共发现117处AVF,大多数患者临床特征不明确。创伤种类包括枪伤(导致72处AVF)、刺伤(24处)、钝性伤(8处)、高处坠落伤(3处)、医源性损伤(2处)。损伤部位常见于肢体(46例)、颈部(19例)、肝脏(13例)和锁骨下血管(11例)。所有病变均可见静脉早显,显示动脉横断52处,撕裂37处,49.6%的AVF与假性动脉瘤有关。最常见的血流特点是Ⅰ型,即瘘口所在的动脉近段和远段、静脉的近段和远段都显示,伴远侧段静脉瓣功能不全,共40处瘘(34.2%),其次是Ⅲ型22个(18.8%),Ⅴ型最不常见(4.3%)。34例接受手术治疗,61例栓塞治疗,7例临床观察。分别采用弹簧圈(47例)、明胶海绵(9例)、无水乙醇(3例)、可脱球囊(2例),其中弹簧圈效果理想、并发症少。6例采用覆膜支架效果好。结论血管造影是诊断创伤性AVF的金标准,造影时准确观察动脉损伤的性质,瘘口的解剖和血流特点及所有进入瘘口的动脉分支,对于选择治疗方式及保证介入治疗的成功完成至关重要。

Objective To analyze the clinical features,angiographic manifestations,angiographic techniques and the optimal therapeutic schemes for traumatic arteriovenous fistulae（AVF）.Methods The clinical data and interventional therapeutic results of all patients with traumatic arteriovenous fistulas encountered at Kings County Hospital Center during the period of 1977-2005 were retrospectively reviewed and analyzed.The items for analysis included the mechanism of injury,the clinical manifestations,the traumatic sites,abnormal angiographic findings,the presence or absence of false aneurysm,the flow dynamic characteristics of AVFs,which was divided into five patterns,and the method of treatment.The results were analyzed and evaluate.Results A total of 117 AVFs were found in 108 patients.All the diagnoses were confirmed by angiography.In most patients the clinical symptoms of AVF were either absent or unrecognizable before angiography.Mechanisms of injury included gunshot wound（72 AVFs）,stab wound（24 AVFs）,blunt trauma（8 AVFs）,injury by falling（3 AVFs） and iatrogenic during the management of trauma（2 AVFs）.The common traumatic locations included the extremities（46 cases）,the neck（19 cases）,the liver（13 cases）,and subclavian vessels（11 cases）.Early venous opacification was seen in all cases.The AVFs were associated with false aneurysms in 49.6% of patients.The most common pattern of the flow dynamics was type I（40 AVFs,34.2%）,namely both the proximal and distal segments of both artery and vein of AVF were displayed with the presence of incompetent distal venous valves.Next common pattern was type Ⅲ（22 AVFs,18.8%）,and the most uncommon pattern was type V（5 AVFs,4.3%）.Half of the AVFs had retrograde arterial flow contribution from distal collaterals.Surgery was carried out in 34 patients.Clinical observation was employed in 7 and embolization therapy was adopted in 61 patients.The embolic agents included coils（n = 47）,Gelfoam（n = 9）,ethanol（n = 3）,detachable balloon（n = 2）.The use of steel coil was most effective with fewer complications.Covered stent was used in additional 6 patients with good mid-term results.Conclusion Angiography is the gold standard for the diagnosis of traumatic AVFs.Careful observation of the traumatic features,the fistulous anatomy,the flow dynamic pattern and both the afferent and efferent branches of the AVF is of great importance for correctly selecting the therapeutic scheme and fully ensuring the success of interventional therapy.