经皮穿刺缝合与股动脉切开在主动脉瘤腔内修复术中的对照研究

Control study of total percutaneous access with preclose technique versus open femoral artery exposure for endovascular aneurysm repair

目的:比较经皮穿刺与传统股动脉切开行主动脉瘤腔内修复术(endovascular aneurysm repair,EVAR)的临床资料,评估预置缝合线技术(preclose technique)的安全性与可行性。方法:回顾性分析2011年12月至2014年11月于北京大学人民医院行EVAR手术的81例主动脉瘤患者的临床资料。患者术前CT显示存在肾下腹主动脉瘤或降主动脉真性动脉瘤,瘤体最大直径>4.5 cm,达到手术治疗指征,且双侧股动脉、髂动脉条件良好,管腔无中重度狭窄,股动脉前壁无严重钙化,既可行经皮穿刺主动脉瘤腔内修复术(percutaneous endovascular aneurysm repair,PEVAR),也可行传统切开主动脉瘤腔内修复术(open endovascular aneurysm repair,OEVAR),根据患者对手术切口意向分为PEVAR组与OEVAR组。收集患者的一般情况、手术时间、术中出血量、技术成功率、术后住院时间、切口并发症等数据,所得结果进行统计学分析。结果:PEVAR组共44例患者78处股动脉切口,OEVAR组共37例患者65处股动脉切口。两组患者在年龄、性别、体重指数(body mass index,BMI)、伴随疾病、平均植入支架数量、支架输送系统外径等方面差异无统计学意义。PEVAR组手术时间明显少于OEVAR组[(119.1±102.0)min vs.(163.6±61.9)min,P=0.025],术中出血量少于OEVAR组[(64.7±97.0)m L vs.(98.6±88.3)m L],但两组差异无统计学意义(P=0.106);两组技术成功率(94.9%vs.95.4%,P=1.000)差异无统计学意义;PEVAR组术后平均住院时间比OEVAR组明显缩短[(7.8±2.8)d vs.(12.3±7.2)d,P<0.001];PEVAR组术后2处切口出现皮下血肿,OEVAR组术后出现7处切口并发症,其中3处淋巴漏,3处入路动脉狭窄导致的下肢缺血,1处皮下血肿,OEVAR组切口并发症发生率较PEVAR组多(2.6%vs.10.8%),但两组间差异无统计学意义(P=0.079)。结论:采用预置缝合线技术经皮穿刺途径完成EVAR安全有效,与传统股动脉切开相比,其可以缩短手术时间和术后住院时间。

Objective： To compare total percutaneous access using preclose technique with femoral artery cut-down in endovascular aneurysm repair（ EVAR） and assess the safety and feasibility of preclose technique. Methods： In the study,81 cases undergoing EVAR from Dec. 2011 to Nov. 2014 in Peking University People＇s Hospital were retrospectively reviewed. Preoperative CT angiography（ CTA） showed presence of infrarenal abdominal aortic aneurysm or descending aortic aneurysm in all the cases. The maximum diameter of aneurysm 4. 5 cm met the indications for surgical treatment. The conditions of bilateral femoral artery and iliac artery CTA showed were good,and there was no moderate or severe stenosis,nor was there any severe calcification in anterior wall of femoral artery. Not only were the cases fit for percutaneous endovascular aortic aneurysm repair（ PEVAR）,but also feasible with open endovascular aneurysm repair（ OEVAR）. According to the intention of the patients about the surgical incision,the cases were divided into group PEVAR and group OEVAR. The data of the general situation,operation time,blood loss,technical success rate,length of hospital stay after procedure and wound complications were analyzed statistically. Results： In the study,44 cases（ 78 incisions） were enrolled in group PEVAR and 37 cases（ 65 incisions） in group OEVAR. There was no significant difference between the two groups in age,gender,body mass index（ BMI）,accompanying diseases,average number of stents and outer diameter of stent delivery system. Average operation time of group PEVAR was less than that of group OEVAR [（ 119. 1 ± 102. 0） min vs.（ 163. 6 ± 61. 9） min,P = 0. 025]. The blood loss in group PEVAR was less than that in group OEVAR [（ 64. 7 ± 97. 0） m L vs.（ 98. 6 ± 88. 3） m L],but there was no significant difference（ P = 0. 106）. There was no difference in the technical success rate（ 94. 9% vs.95. 4%,P = 1. 000）. The average length of hospital stay after procedure was significantly shorter in group PEVAR [（ 7. 8 ± 2. 8） d vs.（ 12. 3 ± 7. 2） d,P〈0. 001]. There were 2 cases with subcutaneous hematoma of wound in group PEVAR and 7 cases of wound complications that occurred in group OEVAR including 3 cases with lymphatic leakage,3 cases with lower limb ischemia and 1 case with subcutaneous hematoma. The analysis showed that PEVAR could reduce the wound complications（ 2. 6% vs. 10. 8%）,but there was no significant difference between the two groups（ P = 0. 079）. Conclusion： Using preclose technique in EVAR is safe and effective. It can shorten the operation time and length of hospital stay after procedure.