基于肾脏血管解剖建立经皮肾通道的实验研究

Experimental study of establishing percutaneous renal channel based on renal vascular anatomy

目的:探讨经皮肾穿刺路径及通道大小与肾脏血管损伤之间的关系。方法:2018年5月至2019年10月收集15例肾动脉造影的影像学资料进行肾动脉分级,收集62例人体肾脏标本进行经皮肾通道扩张损伤模型。其中35例人肾标本由同一术者模拟经皮肾穿刺扩张建立20F操作通道,分别经正常肾锥体正中穿刺(A组)、经融合肾锥体一侧正中穿刺(B组)、经融合肾锥体正中穿刺(C组)、经肾柱正中穿刺(D组)4种穿刺路径,采用组织切片HE染色对比4种穿刺路径中肾动脉损伤情况。27例由同一术者沿正常肾锥体正中线模拟经皮肾穿刺扩张建立大小分别为8F、12F、16F、20F、24F、30F的通道,采用相同方法比较肾动脉损伤情况。结果:肾动脉造影显示肾脏动脉分为6级。镜下观察组织切片显示:4种穿刺路径血管损伤程度总体差异具有统计学意义,其中A、C组间及A、D组间有统计学差异。A、B、C、D组Ⅳ动脉损伤比例分别为5%(1/20)、25%(5/20)、75%(15/20)、85%(17/20),其中A、C组以及B、C组间有统计学差异,C、D组无统计学差异。4种穿刺路径Ⅴ/Ⅵ级血管的损伤比例无统计学差异。6种通道大小总体血管损伤程度有统计学差异,而8F~24F之间无统计学差异。30F分别与8F、12F、16F、20F、24F之间进行比较,均存在统计学差异。结论:与经正常肾锥体穿刺相比,经过肾柱和融合肾锥体正中穿刺叶间动脉损伤的比例及血管总体损伤程度均明显增加。且24F可能是扩张通道大小的临界值,通道大于24F时可能会增加血管损伤的风险。

Objective:To explore the relationship between the different percutaneous renal puncture paths,access sizes and injury of renal arteries.Methods:Between May 2018 and October 2019,the renal arteriography data of 15 cases were selected to grade the renal arteries and 62 human kidney specimens were selected to establish renal arteries injury models.35 human kidney specimens kidneys were used to simulate percutaneous renal puncture to establish F20 operational access by the same surgeon.Under the endoscope and microscope,we compared the effects of four different puncture paths on the occurrence of renal vascular injury when respectively punctured through the centre of the normal renal pyramid(group A),the centreline of one side pyramid of the fused renal pyramid(FRP)(group B),the centre of the entire FRP(group C)and the renal column(group D).27 human kidneys were used to establish operational access with sizes of 8F,12F,16F,20F,24F,and 30F by the same surgeon,and we compared injury of renal arteries by the same way.Results:The renal injuries under microscope showed significant difference among the four groups(P=0.006),especially between group A versus group C(P=0.013),and group A versus group D(P=0.003).The proportion of gradeⅣartery injury in group A,B,C and D was 5%(1/20),25%(5/20),70%(14/20),and 85%(17/20),respectively,and there were significant differences between group A and group C(P=0.001),group B and groupC(P=0.004),while no significant difference between group C and D(P=0.695).There was no significant difference in the injury of gradeⅤandⅥartery in the four groups(P=0.957).There was a statistically significant difference in the overall degree of vascular damage among all access sizes(P=0.015),but there was significant difference only exisit between 30F and other access sizes.Conclusion:Puncturing through the centre of the entire FRP may increase the chance of artery injury.The size of 24F may be the critical value of the access size,and when the size is larger than 24F,the risk of vascular injury may increase.