急性下肢缺血动脉再通后并发骨筋膜室综合征的诊治

Diagnosis and treatment of compartment syndrome after revascularization of acute lower limb ischemia

目的:探讨急性下肢缺血动脉再通后并发骨筋膜室综合征的临床表现、早期诊治及预后。方法:回顾性分析2005年1月至2009年1月因急性下肢缺血在我科行动脉再通治疗后并发急性下肢骨筋膜室综合征病人的临床资料,包括发病原因、时间、治疗方式、治疗效果、骨筋膜室综合征的处理方法及预后。结果:126例病人因急性下肢缺血行动脉再通治疗,发病至再通时间平均为26h(3h至6d),其中24例(共27条肢体)并发骨筋膜室综合征而行筋膜切开(包括3例行双侧肢体预防性切开)。21例动脉再通术后延迟切开时间平均为10(5～48)h,其中2例术中行血液透析,1例行术后血液透析。本组3例截肢,2例死亡(包括1例截肢)。结论:骨筋膜室综合征是急性下肢缺血动脉再通后的严重并发症,动脉再通后持续疼痛或疼痛加重伴局部张力升高者应高度怀疑为骨筋膜室综合征,其治疗方法是充分切开4个筋膜腔减压,同时动态监测病人电解质和肾功能指标,维持肾功能和内环境的稳定,必要时应早期进行透析。

Objective To investigate the clinical manifestation, diagnosis, treatment and prognosis of acute limb compartment syndrome after revascularization of acute lower limb ischemia. Methods Clinical data from the patients with acute lower limb compartment syndrome after revascularizafion of acute lower limb ischemia, admitted from January 2005 to January 2009, were analyzed retrospectively. Results Twenty-four（27 limbs） of 126 cases with acute limb ischemia undergoing revascularization were submitted to fasciotomy. The average time from the onset of ischemia to revascularization surgery were 26 h（3 h to 6 d）; 3 cases underwent bilateral prophylactic fasciotomies because the signs of compartment syndrome developed during the revascularization procedure. The remaining 21 cases （21 limbs） developed compartment syndrome after revascularization and fasciotomy was performed with a mean delay time of 10 （5-48） h. Hemodialysis was performed in 1 case during revascularization, and in 2 cases postoperatively. Two died and 3 underwent amputation. Conclusions Acute compartment syndrome is a life-threatening complication of surgical revaseularization in acute limb ischemia. It should be thought of when the pain aggravated with local hypertension after revascularization. Fasciotomy of four compartments should be performed as soon as the diagnosis is established. It is very important to maintain the balance of internal environment by monitoring the electrolytes and renal function. Hemodialysis should be started early when necessary.