血管介入栓塞在血流动力学不稳定骨盆骨折急救中的应用

Application of intravascular interventional embolization in emergency treatment of hemodynamically unstable pelvic fracture

目的评价血管介入栓塞在血流动力学不稳定骨盆骨折急救中的应用价值。方法回顾性分析2012年10月-2014年12月收治的45例患者的临床资料，其中男27例，女18例；年龄28～54岁[（39．2±10．3）岁]。致伤原因：交通伤29例，高处坠落伤9例，挤压伤7例。受伤至入院时间均为3h内。损伤严重度评分（ISS）（25．3±8．1）分。骨盆骨折按Tile分型：B型32例，c型13例。入院后及时给予抗休克治疗、骨盆带或骨盆外固定支架固定骨盆，在排除其他部位损伤出血后急诊行血管介入栓塞止血。观察患者血管介入治疗情况、治疗后生命体征变化、预后等情况。结果入院至介入治疗的时间为1．2～2．7h[（1．9±0．8）h]，介入治疗时间1．6—3．2h[（2．3±0．6）h]。表现为造影剂外溢38例，血管形态异常5例，未见明显出血征象1例，血管造影静脉期见造影剂外渗1例。造影剂外溢涉及的责任血管包括阴部内动脉26例，闭孔动脉16例，臀上、下动脉各4例，腹壁下动脉1例，髂外动脉1例，合并两处8例，延迟出血1例。45例均早期止血疗效良好，应用介入栓塞技术后，生命体征好转，术后心率（105．2±14．8）次／min，动脉压（79．0±10．6）mmHg，中心静脉压（5．1±0．8）cmH2O，休克指数1．1±0．5，与术前比较差异均有统计学意义（P〈0．05）。4例因多脏器功能衰竭死亡。1例术后3d腹胀加重，髂外动脉分支出血，予以栓塞后好转。41例生存患者ICU治疗时间为（14．5±5．4）d，总住院时间为（35．2±12．8）d，医疗费用为（96755．3±20568．1）元。结论对于血流动力学不稳定骨盆骨折的急救，血管介入栓塞治疗具有快速、微创、止血确切的优势，在有条件的医院值得推广应用。

Objective To evaluate the value of intravascular interventional embolization in the emergency treatment of patients with hemodynamieally unstable pelvic fracture. Methods The retrospective analysis was made on the medical records of 45 cases treated from October 2012 to December 2014. There were 27 male and 18 females（39.2 ±10.3） years （range, 28-54 years）. Time from injury to admission was within 3 h. Injury severity score （ISS） was （25.3 ±8.1 ） points. The pelvic fracture included 32 cases of Type B and 13 Type C according to Tile classification system. After admission, anti- shock treatment and pelvic immobilization with the belt or external fixator were performed, and emergent intravascular interventional embolization was used to stanch bleeding after the bleeding of other organs was excluded. Vascular intervention, post-treatment vitazl signs and prognosis were evaluated. Results Time from admission to interventional therapy was 1. 2-2. 7 h [ （1.9 ± 0. 8 ） h ]. Time of interventionaltreatment was 1.6-3.2 h [ （2.3± 0.6 ） h 1. Of the 45 cases, contrast extravasation was seen in 38 cases, abnormal vascular morphology in 5 cases, no obvious bleeding in 1 case, and contrast extravasation in the angiographic venous phase in 1 case. Among the 38 cases of contrast extravasation, the offending vessels involved were internal pudenda artery （26 cases）, obturator artery （16 cases）, superior gluteal artery （4 cases）, inferior gluteal artery （4 cases）, inferior epigastric artery （1 case） and external iliac artery （ 1 case） , but 8 cases were noted to have two offending vessels and 1 case had delayed bleeding. Of the 45 cases, the hemostatic effect was good in the early stage. After the interventional embolization therapy, the heart rate was （ 105.2 ± 14.8） beats/min, arterial pressure was （79.0 ± 10.6） mmHg, central venous pressure was （5. 1 ± 0. 8） cmH2O, and shock index was 1. 1 ±0. 5, showing improved vital signs postoperatively （ P 〈 0.05 ）. Four cases died mainly due to the multiple organ failure. One case had abdominal distention aggravated 3 days after operation, which were confirmed to be bleeding in the branch of external iliac artery, and the symptom was alleviated after embofization therapy. Forty-one cases survived with ICU length of stay of （ 14.5 ± 5.4） d, hospitalization time of （35.2 ± 12.8） d and medical expense of （96,755.3 ± 20,568.1 ） CNY. Conclusion In the emergency treatment of patients with hemodynamieally unstable pelvic fracture, the intravascular interventional embolization has become an important measure of comprehensive treatment that allows fast and mini-invasive procedure hemostasis, and deserves clinical promoting.