显微血管缝合技术治疗血泡样动脉瘤

Microsurgical sutures for treatment of the blood blister-like aneurysms

目的探讨显微血管缝合技术治疗血泡样动脉瘤的适应证和临床效果。方法回顾性分析2008年3月至2016年6月首都医科大学三博脑科医院神经外科收治的8例血泡样动脉瘤患者的临床资料。动脉瘤位于颈内动脉5例、大脑中动脉2例、大脑前动脉1例。8例均为蛛网膜下腔出血，其中Hunt-Hess分级Ⅰ～Ⅱ级7例，Ⅲ级1例。手术根据病变的部位分离病变的近心端，探查动脉瘤的大小、管壁的部位和形态。如有出血，用临时动脉瘤夹旷置载瘤动脉后，清除病灶处出血，找出破裂动脉部位，确定裂口的形态。若病灶最大径〉3mm，可将血泡壁切开，沿正常血管壁厚度约2-3倍缝合缘距；若病灶〈3mm，无需切开血泡病灶，直接缝合。结果术后8例血泡样动脉瘤患者均恢复良好，无神经功能缺失。4例行数字减影血管造影检查，4例行CT血管成像检查，未出现血管狭窄和动脉瘤残留。8例患者随访1．9～4．1年，其中4例随访3年以上，平均（2．9±0．6）年，未发现手术相关并发症。其中7例患者的改良Rankin量表评分（mRS）为0-2分，1例颈内动脉血泡样动脉瘤患者术后出现记忆力减退，mRS评分为3分。结论显微血管缝合技术适用于颈内动脉及其颅内大血管近段仅累及血管周长1／3的血泡样动脉瘤，其治疗效果满意；对于累计血管周长〉1／3的病灶，缝合后有血管狭窄的风险。

Objective To investigate the indication and outcome of vessel suture technique for treatment of blood blister-like aneurysms. Methods Eight cases with blood blister-like aneurysms （BBA） admitted to Department of Neurosurgery,Fuxing Hospital Affiliated to Capital Medical University from March 2008 to June 2016 were enrolled. Among them, Hunt-Hess grade Ⅰ-Ⅱ was reported in 6 patients and grade Ⅲ in 1. BBA of the internal carotid artery （ICA） occurred in 5 cases, BBA of middle cerebral artery （MCA） in 2 cases, and BBA of anterior cerebral artery （ACA） in 1. The parent artery proximal to BBA was dissected based on the BBA location, size and the site as well as feature of vessel wall. The parent artery of BBA was temporarily clipped followed by identification of lacerative site and feature after removal of hemorrhage in patient with subarachnoid hemorrhage. Two to three sutures were performed with wall resection of BBA for lesion of over 3 mm and direct suture was performed without wall resection of BBA for lesion of less than 3 mm. The distance between tissue edge and the needle hole was feasible when it was 2 -3 times the thickness of normal vessel wall. Results All 8 patients recovered to normal life without neurological symptoms. Satisfactory sutures in all patients with BBA revealed no arterial stenosis and residual BBA on the postoperative digital subtraction angiographies in 4 patients and CT angiograms in 4 patients. None of the 8 patients reported any symptoms related to suture of BBA. Based on the modified Rankin Scale（mRS）, the mRS scores of 0-2 were reported in 7 patients and 1 patient with ICA BBA had the mRS score of 3 and reported memory decline at follow-up lasting for 1.9 - 4. 1 （ mean 2. 9 ± 0.6） years. Conclusions The vascular suture appears to be an effective treatment modality for patients with ICA BBA and BBA affecting 1/3 of vascular perimeter. There might be risk of stenosis associated vascular suture for BBA affecting over 1/3 of vascular perimeter.