复合手术在战、创血管伤救治中的应用研究

Hybrid operation for patients with traumatic injuries of large vessels in neck or regions adjacent to trunk

目的探讨复合手术在颈部与邻近躯干大血管战、创伤救治中的应用价值和方法。方法总结我院神经外科与骨科自1978年以来应用复合手术救治42例颈部与邻近躯干大血管战、创伤大出血及晚期合并动静脉瘘与假性动脉瘤的临床资料。大部分病例复杂且已破裂,或即将破裂,又无法解剖出病变上游血管或用止血带控制出血进行血管重建手术。我们采用“放风筝”法治疗4例(其中3例外伤性颈内动脉海绵窦瘘,1例战时多发弹片伤致颅底高位颈内动静脉瘘合并颈外动脉假性动脉瘤),采用“血管内”止血带辅助外科手术切除假性动脉瘤与动静脉瘘行血管重建血运35例,酌情选择介入与开放手术相结合治疗3例(战伤致左椎动脉动静脉瘘1例,左椎动脉动静脉瘘合并假性动脉瘤破裂大出血1例,医源性颈内动脉损伤大出血1例)。结果42例全部治愈,无死亡或因治疗加重残废。全部病人随访1年以上,病变消失且血运重建良好。结论复合手术在救治颈部与邻近躯干大血管战、创伤出血及晚期并发假性动脉瘤与动静脉瘘时,能有效防止出血,增加手术安全性,将复杂、风险大的手术简单化,可在临床中推广应用。

Objective To explore the value and methods of hybrid operation for the patients with traumatic injuries of large vessels in the neck or regions adjacent to trunk.Methods The clinical data of 42 patients with traumatic injuries of large vessels in the neck or regions adjacent to trunk who underwent hybrid operation in Department of Neurosurgery and Orthopedics of our hospital since 1978 were analyzed retrospectively.All the patients had traumatic hemorrhage in the early stage,and had arteriovenous fistulas and pseudoaneurysms in the late stage.Most arteriovenous fistulas and pseudoaneurysms were ruptured,and were impossible to dissect the vessels upstream or use tourniquets to control bleeding for vascular reconstruction surgery.The"flying kite"method was used in 4 patients including 3 patients with traumatic internal carotid cavernous fistula and 1 with high internal carotid arteriovenous fistula combined with external carotid artery pseudoaneurysm caused by multiple shrapnel injuries in war.The"intravascular"tourniquet assisted surgical removal of pseudoaneurysms and arteriovenous fistulas was used in 35 patients.Interventional therapy combined with open surgery was used in 3 patients including 1 patient with left vertebral artery arteriovenous fistula caused by war injury,1 with left vertebral artery arteriovenous fistula complicated with pseudoaneurysm rupture and 1 with iatrogenic internal carotid artery injury.Results All 42 patients were cured without death or disability.All the patients were followed up for more than 1 year,the DSA showed that the lesions disappeared and the blood supply was good.Conclusions Hybrid operation can effectively prevent bleeding,increase the safety of operation,and simplify complicated and high-risk operations in the treatment of traumatic large vessels injuries associated with pseudoaneurysms and arteriovenous fistulas in the neck or regions adjacent to trunk.It is worthy of promotion and application in the clinical practice.