下腔静脉滤器开放手术取出的安全性与可行性分析

Safety and feasibility of open surgical retrieval of inferior vena cava filters

背景和目的:下腔静脉滤器(IVCF)在预防致死性肺栓塞(PE)中广泛应用,通常经过腔内介入手段取出。对于腔内取出失败或超回收时间窗的滤器,可考虑手术取出。本研究目的是评价开放手术取出IVCF的安全性及可行性。方法:回顾性分析2019年2月—2022年8月在北京积水潭医院血管外科收治的27例IVCF置入后行开放手术取出的患者临床资料。所有患者开放手术前行介入尝试取出的中位次数为1 (1~2)次。结果:所有滤器均全部取出,技术成功率为100%,滤器置入中位时间为20 (5~48)个月。其中,Aegisy滤器8例(29.6%),Denali滤器1例(3.7%),Cordis滤器10例(37.0%),Simon滤器1例(3.7%),Celect滤器3例(11.1%), Tulip滤器4例(14.8%)。1例(3.7%)滤器位于肾静脉上下腔静脉,1例(3.7%)位于肝后下腔静脉,25例(92.6%)滤器位于肾静脉下下腔静脉。术中,2例(7.4%)于滤器回收钩处留置荷包缝合线,未阻断下腔静脉血流,通过直接钳夹回收钩取出,取出后进行荷包缝合;2例(7.4%)未阻断下腔静脉血流,将滤器直接回收至血管鞘后行荷包缝合;1例(3.7%)阻断双肾静脉及滤器远近端下腔静脉血流,1例(3.7%)分别阻断滤器远端下腔静脉、第一肝门及第二肝门血流,21例(77.8%)阻断滤器远近端下腔静脉血流,然后通过切开下腔静脉前壁进行滤器取出,取出后进行血管壁连续缝合。手术平均时间为(224.15±23.85) min。围手术期无下肢深静脉血栓或症状性PE发生,无心肺系统并发症,无伤口感染。1例(3.7%)出现腹痛伴血性胃液,1例(3.7%)出现血尿,均保守对症治疗后缓解。术前血红蛋白平均为(128.59±15.05) g/L,术后为(110.56±22.15) g/L,6例(22.2%)术后输入悬浮红细胞400 mL,未见致命性大出血及休克。中位术后住院时间9 (8~12) d。结论:尽管开放手术滤器取出手术难度较大、技术十分复杂,但滤器取出是安全可行的。术前充分利用CT判断滤器及其回收钩的位置,采用合适的手术方式,通过熟练的手术技巧可以极大地提高开腹手术的安全性和成功率。

Background and Aims: Inferior vena cava filters(IVCF) are widely used in the prevention of fatal pulmonary embolism(PE) and removed by interventional technique, and surgical removal may be considered for filters that are irretrievable by endovascular approach or exceed the time window for retrieval. This study was performed to evaluate the safety and feasibility of open surgery for removal of the IVCF.Methods: The clinical data of 27 patients who underwent open surgery for filter retrieval after IVCF placement from February 2019 to August 2022 in the Vascular Surgery Department of Beijing Jishuitan Hospital was retrospectively analyzed. In all patients, the median number of attempts of interventional filter retrieval was 1(1-2) before open surgery.Results: All filters were removed and the technical success rate was 100%. The median time for filter implantation was 20(5-48) months. There were 8 cases(29.6%) of Aegisy filter, 1 case(3.7%) of Denali filter, 10 cases(37.0%) of Cordis filter, 1 case(3.7%) of Simon filter, 3 cases(11.1%) of Celect filter, and 4 cases(14.8%) of Tulip filter, respectively. The filter was located in the suprarenal inferior vena cava in 1 case(3.7%), in the retrohepatic inferior vena cava in 1 case(3.7%), and in the subrenal inferior vena cava in 25 cases(92.6%). During the operation, a suture line was placed at the retrieval hook, the filter was removed by direct clamping the retrieval hook without occlusion of the inferior vena cava, and a purse-string suture was performed after removal in 2 cases(7.4%);the filter was directly retrieved to the vascular sheath followed by closure without occlusion of the inferior vena cava in 2 cases(7.4%);the filter was removed by incision of the anterior wall of the inferior vena cava followed by continuous suture of the vessel after blocking the blood flow of the bilateral renal veins and the inferior vena cava at distal and proximal ends of the filter in 1 case(3.7%), blocking the blood flow of the distal inferior vena cava, the first hepatic portal and the second hepatic portal in 1 case(3.7%), and blocking the blood flow of the inferior vena cava at the distal end of the filter in 21 cases(77.8%). The average operative time was(224.15±23.85) min. No deep venous thrombosis or symptomatic PE, no cardiopulmonary complications, and wound infection during the perioperative period. Abdominal pain with bloody gastric juice occurred in 1 case(3.7%), and hematuria occurred in 1 case(3.7%), which were relieved after symptomatic treatment. The average hemoglobin level was(128.59±15.05) g/L before surgery, and(110.56±22.15) g/L after surgery. Six patients(22.2%) received 400 mL of red blood cell suspension transfusion after surgery. No fatal hemorrhage or shock occurred. The median length of postoperative hospital stay was 9(8-12) d.Conclusion: Although open surgical filter removal is difficult and technically complex, filter removal is safe and feasible. Sufficient CT evaluation of the position of the filter and its hook before surgery and using appropriate surgical approach, with specific surgical skills, the safety and success rate of open surgery can be greatly improved.