三维CT血管造影在辅助游离胸外侧穿支皮瓣修复四肢创面中的应用

Clinical application of three-dimensional CT angiography in repair of limb wounds with free lateral thoracic perforator flaps

目的探讨三维CT血管造影(3D-CTA)辅助胸外侧动脉穿支皮瓣修复四肢创面的疗效。方法回顾性分析2018年1月至2022年9月华北医疗健康集团邢台总医院骨三科收治的61例四肢软组织缺损患者资料。男37例,女24例;年龄(43.9±12.0)岁;左侧33例,右侧28例;软组织缺损范围4.0 cm×3.0 cm~17.0 cm×8.0 cm;皮瓣面积5.0 cm×4.0 cm~18.0 cm×9.0 cm。按照术前血管探查方式不同将患者分为2组:超声组(术前采用超声多普勒检查)30例和3D-CTA组(术前采用3D-CTA检查)31例。比较两组患者术前检查与术中探查的指标结果是否一致。比较两组患者手术时间、皮瓣成活率、患者对创面修复效果满意率、皮瓣区感觉恢复率、供区优良率等。结果两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。超声组术中发现胸外侧动脉穿支皮瓣类型与术前超声检查情况一致性低(Kappa系数为0.104,P=0.088)。3D-CTA组术中发现胸外侧动脉穿支皮瓣类型与术前3D-CTA检查情况一致(Kappa系数为1.00,P<0.001)。3D-CTA组术前测量胸外侧动脉起始处管径为(1.2±0.3)mm,血管蒂长度为(8.1±2.1)cm,穿支穿出点血管管径为(0.6±0.2)mm,穿支穿出点体表定位结果为肩胛下角水平线上方(1.6±0.3)cm、肩胛下角垂直线外侧(5.3±1.4)cm,与术中实际测量值[(1.1±0.3)mm、(8.3±2.4)cm、(0.7±0.2)mm、(1.5±0.4)cm、(5.2±1.5)cm]相近,差异均无统计学意义(P>0.05)。而超声组术前测量以上指标与术中实际测量值不一致,差异均有统计学意义(P<0.05)。3D-CTA组患者手术时间、皮瓣成活率、患者对创面修复效果满意率、皮瓣感觉恢复率、供区优良率分别为(52.9±16.7)min、100.0%(31/31)、96.8%(30/31)、83.9%(26/31)、87.1%(27/31),均优于超声组[(76.3±21.4)min、86.7%(26/30)、76.7%(23/30)、60.0%(18/30)、63.3%(20/30)],两组间差异均有统计学意义(P<0.05)。结论术前3D-CTA检查能够明确胸外侧动脉及其穿支血管的类型、解剖学分布特点,有助于胸外侧动脉穿支皮瓣的设计和切取,比仅依靠超声多普勒检查方式,手术时间明显缩短,皮瓣成活率明显提高,有助于四肢创面外形及功能的恢复,对供区影响小。

Objective To explore the clinical application of three-dimensional CT angiography(3D-CTA)in repair of limb wounds with free lateral thoracic perforator flaps.Methods A retrospective study was conducted to analyze the clinical data of 61 patients with limb soft tissue defects who had been treated at The Third Department of Orthopedics,Xingtai General Hospital of North China Medical and Health Group from January 2018 to September 2022.There were 37 males and 24 females with an age of(43.9±12.0)years.Thirty-three left and 28 right sides were injured.Soft tissue defects ranged from 4.0 cm×3.0 cm to 17.0 cm×8.0 cm,and flap areas from 5.0 cm×4.0 cm to 18.0 cm×9.0 cm.The patients were divided into 2 groups according to the different preoperative vascular exploration methods:an ultrasound group of 30 cases subjected to ultrasound Doppler examination and a 3D-CTA group of 31 cases subjected to 3D-CTA examination.The preoperative findings were compared with those of intraoperative exploration in the 2 groups.The operation time,flap survival rate,patient satisfaction with trauma repair,sensory recovery of the flap area,and the excellent and good rate of the donor area were also compared between the 2 groups.Results The differences in preoperative general data between the 2 groups were not statistically significant,indicating the 2 groups were comparable(P>0.05).In the ultrasound group,the inraoperative classification of the lateral thoracic perforator flaps showed a low concordance with preoperative classification(Kappa coefficient of 0.104,P=0.088).In the 3D-CTA group,the classification of lateral thoracic perforator flaps was consistent with the preoperative 3D-CTA examination(Kappa coefficient of 1.00,P<0.001).The preoperative measurements in the 3D-CTA group found that the diameter at the origin of the lateral thoracic artery was(1.2±0.3)mm,the vascular pedicle length(8.1±2.1)cm,and the diameter at the perforator exit(0.6±0.2)mm;the preoperative surface positioning at the perforator exit found that the perforator exit was(1.6±0.3)cm above the horizontal line of the subscapular angle and(5.3±1.4)cm outside the vertical line of the subscapular angle.These measurements were similar to the intraoperative ones[(1.1±0.3)mm,(8.3±2.4)cm,(0.7±0.2)mm,(1.5±0.4)cm,and(5.2±1.5)cm],showing no significant differences(P>0.05).In contrast,the preoperative measurements of the above indexes in the ultrasound group did not coincide with the actual intraoperative measurements,and the differences were all statistically significant(P<0.05).The operation time,flap survival rate,rate of patient satisfaction with wound repair,rate of sensory recovery in the flap area,and the excellence and good rate of the donor area in the 3D-CTA group were(52.9±16.7)min,100.0%(31/31),96.8%(30/31),83.9%(26/31),and 87.1%(27/31),respectively,which were significantly better than those in the ultrasound group[(76.3±21.4)min,86.7%(26/30),76.7%(23/30),60.0%(18/30),63.3%(20/30)](P<0.05).Conclusions As preoperative 3D-CTA examination can clarify the types and anatomical characteristics of the lateral thoracic artery and its perforators,it helps the design and harvest of the lateral thoracic perforator flaps.Compared with the ultrasound Doppler examination,preoperative 3D-CTA examination shortens operation time,raises survival rate of the flaps,and facilitates recovery of the appearance and function of the limb wounds,and leads to little impact on the donor site.