血管腔内介入联合腹腔镜外科治疗急性肠系膜动脉缺血

Endovascular therapy combined with laparoscopic surgery for acute mesentery artery occlusion

目的探讨血管腔内介入联合术前腹腔镜探查治疗急性肠系膜动脉缺血患者的疗效。方法采用前瞻性队列研究(NCT04686981),自2020年10月1日至2022年10月1日共入组急性肠系膜动脉缺血患者31例。男26例(84%),年龄(67±13)岁,发病时间(21±8)h。于杂交手术室先进行腹腔镜探查,如存在肠道坏死,患者接受开腹手术(肠系膜动脉切开取栓+肠切除、造口术);如果腹腔镜未发现肠坏死,患者接受血管腔内介入手术。本研究主要观察终点是30 d内可经口饮食完全脱离肠外营养的患者比例及全因死亡率;次要观察指标是30 d内肠系膜血管通畅率,介入中转为开腹手术的比例。结果6例患者接受了开腹手术,25例患者接受了腔内介入治疗,其中单纯血栓减容13例,减容后同期植入支架3例,单纯植入支架9例。术后30 d内24例(77%)患者完全脱离全肠外营养,全因死亡3例(9.7%);术后30 d内肠系膜动脉通畅率82.1%,介入术后中转开腹率16%。结论血管腔内介入联合术前腹腔镜探查,可以尽早明确急性肠系膜动脉缺血患者肠道坏死情况,经多学科会诊后采取个体化治疗策略,有可能会改善此类患者的预后。

Objective To explore the efficacy and safety of endovascular intervention combined with preoperative laparoscopic exploration in the treatment of patients with acute mesenteric artery ischemia.Methods This was a prospective cohort study(NCT04686981).The study enrolled 31 patients with acute mesenteric artery ischemia from Oct 1,2020 to Oct 1,2022.Among them,26 patients(84%)were male,with a mean age of(67±13)years and a mean time to onset of(21±8)hours.All patients underwent laparoscopic exploration in the hybrid operating room.If the presence of intestinal necrosis or suspected necrosis was clearly determined,the patient would undergo open surgery(mesenteric artery embolization,intestinal resection and intestinal double stoma)as the treatment by gastrointestinal surgeon.If intestinal necrosis or suspected necrosis was not found by laparoscopy,the patient would undergo endovascular intervention by vascular surgeon.The primary observational endpoints of this study were the proportion of patients who were not dependent on total parenteral nutrition and all-cause mortality within 30 days after operation.The secondary observational endpoints were the rate of mesenteric vascular patency within 30 days and the proportion of interventions that were converted to open surgery.Results Six patients underwent open surgery and 25 patients underwent endovascular intervention,including 13 cases of thrombus reduction alone,3 cases of stent implantation during the same period after reduction,and 9 cases of stent implantation alone.Twenty-four patients(77%)were completely weaned from the TPN within 30 days after the procedure,and all-cause mortality was observed in 3 cases(9.7%).The patency rate of the mesenteric artery within 30 days after the procedure was 82.1%.The rate of conversion to open surgery after intervention was 16%.Conclusions Endovascular intervention combined with preoperative laparoscopic exploration can clarify intestinal ischemia in acute mesenteric patients as early as possible,and individualized treatment strategies for each patient by multidisciplinary care team can potentially improve the prognosis of such patients.