自发性孤立性肠系膜上动脉夹层腔内介入治疗的临床疗效

Clinical efficacy of endovascular interventional therapy for spontaneous isolated superior mesen-teric artery dissection

目的探讨自发性孤立性肠系膜上动脉夹层(SISMAD)腔内介入治疗的临床疗效。方法采用回顾性队列研究方法。收集2012年3月至2023年3月陆军军医大学第一附属医院收治的87例SISMAD患者的临床资料;男80例,女7例;年龄为54(49,61)岁。87例患者中,行保守治疗55例,设为保守治疗组;行腔内介入治疗32例,设为腔内介入治疗组。观察指标:(1)临床特征。(2)治疗情况。(3)随访情况。正态分布的计量资料以x±s表示,组间比较采用t检验。偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用秩和检验。计数资料以绝对数表示,组间比较采用χ^(2)检验或Fisher确切概率法。结果(1)临床特征。两组患者有症状、中性粒细胞百分比比较,差异均有统计学意义(P<0.05)。两组患者Yun分型构成比比较,差异无统计学意义(P>0.05)。(2)治疗情况。两组患者血管完全重塑、住院时间、总费用比较,差异均有统计学意义(χ^(2)=23.752,t=-4.213,-16.421,P<0.05);腹痛缓解分别为34例和24例,两组比较,差异无统计学意义(P>0.05)。保守治疗组有症状患者出院时腹痛、恶心呕吐、腹泻、便血等症状均缓解或消失,无肠缺血或肠破裂者。腔内介入治疗组中,成功行支架植入术30例,手术时间为115(86,155)min,术中出血量为5(5,10)mL,造影剂用量为(200±51)mL,造影剂使用碘克沙醇、碘普罗胺、碘海醇分别为23、8、1例,手术方式为单个裸支架植入、裸支架辅助弹簧圈栓塞、多个裸支架、覆膜支架、单纯血管造影分别为14、3、10、3、2例,支架类型为自膨式金属裸支架、自膨式覆膜支架分别为39、3枚,支架直径为(6.5±1.0)mm,支架长度为(69±23)mm。2例无症状患者,腔内介入治疗未成功,均行肠系膜上动脉造影术。腔内介入治疗组中,92.3%(24/26)的患者术后腹痛缓解;2例术后腹痛患者经对症治疗后腹痛均好转。(3)随访情况。87例患者均获得随访,随访时间为12(4,24)个月,均无腹痛复发及二次干预。随访期间,82例患者行CT血管成像或超声检查,5例CT血管成像或超声检查结果未能获得,无SISMAD相关死亡或肠系膜上动脉破裂者。保守治疗组和腔内介入治疗组达到血管完全重塑分别为8例和21例,两组比较,差异有统计学意义(χ^(2)=23.752,P<0.05)。结论与保守治疗比较,行腔内介入治疗SISMAD患者住院时间更长、总费用更高,血管完全重塑率更高,两者均无腹痛复发。

Objective To investigate the clinical efficacy of endovascular interventional therapy for spontaneous isolated superior mesenteric artery dissection(SISMAD).Methods The retrospective cohort study was conducted.The clinical data of 87 patients with SISMAD who were admitted to The First Affiliated Hospital of Army Medical University from March 2012 to March 2023 were collected.There were 80 males and 7 femals,aged 54(49,61)years.Of 87 patients,55 cases undergoing conservative therapy were allocated into conservative therapy group and 32 cases under-going endovascular interventional therapy were allocated into endovascular interventional therapy group.Observation indicators:(1)clinical characteristics;(2)treatment;(3)follow-up.Measure-ment data with normal distribution were represented as Mean±SD,and comparison between groups was conducted using the t test.Measurement data with skewed distribution were represented as M(Q1,Q3),and comparison between groups was conducted using the rank sum test.Count data were represented as absolute numbers and comparison between groups was conducted using the chi-square test or Fisher exact probability.Results(1)clinical characteristics.There were significant differences in the cases with symptoms,percentage of neutrophils between the conservative therapy group and the endovascular interventional therapy group(P<0.05).There was no significant difference in the proportion of Yun classification between the two groups(P>0.05).(2)Treatment.There were significant differences in the complete vascular remodeling,duration of hospital stay,and total expenses between the conservative therapy group and the endovascular interventional therapy group(χ^(2)=23.752,t=-4.213,-16.421,P<0.05).There were 34 patients in the conservative therapy group and 24 patients in the endovascular interventional therapy group with relieved abdominal pain,respectively,showing no significant difference between the two groups(P>0.05).For symptomatic patients in the conservative therapy group,symptoms including abdominal pain,nausea,vomiting,diarrhea,hematochezia were relieved or disappeared,and no intestinal ischemia or rupture occurred.For patients in the endovascular interventional therapy group,30 cases were implanted stents,the operation time was 115(86,155)minutes,volume of intraoperative blood loss was 5(5,10)mL,dose of contrast media was(200±51)mL.There were 23,8 and 1 cases with the contrast medium as Iodoxanol,Ioprosamide,Iodohexanol,respectively.About the surgical methods,14 patients received single bare stent implantation,3 cases received bare stent-assisted coil embolization,10 cases received multiple bare stent implantation,3 cases received covered stent implantation,2 cases received angi-ography alone.A total of 39 self-expandable bare metal stents and 3 self-expandable covered stents were implanted.The diameter and length of the stents were(6.5±1.0)mm and(69±23)mm,respec-tively.Two asymptomatic patients had failure in endovascular interventional therapy and underwent superior mesenteric artery angiography.For the endovascular interventional therapy group,92.3%(24/26)of patients were relieved abdominal pain and 2 patients with abdominal pain were improved after symptomatic treatment.(3)Follow-up.All the 87 patients were followed up for 12(4,24)months,without recurrent abdominal pain or secondary intervention.During the follow-up,82 patients underwent computed tomography angiography or ultrasonography,and 5 patients had no available results.There was no SISMAD related death or superior mesenteric artery rupture.Eight patients in the conservative therapy group achieved complete vascular remodeling,versus 21 cases in the endo-vascular interventional therapy group,showing a significant difference between the two groups(χ^(2)=23.752,P<0.05).Conclusions Compared with conservative therapy,patients undergoing endovas-cular interventional therapy for SISMAD has loner hospital stay,higher total costs,higher complete vascular remodeling rate.There is no recurrent abdominal pain in two methods.