隐匿性血管损伤的临床特点与诊疗策略

目的 探讨临床骨科中隐匿性血管损伤的临床特点、诊断与治疗,以期提高对此类损伤的认识和临床诊治效率.方法 2003年3月至2010年10月共收治649例血管损伤患者,其中隐匿性血管损伤50例(7.7%),男42例,女8例;年龄13～66岁,平均34.0岁.血管损伤类型:静脉损伤1例,动脉损伤42例,动、静脉同时损伤7例.根据张英泽等提出的肢体动脉编码和损伤分型:A型14例,B型20例,C型16例.初始损伤至诊断时间平均为43.4 d(2～337 d),表现为肢体缺血、骨筋膜室综合征、血肿或假性动脉瘤、出血、神绛受压等征象.辅助检查包括:彩色多普勒超声17例,CT血管造影7例,X线血管造影25例.手术治疗43例,包括血管修补、直接吻合、自体静脉移植、结扎及截肢,其中2例术后行血液滤过治疗;内科治疗3例;介入栓塞治疗4例.结果 4例患者截肢后伤口愈合良好,无并发症发生;其余46例患者出院时患肢皮肤温度、颜色均恢复正常,远端动脉搏动存在,平均随访6.7个月(1～42个月),患肢血运良好.结论临床工作中的隐匿性血管损伤并非少见,其临床表现具有延迟出现、多种多样及不典型的特点.诊断方法应优先选择血管造影.治疗以手术为主,酌情采用血管内介入治疗和血液滤过治疗.

Abstract：

Objective To investigate clinical characteristics, diagnosis and treatment of insidious vascular injuries in orthopaedic cases. Methods Between March 2003 and October 2010, we treated 649 cases of orthopedic and vascular injuries, 50 (7. 7% ) of which were identified as insidious injuries. They were 42 men and 8 women, aged from 13 to 66 years (average, 34. 0 years). The insidious injury affected the vein in one case, the artery in 42 cases and both in 7 cases. The vascular injuries were categorized as type A (14 cases), type B (20 cases) and type C (16 cases) according to the classification system proposed by Zhang Ying-ze. The diagnoses were made after an average of 43. 4 days from primary injuries, with the assistance of color Doppler ultrasound in 17 cases, CT angiography in 7 and X-ray angiography in 25. Clinical manifestations included limb ischemia, compartment syndrome, hematoma or pseudoaneurysm, hemorrhage and nerve entrapment. Forty-three patients were treated by a variety of surgical options, such as angiorrhaphy, anastomosis, transplantation of autogenous venous graft, ligation and amputation. Among them, hemofiltration was performed in 2 cases as adjuvant therapy. Endovascular embolization was performed in 4 cases and conservative treatment in the other 3. Results Forty-six patients had their limbs salvaged, with normal temperature and color of the skin and existence of distal arterial pulses at discharge from hospital. The other 4 patients had to sustain amputation. An average follow-up of 6. 7 months (from one to 42 months) revealed that all the affected limbs regained normal blood circulation. Conclusions The insidious presentations and atypical clinical manifestations make diagnosis of insidious vascular injury very difficult. We recommend angiography as the first step in diagnosis. Surgical approaches should be considered as the main treatment choice, and hemopurification can be used as adjuvant therapy if necessary. In some cases, endovascular intervention may be faster and safer.

Insidious vascular injuries in orthopedics: a report of 50 cases

Objective To investigate clinical characteristics, diagnosis and treatment of insidious vascular injuries in orthopaedic cases. Methods Between March 2003 and October 2010, we treated 649 cases of orthopedic and vascular injuries, 50 (7. 7% ) of which were identified as insidious injuries. They were 42 men and 8 women, aged from 13 to 66 years (average, 34. 0 years). The insidious injury affected the vein in one case, the artery in 42 cases and both in 7 cases. The vascular injuries were categorized as type A (14 cases), type B (20 cases) and type C (16 cases) according to the classification system proposed by Zhang Ying-ze. The diagnoses were made after an average of 43. 4 days from primary injuries, with the assistance of color Doppler ultrasound in 17 cases, CT angiography in 7 and X-ray angiography in 25. Clinical manifestations included limb ischemia, compartment syndrome, hematoma or pseudoaneurysm, hemorrhage and nerve entrapment. Forty-three patients were treated by a variety of surgical options, such as angiorrhaphy, anastomosis, transplantation of autogenous venous graft, ligation and amputation. Among them, hemofiltration was performed in 2 cases as adjuvant therapy. Endovascular embolization was performed in 4 cases and conservative treatment in the other 3. Results Forty-six patients had their limbs salvaged, with normal temperature and color of the skin and existence of distal arterial pulses at discharge from hospital. The other 4 patients had to sustain amputation. An average follow-up of 6. 7 months (from one to 42 months) revealed that all the affected limbs regained normal blood circulation. Conclusions The insidious presentations and atypical clinical manifestations make diagnosis of insidious vascular injury very difficult. We recommend angiography as the first step in diagnosis. Surgical approaches should be considered as the main treatment choice, and hemopurification can be used as adjuvant therapy if necessary. In some cases, endovascular intervention may be faster and safer.