血管移植在四肢血管损伤中的应用

目的:探讨血管移植在四肢血管损伤中的作用。方法:44例(52条)四肢血管损伤患者,男35例,女9例,年龄14~58岁,平均27·3岁,分别采用自体血管(42条)和人造血管(10条)移植。结果:截肢3例,人工血管移植物感染行股浅-静脉原位置换2例,肢体缺血挛缩6例,神经功能恢复不完全7例。其余移植血管均通畅,远端肢体血循环良好。结论:血管移植治疗血管损伤保肢成功率高;治疗中须注意早诊断、早修复、严格显微外科原则、积极行骨筋膜室切开减压。     

临时血管内转流术在肢体血管损伤修复中的应用

目的：探讨临时血管内转流术在治疗血管损伤中的价值。方法：总结2006年6月—2013年6月采用临时血管内转流术的血管损伤患者临床资料。结果：全组5例患者，共9条肢体血管受损（3例因外伤、2例因肿瘤切除手术）。5例患者共 8条临时血管内转流管（动脉5条,静脉3条）置入受损血管快速重建肢体血运，然后再行创面的处理及骨折手术；转流时间2~3 h，移除转流管后采用自体大隐静脉移植行血管重建术。全组无死亡，术后1例发生缺血肌挛缩，1例并发下肢深静脉血栓。结论：临时血管内转流术可快速重建肢体血供，缩短肢体缺血时间，为其他合并损伤的处理提供了条件。

     

四肢主干血管急性损伤的外科处理

目的 探讨四肢主干血管急性损伤的外科治疗方法。方法 回顾性分析我院收治四肢主干血管急性损伤患者100例。共行手术106次,其中行血管移植58条(人造血管移植40条,大隐静脉移植18条),血管断端直接吻合44条,血管裂口修复28条,单纯动脉结扎2条。结果 治愈94例,无血栓形成及肢体缺血。1例大隐静脉移植术后移植段静脉血栓形成,1例切口感染,3例下肢因挤压伤致大面积肌肉坏死,均治愈,另1例右小腿远端缺血截肢。结论 正确的现场处理、精细的血管外科技术、血管移植材料的合理选择是提高治疗效果的关键。     

高压电烧伤合并肢体血管损伤治疗10年回顾性分析

背景与目的 高压电烧伤虽然发生率很低，但是潜在的肌肉、神经和血管受损比火焰灼伤更加隐匿，危及肢体的缺血和迟发破裂出血会导致肢体功能丧失、致残甚至致死。高压电烧伤后的肢体血管损伤尚无明确的发生率，也没有诊疗指南的推荐，各个中心的治疗方案也不尽相同。北京积水潭医院作为全国烧伤抢救中心，每年要收治大量的烧伤患者，其中高压电烧伤合并血管损伤的患者屡见不鲜。本文总结了近10年来北京积水潭医院收治的高压电烧伤合并血管损伤的患者诊治方案，试图从中分析出此类患者与创伤性动脉损伤患者的差异，归纳出此类患者的诊疗特点，为今后的临床工作提供有力的证据支持。方法 回顾本中心2010年1月—2020年1月收治的由于高压电烧伤导致肢体血管损伤的患者94例，患者的血管修复方式包括直接局部修补、自体血管重建和人工血管重建。分析术后血管血栓形成、迟发破裂出血、感染、截肢等术后并发症的发生比例，对比数据间的差异。结果 94例患者中，男83例，女11例；平均年龄（30.4±20.1）岁。7例来院时肢体毁损严重，行截肢术。87例完成血管修复，29例行局部修补术，53例采用自体血管重建，5例采用人工血管材料重建，技术成功率100%。局部修补患者术后2周内血栓形成3例，假性动脉瘤2例，均再次手术行自体血管重建。自体血管重建患者中，术后2周内血栓形成7例，切开取栓后血运改善，发生迟发破裂出血4例，切开止血再次重建1例，腔内介入置入覆膜支架3例，术后感染或软组织严重坏死截肢3例。人工血管材料重建患者中，术后2周内血栓形成1例，切开取栓后恢复血运，发生迟发破裂大出血1例，腔内介入置入覆膜支架。75例患者获随访3~6个月，血管通畅率89.3%（67/75）。结论 高压电烧伤后的血管损伤远超肉眼可见的损伤范围，不同于一般创伤导致的相关损伤；血管重建前应充分评估损伤血管及周围组织条件，在充分清创的前提下自体血管和人工血管均可成为良好的重建材料；高压电烧伤导致的血管损伤会随时间推移而进展，应该警惕血栓形成和迟发破裂出血，一旦发生迟发破裂需再次切开止血重建或腔内介入治疗，这样才能保全患肢。     

胎儿骨软骨镶嵌移植成形术治疗股骨头缺血性坏死

目的:探讨简单有效的治疗股骨头缺血性坏死的新方法,以保护髋关节,改善临床症状。方法:采用新鲜胎儿骨软骨镶嵌移植、髋关节滑膜切除、股骨头髓心减压及旋股外侧血管植入联合手术治疗股骨头缺血性坏死85例（91髋）,男62例,女23例,年龄14⁵9岁,平均39·8岁。术后对其髋关节功能进行评定。结果:经过1·5¹0年随访,全部病例临床症状改善,髋关节功能恢复良好,按Harris髋关节评分:优45例,良32例,可4例,差4例,优良率90·59%（77/85）。结论:采用新鲜胎儿骨软骨镶嵌移植治疗股骨头缺血性坏死适用于FicatⅡ、Ⅲ期股骨头坏死的患者,尤以中青年患者为宜。     

血管损伤的外科治疗

目的:探讨血管损伤的外科处理方法。方法:166例血管损伤均行手术治疗,1例股动脉损伤形成假性动脉瘤合并感染行血管结扎、脓肿引流术;1例腰动脉损伤行结扎术;截肢术10例;血管端端吻合术43例,自体静脉移植重建术72例,人工血管移植重建术4例,血管修补术35例。结果:随访1个月至4年,平均2.4年。四肢血管损伤共截肢32例(术后22例出现肢体坏死行截肢术);71例肢体功能恢复良好;51例患肢得以保存,但遗留不同程度的功能障碍。1例颈部血管损伤有眼睑下垂。结论:血管损伤早期诊断是关键,血管重建是血管损伤的主要治疗手段。     

肢体恶性骨肿瘤及骨转移癌保肢治疗

目的:探讨肢体恶性骨肿瘤及转移癌行瘤段切除假体重建的方法及意义。方法:本组共62例,男38例,女24例;年龄10⁷2岁,平均28.4岁。原发肢体恶性骨肿瘤41例,其中骨肉瘤19例,骨巨细胞瘤9例,恶性纤维组织细胞瘤8例,浆细胞瘤3例,尤文氏瘤1例,骨血管内皮瘤1例。骨转移癌21例,原发病灶分别为:肺癌9例,胃癌3例,肾癌2例,乳腺癌2例,甲状腺癌1例,颌下腺癌1例,原发灶不明者3例。对62例肢体恶性骨肿瘤及转移癌应用肿瘤段切除并修复重建治疗。方法有:①瘤段切除人工假体置换术;②瘤段切除自体腓骨移植术;③瘤段切除髓内针骨水泥重建术。结果:术后随访5⁴2个月,平均14.2个月,41例恶性骨肿瘤中,术后无瘤生存21例,死亡4例,7例发生肺转移,3例发生其他部位转移,6例局部复发后截肢。37例生存患者患肢功能按Enneking骨肿瘤外科治疗后功能评定标准,优良率81.1%。21例骨转移瘤患者中,术后存活3个月以上者19例（占90.4%）;术后疼痛消失15例（占71.4%）,其余均有疼痛减轻;日常生活工作恢复者11例（占52.3%）。结论:对可施行广泛切除的肢体恶性骨肿瘤患者采用不同方法修复重建,行保肢治疗,可在治疗肿瘤的前提下尽量保留肢体功能,对肢体骨转移癌行合适的保肢手术对提高骨转移癌患者的生存质量有积极意义。     

四肢主要血管损伤的显微外科治疗

目的 探讨四肢血管损伤的显微外科治疗的临床效果。 方法 回顾分析四肢血管损伤治疗52例的临床资料,其中行血管端端吻合38例45条血管,血管修补7例12条血管,静脉移植修复7例7条血管,同时处理合并伤。 结果 术后肢体存活51例,患肢血运及感觉和功能恢复良好,因缺血时间过长肢体远端坏死截肢1例。 结论 早期正确诊断,及时采用显微外科技术修复损伤血管可获得良好的临床效果。     

四肢主干动脉外伤缺损长度的判断与修复重建

目的：研究四肢主干动脉损伤实际缺损长度、缺损裂隙宽度对修复重建选择的影响。方法：回顾性研究1996年至2009年治疗的32例四肢主干动脉损伤患者,其中男30例,女2例;成人30例,年龄18～51岁,平均36岁,儿童2例,年龄分别为4岁和5岁。受伤部位：腋动脉4例、肱动脉7例、桡动脉2例、股动脉4例、腘动脉13例和胫后动脉2例。观察分析动脉损伤后缺损裂隙的宽度以及形成原因,对所有病例采取了血管拉伸后端端吻合的方法进行修复。结果：动脉缺损裂隙宽度3～7 cm,平均（4.375±1.200） cm,上肢肱动脉和腋动脉11例（5.73±0.63） cm,下肢股动脉和腘动脉17例（3.80±0.73） cm,胫后动脉2例（3.25±0.35） cm,桡动脉2例（3.00±0.00） cm.上肢肱动脉和腋动脉缺损间隙宽度大于其他3个部位（P<0.01）.所有患者血管端端吻合成功,血运恢复良好。因肢体感染后期截肢2例。所有患者得到随访,不伴骨折患者随访至术后2周,伴骨折患者至少随访1年,所有患者肢体血运良好。结论：血管缺损裂隙宽度不同于实际血管缺损,而是大于实际血管缺损,对血管缺损长度的错误判断将导致更多的血管移植。绝大多数的血管外伤缺损可以通过血管游离,拉伸延长后直接修复。     

骨巨细胞瘤术后复发的手术治疗

目的:探讨骨巨细胞瘤术后复发的手术方法及疗效。方法:1994年6月-2003年10月,收治四肢长骨复发性骨巨细胞瘤18例,男12例,女6例;年龄18⁴4岁,平均26岁。股骨下端5例,胫骨上端8例,股骨上端1例,桡骨远端4例。Enneking分期:Ⅰa期14例,Ⅰb期4例。放射影像学Cam-panicci分级:Ⅰ级7例,Ⅱ级7例,Ⅲ级4例。病理学Jaffe分级:Ⅰ级8例,Ⅱ级7例,Ⅲ级3例。采用肿瘤扩大切除,吻合血管的自体腓骨、髂骨联合移植术治疗9例;瘤段切除,吻合血管的腓骨头移植重建术4例;瘤段切除,人工假体置换术5例。结果:随访时间11¹10个月,平均66个月。所有移植骨术后均愈合,一侧关节间隙轻度狭窄2例,术后再复发1例。术后功能评价:优13例,良3例,可1例,差1例。结论:肿瘤扩大切除,吻合血管的自体腓骨、髂骨联合移植术既能彻底切除病变,又能保持和重建关节功能,是一种较理想的方法,Campanicci分级Ⅲ级、病理学Jaffe分级Ⅱ^Ⅲ级的复发性骨巨细胞瘤原则上应施行更为广泛的瘤段切除术,桡骨远端复发性骨巨细胞瘤因其部位的特殊性,应用自体腓骨移植重建效果良好。     

Systemic anticoagulation in the setting of vascular extremity trauma

IntroductionThere is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities.MethodsWe analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data.ResultsBetween February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4–91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p = 0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p = 0.002). Patients treated with ISA also stayed longer in the ICU (median 3 days vs. 1 day, p = 0.001) and hospital (median 9.5 days vs. 6 days, p = 0.01).DiscussionIn this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries.     

Outcomes of traumatic extremity vascular injuries from a Malaysian level 1 trauma center

BackgroundIn Malaysia, management of traumatic vascular injuries is at the discretion of the treating surgeon (trauma or vascular surgery). This study was conducted to report on the epidemiology, mechanism of injury and outcomes of vascular injuries managed in a regional level 1 trauma center.MethodsThis is a retrospective cohort study of all patients treated for traumatic extremity vascular injuries from January 2018 to December 2020. Demography, mechanism of injury, pre-operative physiologic vital signs, vessel injured, injury severity (NISS, RTS and TRISS score), type of revascularization surgery, fasciotomy, post-operative blood investigations, operative outcomes (amputation, length of stay and ICU admission) and long-term rehabilitation follow-up were recorded and analyzed.ResultsAmongst the 35 recorded vascular injuries only 28 patients had adequate data that were included in the analysis. Majority of patients were males (23/28patients; 82%). Blunt injury to vessels was more likely in motorcycle crashes (16/28patients; 76%) than in automobile crashes (5/28patients; 24%). There were three lower limb amputees (3/3patients; 100%) that had early fasciotomy and were associated with three-fold higher post-operative median (interquartile range) CK levels of 16740 (8157 to 23116) u/l. Only two thirds (16/28 patients) had active rehabilitation follow-up and were back to work after a median duration of four months.ConclusionMale gender, blunt injury, road traffic crashes and motorcycles were the majority of vascular injuries. Lower limb vascular injuries had poorer outcome with three amputations performed after attempts at revascularization. Fasciotomy and high CK level may be related to higher risk of limb loss. Our study highlights the importance of rehabilitation and long-term follow-up in this cohort of patients.     

人工血管移植修复肢体血管缺损及临床观察

目的 总结应用人工血管移植修复技体血管闭塞及缺损的临床效果。方法 1992年6月-2000年12月，采用Gore-Tex膨胀泡沫聚四氟乙烯（ePTEE）人工血管移植修复肢体动脉及静脉缺损，动-静脉造瘘及复合皮瓣移植，神经移植共65例。结果 创伤性下肢肢体人工血管移植有1例行截肢术，桡动脉重建档中有3例闭塞，1例血管旁路重建术后3d并发急性心肌梗死而死亡，其余血管移植后肢体液血循环良好。术后行彩色多普勒检查、螺旋CT及DSA造影显示血管通畅。动-静脉造瘘28例全部成功，全部患者在临床上定期进行血液透析。随访2-5年，血管通畅率为71%。结论 人工血管移植修复肢体血管缺损、血管旁路术及动-静脉造瘘是一种有效的手术方式。既能解决自体血管来源困难的难题，又能保证临床应用的效果。     

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.Type of study/level of evidenceTherapeutic III.     

Concomitant multiple closed contiguous physeal injuries in a limb with an undescribed ‘distractional-separation’ type with vascular compromise: a report of two cases

Introduction: Though physeal injuries are common in children, concomitant multiple closed contiguous physeal injuries in a limb along with vascular compromise are rare. An associated distractional-separation type of physeal injury is being documented for the first time. We present here two such cases. Materials and methods: Two children, aged 6 months and 3 years, respectively, suffered a roadside high velocity trauma and thus form the part of this case report. Results: Because of the delay in seeking treatment and, or, the nature of injuries, it was associated with a tragic complication—an amputation in both cases. Conclusion: Although, the limb in our cases could not be salvaged, these reports describe these unusual injury patterns for the first time and re-emphasize the awareness of urgent recognition of the associated vascular insult.