急性肠系膜血管闭塞41例早期诊治体会

目的探讨急性肠系膜血管闭塞（AMVO）的早期诊断及治疗方法。方法回顾性分析41例AMVO患者的临床特征、早期诊治方法及预后情况。结果AMVO41例中,肠系膜上动脉栓塞20例,肠系膜上动脉血栓形成5例,肠系膜上静脉血栓形成12例,非阻塞性肠系膜血管供血不全4例。41例均急诊行剖腹探查术,2例因病变广泛未能切除坏死肠段,39例行肠切除肠吻合术。治愈37例,死亡4例。结论早期诊断和及时剖腹探查是提高AMVO疗效的关键。     

12例缺血性肠病的临床分析

目的分析缺血性肠病（ischemic bowel disease,IBD）的临床特点、诊断及治疗。方法回顾性分析12例患者临床表现、合并症、腹部血管CT成像（CT angiography,CTA）或腹部血管彩超、电子结肠镜、治疗等。结果急性缺血性肠病3例,2例经手术治疗,1例发病72h内死亡。慢性缺血性肠病9例,8例经内科治疗好转,1例死亡。结论急性缺血性肠病多见于肠系膜上动脉闭塞,早诊断、早治疗较重要,出现肠坏死预后差。慢性性缺血性肠病多见于肠系膜上、下动脉狭窄及灌注不足,内科治疗疗效良好。肠道排空障碍可能是IBD的早期表现。     

急性肠系膜动脉性缺血26例

目的:探讨急性肠系膜动脉性缺血的诊断及治疗.方法:回顾分析26例急性肠系膜动脉性缺血的临床特征、诊断、治疗及预后.结果:入院后确诊11例,其中:彩色多普勒超声6例,螺旋CT 9例,血管造影5例.其余15例因血性腹水探查术中确诊.全身抗凝治疗4例,Fogarty导管取栓术后完全恢复5例,小肠部分切除8例,小肠大部及右半结肠切除7例,2次探查术2例.术后6mo内死亡6例.结论:超声可作为急性肠系膜动脉性缺血患者的初步检查,发现血性腹水者及早行剖腹探查术.早期诊断与治疗使降低肠系膜血管死亡率和致残率的关键.     

急性肠系膜动脉缺血性疾病的诊治分析——附27例报道

目的:探讨急性肠系膜动脉缺血的诊断和治疗方法。方法:回顾性分析自2002年5月至2008年12月我院共收治肠系膜动脉缺血性疾病患者27例。急诊行手术治疗21例,其中单纯行肠系膜上动脉取栓术9例,肠系膜上动脉切开取栓加肠切除吻合术8例,单纯肠切除吻合术3例,肠切除加肠造瘘术1例。保守治疗6例。结果:手术治疗21例,1例于死于感染性休克,5例出现短肠综合征,经胃肠外营养等对症治疗后症愈出院,6例行保守治疗者均症状减轻,好转出院。结论:彩超是早期诊断肠系膜动脉缺血的重要手段,及时手术和加强术后监护是提高疗效的关键。     

CDFI在诊断急性肠系膜上动脉狭窄或闭塞性肠缺血中的临床应用

目的探讨彩色多普勒血流显像（CDFI）诊断肠系膜上动脉狭窄或闭塞性肠缺血的临床价值。方法选择18例经数字减影血管造影（DSA）证实为肠系膜上动脉狭窄或闭塞性肠缺血的患者,回顾性分析其术前1周CDFI和DSA检查结果,并以后者为金标准判定前者诊断肠系膜上动脉狭窄或闭塞性肠缺血的准确率。结果本组术前CDFI与DSA检查结果基本一致,CDFI诊断肠系膜上动脉狭窄或闭塞性肠缺血的准确率为90％。结论CDFI诊断肠系膜上动脉狭窄或闭塞性肠缺血准确率高,且具有无创、应用方便、经济适用等特点。     

Angiojet血栓抽吸系统在急性肠系膜上动脉栓塞治疗中的应用

目的探讨Angiojet血栓抽吸系统对急性肠系膜上动脉栓塞的治疗效果。方法回顾我院用Angiojet血栓抽吸系统对3例急性肠系膜上动脉栓塞患者的治疗经验,结合文献对急性肠系膜上动脉栓塞的诊断、治疗进行综合分析。结果收治的3例急性肠系膜上动脉栓塞患者中,2例有心房颤动病史,1例为肠系膜上动脉夹层;采用Angiojet血栓抽吸系统早期清除血栓后再联合导管溶栓等治疗,均取得满意疗效。结论急性肠系膜上动脉栓塞起病急促,早期诊断尤为重要,肠系膜上动脉造影有助于早期诊断,Angiojet血栓抽吸系统能够早期清除血栓,恢复血供,对急性肠系膜上动脉栓塞具有良好的效果。     

急性心肌梗死合并急性肠系膜上动脉闭塞经介入抢救成功一例

急性肠系膜动脉闭塞临床表现极不典型,容易误诊漏诊,同时合并急性心肌梗死则更为罕见。该病诊断困难,死亡率高,抢救成功的关键在于早期诊断,及时处理。湖南师范大学第一附属医院2011年经多科合作抢救成功1例急性心肌梗死合并急性肠系膜上动脉闭塞的患者,现报道如下。     

双支架并联取栓术治疗急性基底动脉闭塞初步研究

目的初步探讨双支架取栓治疗急性基底动脉闭塞患者的可行性、有效性及安全性。方法回顾性分析采用Solitaire FR双支架并联取栓术治疗血栓负荷重的急性基底动脉闭塞所致脑梗死5例患者,统计手术时间,评价取栓后即刻血流再灌注、24 h神经功能改善及术后90天随访mRS评分。结果 5例患者均通过双支架并联取栓术获得闭塞血管良好再通,改良脑梗死溶栓分级(mTICI)为2b-3级,其中完全再通4例(mTICI 3级)。无明显与操作相关并发症,术后24 h NIHSS评分较术前减少10分。术后90天随访,2例患者预后良好,2例残疾,1例患者死亡。结论使用Solitaire FR双支架并联取栓术治疗血栓负荷重的部分后循环急性脑梗死患者是安全有效的。     

肠系膜炎症性静脉栓塞病的研究进展

肠系膜炎症性静脉栓塞病(MIVOD)是肠系膜缺血性疾病中一种特殊的类型,其组织学特点是孤立性的肠系膜炎症性静脉闭塞,病变不累及肠系膜动脉,同时又无系统性脉管炎和其它可导致肠系膜静脉炎症的疾病存在。由于该病主要依靠术后病理诊断,早期正确诊断很困难,因而在治疗上尚无有效的内科治疗方法,所有患者均需外科手术治疗,而且手术切除病变肠段后症状可缓解,是目前比较有效的治疗方法。     

SolitaireAB型支架用于急性脑梗死后动脉内取栓的临床疗效

目的探讨Solitaire AB型支架取栓应用于治疗急性脑梗死-急性颅内动脉闭塞的临床效果及安全性。方法采用Solitaire AB型支架取栓术治疗急性脑动脉闭塞病人18例(MCA闭塞9例,ICA闭塞2例,BA闭塞6例,ICA合并MCA闭塞1例)。分析即时取栓效果、术后24 h出血情况及患者治疗前后神经功能缺损(NIHSS)评分及预后情况。结果 17例血管再通,其中有5例再通后存在明显狭窄,予支架植入及球囊扩张;1例未开通;1例术后24 h颅内出血;2例死亡,死亡病例为颈内动脉闭塞取栓后出血及大脑中动脉合并颈内动脉闭塞取栓未成功;出院90 d后MRS评分2分的10例。结论 Solitaire AB支架治疗急性颅内大血管闭塞相对安全、有效,患者预后良好。     

Acute thromboembolic occlusion of the superior mesenteric artery following covered stent occlusion in the superior mesenteric artery: endovascular therapy using mechanical rotational thrombectomy

Acute thromboembolic occlusion of the superior mesenteric artery is a rare and often fatal condition in which surgery represents the golden standard in therapy. We present a case in which a patient was treated with covered stent implantation for acute bleeding from the superior mesenteric artery following pancreatic resection, radiation, and embolization of a hepatic artery pseudoaneurysm. Some weeks later clinical signs were suggestive of acute thromboembolic occlusion of the superior mesenteric artery and digital subtraction angiography showed occlusion of the previously implanted covered stents. The patient was successfully treated transfemorally with percutaneous mechanical instent thrombectomy using a 6F Rotarex? catheter. We conclude that in selected cases percutaneous mechanical thrombectomy may represent a minimally-invasive alternative to open surgical thrombectomy for treatment of acute thromboembolic occlusion of the superior mesenteric artery.     

Real-time energy metabolism of intestine during arterial versus venous occlusion in the rat

Background. Although it is less frequently encountered, mesenteric vein occlusion poses as important a problem as mesenteric artery occlusion. The energy metabolism of intestinal tissue during venous occlusion and reperfusion was studied. Methods. Male Wistar rats were studied in four groups of 17 animals each. Intestinal ischemia was induced by clamping the superior mesenteric artery ([SMA] occlusion [O]) or vein (SMVO) for 30 or 60min, followed by reperfusion. Magnetic resonance spectroscopy was employed to continuously monitor the energy metabolism. Additionally, intestinal motility was monitored and histological examination was performed on resected specimens. Results. Energy metabolism in SMVO during ischemia was reduced more slowly than in SMAO, but recovery after reperfusion was poorer in SMVO. During ischemia, the contractive response of the intestine lasted longer in SMVO than in SMAO. Histologically, mucosal and subserosal hemorrhage was more severe in SMVO. Conclusions. In contrast to SMAO, SMVO caused less severe reduction of energy metabolism, at the expense of hemorrhage and tissue damage.     

Shunting of the microcirculation after mesenteric ischemia and reperfusion is a function of ischemia time and increases mortality

OBJECTIVE: Shunting of the microcirculation contributes to the pathology of sepsis and septic shock. The authors address the hypothesis that shunting of the microcirculation occurs after superior mesenteric artery occlusion (SMAO) and reperfusion, and explore functional consequences. METHODS: Spontaneously breathing animals (rats) (n = 30) underwent SMAO for 0 (controls), 30 (SMAO_30) or 60 min (SMAO_60) followed by reperfusion (4 h) with normal saline. Leukocyte-endothelial interactions in mesenteric venules were quantified in an exteriorized ileal loop using intravital microscopy. Abdominal blood flow was recorded continuously, and arterial blood gases were analyzed at intervals. The above groups were matched by comparable groups with continuous superior mesenteric artery blood flow measurements and without exteriorizing an ileal loop (controls*, SMAO_30*, SMAO_60*). RESULTS: Adherent leukocytes increased shortly after reperfusion in ischemia groups, and plateaued in these groups. Centerline velocity in the recorded venules was significantly reduced after reperfusion down to low-flow/no-flow in SMAO_60 as compared to SMAO_30 and controls, whereas perfusion of the SMA and ileal vessels persisted. The microcirculatory changes in SMAO_60 were accompanied by progressive metabolic acidosis, substantially larger volumes of intravenous fluids needed to support arterial blood pressure and significantly reduced survival (30%). SMA blood flow increased in relation to abdominal blood flow after reperfusion in SMAO_60*, and remained constant in SMAO_30* and controls*. Survival was 80% in SMAO_60*. CONCLUSION: Shunting of the microcirculation can be observed after SMAO for 60 min and reperfusion, and contributes significantly to the pathology of mesenteric ischemia and poor outcome.     

Treatment of superior mesenteric artery embolism with a fibrinolytic agent: case report and literature review

Successful treatment of superior mesenteric artery embolism depends on an aggressive approach in patients at risk for mesenteric ischemia. This approach favors an early diagnosis and permits the reestablishment of arterial flow within an appropriate time, with prevention of vasospasm and control of organic insufficiencies. We report here a case of superior mesenteric artery embolism in which arterial flow was reestablished by selective intra-arterial infusion of streptokinase. The literature has reported 18 similar cases thus far. This procedure could be an alternative to embolectomy in selected patients, i.e., patients with an early diagnosis, no evidence of intestinal necrosis and with partial occlusion and/or occlusion of secondary branches of the superior mesenteric artery. Frequent arteriographies and intensive care are necessary in this approach. The patient should be continuously monitored because of the possibility of treatment failure and the need for embolectomy.     

Paralytic ileus following myocardial infarction

Clinically severe adynamic ileus has been found to be a rare complication of acute myocardial infarction. Two such patients have been presented; each died suddenly after a prolonged hospital course. Complete autopsy study was made, and each was found to have died from a very recent myocardial infarction. In Case 1, clinical diagnosis was directed to mesenteric arterial occlusion with bowel infarction, and Case 2 clinically suggested intraor retroperitoneal hemorrhage. The post-mortem studies indicated that both patients had congestive failure secondary to arteriosclerotic heart disease and that the ileus was probably a manifestation of mesenteric vascular insufficiency. The prognosis of intestinal obstruction following myocardial infarction must rest upon the cause of the ileus and need not be ominous. In these cases, conservative management of the adynamic ileus was effective; however, they emphasize that the surgical implications of ileus must always be considered and directed to the pericardium as well as the abdomen.     

A new test to avoid arterial complications during pancreaticoduodenectomy

Celiac trunk or superior mesenteric artery stenosis are usually innocuous conditions. In such patients, arterial blood supply to the stomach, spleen, liver and bowel is sustained through extraordinarily well-developed pathways through the pancreas. If division of these collateral vessels is necessary during a surgical procedure such as pancreaticoduodenectomy, life-threatening celiac organ or bowel ischemia may occur. The authors describe a new test, using pancreatic inflow occlusion, to reliably identify celiac trunk or superior mesentery artery stenosis. The authors describe two cases of celiac axis occlusion and one case of superior mesenteric artery stenosis. In all three presented cases the gastroduodenal artery clamping test was negative and ischemia was only noticed after pancreatic section, suggesting that in severe occlusions this test may fail in diagnosing the vascular abnormality. All patients were successfully treated by revascularization with no operative mortality. If the diagnosis is unsuspected and in cases where appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery should always precede its ligation. However, this test may not be effective in all cases and in instances where high suspicion of celiac axis or mesenteric stenosis is present, other maneuvers, such as pancreatic inflow test, could be helpful for the diagnosis of these rare and morbid situations.     

Open abdominal surgery with mesh and zipper for superior mesenteric artery occlusion

Intestinal infarction caused by superior mesenteric arterial occlusion (SMAO) often requires massive resection of the necrotic bowel. However, this procedure frequently causes the short bowel syndrome. To avoid the development of this syndrome, it is important to conserve as much of the remnant bowel as possible. However, SMAO frequently occurs in patients with atrial fibrillation; even if the operation saves the patient's life, the risk of disease recurrence remains. We developed a novel open abdominal surgical technique involving the use of a mesh with a zipper to monitor the blood flow around the primary anastomosis created during the initial operation. Here, we described this technique and the postoperative management procedures and evaluate the efficiency of the technique.     

抗磷脂抗体综合征肠系膜血管血栓形成的特点

目的 了解抗磷脂抗体综合征(APS)患者发生肠系膜血管血栓的特点.方法 在Pubmed及中国生物医学文献数据库(1983年1月至2007年7月)检索、分析、总结有关APS发生肠系膜血管血栓的病例报道.结果 共检索病例报道21例,男性13例,女性8例,年龄5个月～69岁,平均(37±17)岁.既往深静脉血栓形成病史3例(14%),自然流产史4例(19%).病程4 h～4个月.表现腹痛18例(86%)、便血或黑粪4例、呕吐3例、腹泻2例、呕血2例,其他有发热等表现.查体腹部压痛10例(48%)、腹膜刺激征5例(24%)、移动性浊音3例、肠鸣音减弱或缺如3例.10例行B超检查,其中3例(33%)检测到肠系膜血管血栓,13例行CT检查者中9例(69%)发现肠系膜血管血栓,4例行磁共振成像(MRI)检查及4例行多普勒超声均发现肠系膜血管血栓(100%),6例通过血管造影证实血栓形成.21例中抗心磷脂抗体阳性18例(86%),其中IgG型占14例(67%).16例行剖腹探查,发现肠缺血坏死者9例(56%).21例中肠系膜上静脉血栓17例(81%),肠系膜上动脉血栓4例(19%),肠系膜下动脉血栓1例(5%),其中肠系膜静脉血栓中7例同时存在门静脉血栓(33%).结论 APS肠系膜血管血栓以肠系膜上静脉为主,常同时存在门静脉血栓,男性略多,中青年略多,可有血栓或自然流产史,可急性起病或逐渐进展,常表现为肠梗阻、肠缺血坏死,IgG型抗心磷脂抗体阳性多见,多种影像学方法联合检测利于及时发现血栓,抗凝及必要时及时手术对多数患者有益.