四肢主要动脉损伤诊治体会

目的 探讨四肢主要动脉损伤的早期诊断方法和治疗效果。方法 对1991年1月～2003年10月36例四肢主要动脉损伤患者，分别采用端端吻合、血管修补、自体大隐静脉移植、残端结扎等方式修复损伤血管。结果1例血管吻合重建血循环后因肢体损伤严重，广泛坏死而截肢，其余35例全部存活。结论 ①早期诊断是肢体抢救成活的关键，诊断明确或疑有血管损伤者应尽早手术探查；②血管修补缝合术，血管端端吻合术是主要修复方法，血管缺损2cm以上者应行自体静脉移植术；③动脉血管修复的时限可根据伤情及全身情况适当延长。     

胸廓上口大血管损伤的外科治疗

目的 总结胸廓上口大血管损伤的外科治疗经验。方法 回顾性分析经手术治疗的32例胸廓上口大血管损伤患者的临床资料,其中男性24例,女性8例;年龄2－48岁。致伤原因为锐器伤、钝性或减速伤。损伤血管为颈总动脉、无名动脉、锁骨下动脉以及伴行的静脉。治疗方法为：急诊缝合动脉破口,或加涤纶片修补15例;动脉瘤切除6例;受损血管切除端端吻合5例;以Gore-Tex重建血管3例;大隐静脉移植3例。结果 治愈24例（75％）,死亡7例（21．9％）,1例致残。结论 胸廓上口大血管损伤患者,早期常因失血、脑缺氧或并存的多发伤致死;后期多演变成假性动脉瘤。手术多采用血管破口修复;在体外循环支持下实施假性动脉瘤切除,Gore-Tex人造血管或大隐静脉移植重建血管。     

12例开放性腋动脉损伤的诊治

目的探讨开放性腋动脉损伤的诊治体会。方法1996年-2002年，共诊治12例开放性腋动脉损伤的患者，从受伤到入院时间为3～14h，入院时均处于不同程度的休克状态，桡动脉搏动减弱或消失。在积极抗休克治疗的同时，急诊进行清创、血管神经探查和修复术。其中行腋动脉修补5例，腋动脉直接吻合6例，自体静脉移植修复1例。结果伤后8h内腋动脉再通8例，8～16h内腋动脉再通4例，无病例发生截肢或死亡。术后伤口均Ⅰ期愈合，桡动脉搏动良好。结论对开放性腋动脉损伤早期诊断和及时手术探查是控制休克、获取良好疗效的关键。     

下肢血管损伤的处理

本文报告美国波斯顿大学医院(1973～1981年)56例下肢钝性伤和穿透伤引起血管损伤的处理经验,特别对伴有骨折和广泛性软组织伤的处理有所改进。本组为腹股沟韧带以下69处血管损伤,其中36例仅有动脉损伤,7例仅有静脉损伤,13例动静脉同时损伤。动脉伤常见部位为股浅动脉和腘动脉。静脉伤常见部位为腘静脉。49例动脉伤修复中,19例采用最常用的静脉旁路移植法,12例作切除和端端吻合,1例作侧面修补,5例用静脉片修补,2例用人造血管移植,10例行动脉结扎。20例静脉伤修补术中,11例作常用的侧面修补,5例作切除和端端吻合,3例作静脉旁路移植,1例因腘静脉横断而作结扎。56例中21例术前作动脉造影;25例在完成手术时作术中动脉造影;12例需作正规筋膜切开术     

四肢主干血管损伤的诊治

目的探讨四肢主干血管损伤的早期诊断、治疗方法以及临床效果。方法2001年1月-2006年6月，收治72例四肢主干血管损伤患者。男50例，女22例；年龄5～60岁，中位年龄39岁。开放性损伤44例，闭合性损伤28例。动脉损伤部位：锁骨下动脉1例，股动脉23例，胭动脉20例，尺桡动脉同时损伤12例，肱动脉11例，腋动脉3例，胫前后动脉同时损伤2例。伤后至入院时间30min～27d。术中血管破口直接修补3例，端端吻合39例，自体大隐静脉移植修复30例，移植长度3～8cm。结果67例肢体成活，5例截肢。48例获6个月～5年随访，彩色多普勒血流仪检查血流速度及血管口径与健侧无明显差异。40例肢体功能恢复满意，8例残留不同程度功能障碍，其中4例行矫形或功能重建手术，功能及外形得到改善。结论了解损伤机制及受伤情况，认真体检，综合分析，是主干血管损伤早期诊断的关键；显微外科修复是提高血管通畅率的保障；术后筋膜间室综合征及肢体缺血时间超过4h的肱动脉、胭动脉以上的血管损伤，及时行筋膜间室切开是恢复肢体功能、避免伤残的有效手段。     

111例血管损伤的诊治体会

回顾分析10年间我院收治的血管损伤病例的病因、临床表现和经验。方法和结果:111例(12～55岁)血管损伤的原因有钝性损伤、刀刺伤、枪弹伤。下肢50例,上肢36例,颈部13例,腹部12例。67例(60％)合并有骨和周围神经损伤。20例(18％,四肢17例,腹部3例)行血管造影和超声多普勒检查。17例(15％)在清创手术时未发现血管损伤,日后形成假性动脉瘤,4例伤后形成动-静脉瘘而再度就诊。动脉损伤的治疗:侧壁修补43例,损伤段动脉切除吻合25例,自体静脉移植8例,人工血管移植5例和动脉结扎1例。静脉损伤治疗:侧壁修补10例,损伤段静脉切除吻合6例,静脉补片1例,静脉结扎2例及非手术治疗1例,腹主动脉和腔静脉损伤者死亡3例(3％)。四肢血管损伤肢体存活率为97％。结论:手术探察是目前急诊诊断血管损伤的主要方法;术前血管造影检查对血管损伤的诊断具有决定意义;术式选择和合并脏器损伤的处理应根据伤情而定。     

四肢动脉损伤诊治体会

目的探讨四肢动脉损伤的诊断和治疗方法。方法回顾分析我院1996年1月至2006年7月共诊治的23例四肢动脉损伤患者的临床资料。分别采用直接动脉修补、动脉结扎、端端吻合、自体大隐静脉移植及人工血管吻合。术中取栓6例,合并静脉损伤修复8例。结果截肢3例(13.0%)。获得随访12例,随访时间3个月～5年,11例多普勒超声证实损伤血管血流通畅,下肢肌肉挛缩1例;下肢血供不足1例。结论早期诊断是提高肢体存活率和避免假性动脉瘤发生的关键。手术方式的合理选择、Fogarty导管常规取栓和早期筋膜切开可提高治愈率。     

下肢假性动脉瘤15例诊治分析

目的　探讨下肢假性动脉瘤的诊断及治疗经验。方法　回顾分析 15例下肢假性动脉瘤的临床资料。结果　保守治疗 2例 ,瘤腔内修补 6例 ,静脉补片 1例 ,动脉端端吻合 2例 ,血管旁路移植 1例 ,动脉结扎 3例。合并动静脉瘘 2例同时行静脉瘘口修补。 15例全部治愈 ,10例获随访 0 .5～ 10年 ,无肢体缺血。结论　下肢假性动脉瘤大部分与外伤有关 ,根据病史、体格检查及必要的辅助检查均可诊断。部分病人可采取超声引导下压迫保守治疗 ,大部需要手术解决 ,主干动脉需要行动脉重建。     

创伤性周围假性动脉瘤的外科治疗分析

目的　探讨创伤性周围假性动脉瘤的诊断和治疗方法。方法　回顾性分析 5 8例创伤性周围假性动脉瘤。均手术治疗 ,其中动脉重建 17例 ,直接修补 2 9例 ,补片修补 6例 ,动脉结扎6例。结果　死亡 1例 ,其余 5 7例术后痊愈出院。随访 3 5例 ,均未截肢或出现脑缺血症状 ,3例移植血管闭塞 ,其余均保持通畅。结论　凡损伤性假性动脉瘤的诊断一经确定 ,应行手术治疗 ,以避免并发症的发生。阻断动脉血流是手术成败的关键 ,使用Fogarty导管简便易行 ,介入法置入气囊导管 ,也可阻断血流。防止假性动脉瘤的发生的最好方法是创伤早期对血管损伤的正确处理。     

周围静脉损伤的治疗（附33例报告）

对我院近３０年收治的３３例周围静脉损伤患者的资料进行了分析总结。作者认为，周围静脉损伤在血管损伤中占有一定的比例，绝大部分静脉伤都伴有动脉伤；静脉高压是导致筋膜间综合征的重要因素，因此结扎或不修复损伤的主干静脉有可能导致筋膜间综合征；持续性暗红色的伤口出血、弥漫性皮下血肿、肢体肿胀及青紫是静脉损伤的特点；多普勒超声血管检查及静脉造影有助于诊断；对损伤静脉宜行静脉修复，其修复方法根据损伤类型而定，可作侧面修补、补片移植、端端吻合或自体静脉移植等；静脉重建后早期可能有血栓形成，但这一并发症可以预防。     

四肢主干动脉损伤的诊治

目的 探讨四肢主干动脉损伤的诊断与治疗。方法 1999年9月～2002年6月，收治129例176条动脉损伤，应用显微外科方法修复122例162条动脉。结果 患肢成活116例154条血管，总成活率89．9％；血管再通率95．06％。结论 认真细致的体格检查和血管多普勒探测仪检测可避免漏诊；早期应用显微外科技术进行血管修复，可成功地挽救肢体。     

Vascular trauma of the lower limbs

BACKGROUND: This study was conducted to evaluate the results of treatment of vascular trauma of the lower extremities and those factors associated with limb loss. Design: a retrospective evaluation of a series with lower extremities vascular trauma. Setting: University Hospital. METHODS: Thirty-one patients accounting for 45 vascular lesions of the lower extremities (27 arterial and 18 venous injuries), over a 15 years period ending December 1998. Age, sex, modality of the trauma, site of the lesion and associated skeletal injuries, diagnostic procedures, ischemic time, arterial and venous repair performed were analyzed. RESULTS: Perioperative mortality was 7.4%. For arterial injuries, limb salvage was obtained in 22 patients (81.5%). Five amputations (18.5%), 1 primary and 4 secondary have been performed. Amputation rate was 26.7% for popliteal lesions versus 8.3% for other locations, 40% when a skeletal lesion was associated versus 5.9% for those without such injuries, 37.5% for reverse saphenous vein interpositions versus 5.6% for arterial repair without interposition. CONCLUSIONS: In this study, the factors influencing limb loss in vascular trauma of the lower extremities are popliteal location, the association with skeletal injuries, the need of saphenous vein interposition for arterial repair.     

四肢骨折伴主要血管损伤的临床治疗

目的探讨四肢骨折伴主要血管损伤急诊处理的临床效果。方法分别采用带锁髓内针、钢板螺钉和外固定支架固定骨折,根据血管损伤情况选择血管直接修补术、血管端端吻合术和血管移植术等方法治疗四肢骨折伴主要血管损伤45例。结果本组45例,肢体全部成活,伤口愈合好。随访6个月～3年。有6例骨不连,其余骨折愈合好;有7例因神经损伤恢复不理想,肢体感觉和运动功能部分障碍。结论四肢骨折合并主要血管损伤要早期诊断、及时和正确处理,才可能获得良好的临床治疗效果。     

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.     

Orthopedic trauma of limbs associated with vascular injuries

Objective： To evaluate the treatment for patients with major vascular injuries associated with traumatic orthopedic injuries. Methods： A total of 196 patients, aged from 4-67 years with the mean age of 29.88 years, had major vascular injuries associated with traumatic orthopedic injuries and were treated in our hospital in a period of 44 years. The most common mechanism of trauma was blunt trauma （67.3 % ）, open injuries accounted for 32.4 % and 54.5 % of the injuries were located in the lower extremities. The vascular injury frequently happened in the femoral artery （26. 7 % ） and popliteal artery （ 20. 3 % ）. The treatment principle consisted of aggressive resuscitation, Doppler imaging and stable bone internal fixation with subsequent vascular repair and debridement. The vascular repair for injuries included end-to-end anastomosis （80 cases, 39.6 % ）, interpositional vein graft （94, 46.5 % ）, vascular decompression through fracture distraction （ 18, 8.9% ）,arterial ligation （6, 3.0% ）, vein patch （2, 1. 0%）, bypass graft （ 2, 1.0% ）, venous repair including autogenous vein graft （9, 24. 3%） and ligation （28, 75.7% ） and prophylactical fasciotomy （15. 7. 4%）. Postoperative amputation was performed in 16 cases （16.3%）. Results： No intraoperative death was observed and all fractures united within 6 months. Limbs were salvaged in 180 patients （91. 8% ）. Among these patients, early complications were found in 19 patients （9. 7 % ） and late complications were observed in 8 patients （4.1% ）. Conclusions： A well-organized approach, based on a specific treatment principle, not only improves clinical outcome but also does good to excellent functional recovery for patients with severe orthopedic injuries and concomitant vascular lesion.     

无伴行动脉损伤的肢体静脉干损伤的修复

目的探讨无伴行动脉损伤的肢体静脉干损伤的机制,以及诊断、救治和修复方法. 方法 1993年1月～2002年6月共收治12例患者,均为男性,年龄18～35岁.受伤至手术时间30 min～2 h.均为锐器刺伤.在积极抗休克的同时进行血管修补7例,端端吻合5例.合并头颅胸腹部损伤患者同时给予相应手术处理. 结果除1例患者因严重的脑外伤死亡外,余11例患者伤口均Ⅰ期愈合.随访1～5年,平均2年4个月,彩色多普勒检查见血流通畅,无血栓形成.其中8例肢体功能和血循环恢复良好;3例合并伴行神经损伤者血循环恢复良好,但肢体功能恢复欠佳,遗留感觉及运动障碍. 结论无伴行动脉损伤的肢体静脉干损伤是一种严重的损伤,采取应急止血、积极抗休克、及早修复损伤血管和合理处理合并伤等是挽救患者生命的重要措施.     

下肢主干血管损伤超时限修复与功能重建

[目的]探讨下肢主干血管损伤后超时限修复及其功能重建,并观察临床疗效。[方法]回顾性研究收治的30例下肢主干血管超时限修复患者,男21例,女9例,年龄13~55岁,平均(34.17±9.40)岁。其中股动脉13例,包括开放性3例,闭合性10例;腘动脉17例,包括开放性6例,闭合性11例。[结果]30例患者中,直接吻合者22例,行对侧大隐静脉移植者7例,1例肢体短缩后吻合。损伤至血流再通时间10~72 h,平均(41.07±19.32)h;27例患者术后肢体血运良好,2例截肢,1例因大出血,给予结扎血管,肢体虽然存活,但末端血运差。30例患者最终截肢2例,截肢率6.67%。28例保肢功能者随访24~60个月,平均(41.25±10.45)个月。11例患者出现继发性足下垂畸形,再次手术,行Ilizarov踝支架矫正畸形。末次随访时,28例患者足底感觉、足背伸肌力、足背伸-跖屈ROM、膝伸-屈ROM和VAS评分均较术后1个月时显著改善,差异均有统计学意义(P<0.05)。28例患者开始行走时间20~240 d,平均(75.25±55.35)d,完全负重时间30~400 d,平均(148.57±90.02)d。[结论]对超时限主干血管损伤,经积极手术,术后综合治疗,仍可获得较满意临床效果。     

Vascular trauma of the upper extremities

The aim of this study was to evaluate short- and long-term results of the treatment of upper extremities vascular trauma considering aetiology of the lesions, percentage of limb salvage and residual functional disability. The Authors retrospectively evaluated 17 patients accounting for 21 vascular lesions of the upper extremities (16 arterial and 5 venous injuries). Age, sex, modality of trauma, site of the vascular lesions and of the associated injuries, diagnostic procedures at the admission, ischemic time, arterial and venous repair performed were analyzed. The over all peri-operative mortality was 5.8%. Of the 16 arterial injuries long-term reconstruction viability was obtained in 15 patients (93.7%). In all cases limb salvage was obtained. In 3 patients invalidating functional defects due to associated injuries of the major brachial plexus were observed. The Authors believe that associated nervous lesions are the main factor determining invalidating residual disability. In this series ischemic time, technique of vascular repair performed, associated skeletal injuries didn't influence the functional outcome of the reconstruction.     

Endovascular solutions to arterial injury due to posterior spine surgery

Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. We identified five patients with iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe their endovascular treatment. Intraoperative arterial bleeding was encountered in two patients during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patient was placed supine. In both patients, angiography demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting/penetrating the thoracic or abdominal aorta. Angiography or intravascular ultrasound imaging, or both, confirmed indention/perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. Endovascular repair of arterial injuries occurring during posterior spinal procedures is feasible and can offer a safe and less invasive alternative to open repair.     

医源性血管损伤27例临床分析

目的探讨医源性血管损伤的原因、部位及类型。方法总结2001年1月至2006年12月间27例（29支）医源性血管损伤的经验、教训。结果全组27例中，动脉损伤15例（17支）：截肢2例，动脉重建术3例，假性动脉瘤切除行动脉重建手术5例，假性动脉瘤保守治疗治愈5例。静脉损伤12例（12支）：修复10例，股动、静脉同时损伤截肢2例（4支）。结论造成医源性血管损伤的主要原因，与手术操作粗暴、解剖知识不牢及缺乏应急措施有直接关系。