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。     

四肢主要血管严重损伤的治疗

各种原因所致的血管损伤中,部分病例由于损伤范围较广,血管缺损较长,直接修补或吻合比较困难。在此种情况下,采用自体大隐静脉移植,有助于四肢主要血管损伤的修复,对减少残废有重要价值。我院自1979年以来,用自体大隐静脉移植修复主要动脉损伤共13例。现报告如下: 手术方法 一般在非受伤侧下肢获取被移植的大隐静脉。于大腿上部作纵行切口,显露大隐静脉上段,选择分肢少的一段静脉,结扎和切断其各分枝。根据静脉缺损长度决定所需静脉的长度,取下的静脉段,高压注入生理盐水,使血管管腔适当扩张,将大隐静脉方向倒置后,移植到缺损处行两断端吻合。吻合时局部以稀释肝素液     

纵向生物力学特性因素在人体四肢主要动脉损伤修复方法选择时的作用

目的 探讨人体四肢正常动、静脉的纵向残余应变特征和应力－应变关系,以及人体四肢主要动脉伤不同长度血管损伤与修复方法选择之间的关系,比较由于血管纵向生物力学特征而产生的修复差异,为临床血管损伤的修复效果及近、远期疗效评价提供依据。方法 以人体正常血管标本为研究对象,通过血管拉伸试验及检测血管纵向伸长率,获取四肢正常动、静脉纵向残余应变及应力－应变变化规律。对损伤部位相同而修复方法不同的血管真性缺损长     

四肢主要动脉损伤的临床治疗

目的：总结四肢主要动脉损伤的诊治经验。方法：1989—2000年68例四肢主要动脉损伤患者，分别采用断端吻合、血管修补、自体静脉移植、残端结扎等方式修复损伤血管。结果：随访2--11年，62例肢体存活，6例截肢，2例出现轻度缺血性肌挛缩。结论：早期诊断是肢体抢救成活的关键，损伤动脉应尽可能在6—8h内进行修复，根据不同的损伤类型，分别采用不同的血管修复方法。积极治疗多发伤、及时处理并发症。     

人造血管移植修复四肢动脉损伤

１９８７年６月￣１９９４年６月，在收治的１２８例四肢主要动脉损伤中，有２０例采用国产高分子涤纶人造血管移植修复血管缺损。１８例为急诊手术，２例为次期手术。其中髂外动脉１例，股动脉１５例，Ｇｕｏ动脉２例，肱动脉２例。修复血管缺损长度为３．０￣１２．０ｃｍ。其中２例为采用自体大隐静脉移植失败病例。修复后的近期通畅率为１００％，远期通畅率为９５％。讨论了血管损伤的诊断、人造血管的特点及手术注意事项等。     

不同长度自体静脉移植对修复动脉缺损早期影响的实验研究

本研究通过动物实验，观察不同长度自体静脉移植对修复动脉缺损早期的影响。将兔自体耳静脉分别取８、１２、１６、２０ｍｍ移植到自体股动脉，修复动脉缺损。８周时，行肉眼观察，电磁血流量测量，光镜和电镜下观察移植静脉的组织学及超微结构的变化，综合判断自体静脉移植的长度因素对血管近期通畅率和血管功能的影响，结果表明：（１）静脉移植长度因素对早期血管通畅率不构成影响（Ｐ值＞０．０５）。（２）自体静脉移植后血管口径增大，静息状态下血流量增加（Ｐ值＜０．０５）。（３）形态学观察，静脉移植后该段静脉有明显的动脉化趋势，内皮细胞修复管腔面，中膜平滑肌层数增多，弹力纤维增生，仍保持血管壁的三层结构。（４）随着血管移植长度的增加，内膜增生明显，中膜胶原纤维组织增多，内皮细胞修复不完全，弹力纤维增生减少，提示：移植长度过长，可能构成对血管功能的影响。     

四肢主要血管火器伤的修复重建

目的对40例四肢主要血管火器伤患者的临床资料进行回顾性分析，总结损伤的有效救治方法。方法1986年5月-2006年11月。收治40例四肢主要血管火器伤患者。男35例，女5例；年龄16～50岁，平均31．2岁。动脉完全断裂16例，动脉部分断裂6例，动脉缺损14例，动脉血栓形成2例，假性动脉瘤2例。病程12min～20h。彻底清创、充分减压和引流，根据不同情况选择自体静脉移植25例，人造血管移植3例，血管吻合6例。血管修补4例。带血管蒂的轴型皮瓣游离移植2例。结果经抗感染、输血补液及抗凝、扩张血管等治疗，死亡1例，截肢2例，肾衰竭截肢1例，成功修复36例。伤口Ⅰ期愈合29例，Ⅱ期愈合7例。经7个月～2年随访，修复血管均恢复通血，肢端血运良好，动脉搏动正常，按英国医学会感觉运动功能评定标准：优28例，良6例，差2例。结论“生命第一、肢体第二”是四肢主要血管火器伤的救治原则，采用自体静脉或人造血管旁路移植修复可获良好效果。     

四肢主要血管损伤的显微外科修复

目的 通过对四肢主要血管损伤158例的诊治分析，探讨四肢主要血管损伤的早期诊断，提高疗效，降低截肢率。方法 应用显微外科技术修复四肢主要血管损伤158例，其中直接血管吻合88例，自体静脉移植修复32例，单纯修复38例。术后按显微外科方法监测治疗。结果 治愈145例，截肢13例，死亡1例。结论 严密观察伤肢缺血现象和综合分析临床表现对血管损伤的早期诊断至关重要，应用显微外科技术早期修复损伤血管有助于降低截肢率；缺损大于3cm应作静脉移植；术后注意骨筋膜室综合征的发生并及早切开减压是提高治愈率和功能恢复的关键。     

大隐静脉移植治疗四肢大动脉创伤性缺损（附8例报告）

目的 探讨大隐静脉移植治疗四肢大动脉创伤性缺损的处理及效果。方法 回顾性分析8例四肢大动脉创伤性缺损行自体大隐静脉移植修复的临床资料。结果 8例四肢大动脉缺损长度为3－5cm2例,5．1－8cm6例,均采用自体健侧大隐静脉倒置移植,术后移植血管通畅,肢体全部成活。经4个月－5年随访,8例的肢体情况均良好。结论 自体大隐静脉移植是修复肢体大动脉缺损的理想材料,具有取材容易、抗感染能力强、血管通畅率高等特点。     

四肢血管损伤晚期并发症的显微外科治疗

[目的]回顾四肢血管损伤晚期并发症一动脉瘤、动静脉瘘、动脉栓塞的治疗疗效。[方法]采用动脉瘤、动静脉瘘切除后血管直接吻合；动脉瘤、动静脉瘘切除后血管缺损，动脉栓塞两断端自体静脉移植吻合；髂外动脉栓塞股动脉健侧与患侧耻骨联合上大隐静脉搭桥术。[结果]64例病人术后随访了50例，都有不同程度的症状改善。[结论]四肢血管损伤晚期并发症应用显微外科治疗可获得理想疗效。     

Biomechanical effect of major extremity vessels in choosing repair methods for peripheral artery injury

Objective： To investigate the biomechanical effect of major extremity vessels to choose appropriate repair methods for vascular injuries of the extremities. Methods ： The data of 385 patients （337 males and 48 females, aged 18-71 years, mean = 32.6 years ） including 403 injured vessels, who suffered from vascular injuries of the extremities and were treated in our hospital from October 1960 to August 2005, were studied retrospectively in this article. We compared the results of different repair methods for the defect of vessels and evaluated different injured vessels for repairing arterial injuries with anastomosis and venous graft, respectively. Results： A significant difference was found between the defect lengths of the arteries repaired with anastomosis and venous graft （ P 〈 0. 0001 ）. The upper limits of the confidence interval in the defect lengths of the brachial artery, the femoral artery and the popliteal artery were 3.43 cm, 2. 38 cm and 2. 42 cm, respectively, when repaired with anastomosis. The lower limits were 2.16 cm, 2.16 cm and 1. 63 cm, respectively, when repaired with venous graft. The defect length of each artery repaired with venous graft had linear correlation with the graft length. Conclusion - Because of the longitudinal biomechanical difference of different options of repair arterial injuries. human peripheral vessels, are necessary for different arterial injuries.     

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。     

自体静脉移植修复四肢陈旧性动脉损伤

目的 探索动脉损伤距修复时间的长短对血管通畅率、末梢血循环及功能的影响,为陈旧性动脉损伤的临床修复提供依据.方法 在自体静脉移植修复家兔陈旧性动脉损伤的实验研究的基础上,1995年4月～1997年12月采用自体大隐静脉修复陈旧性动脉损伤16例,按损伤时间组(<3个月与>3个月)分期随访检测.结果 本组病例通畅率100%,总有效率91.57%,其中痊愈率78.31%.经统计学处理,修复后远端皮温的恢复、血流量的改善、血流阻力指数(RI)及疗效对比,<3个月组显著优于>3个月组(P<0.01).其改善程度梯度:肱动脉>尺动脉>挠动脉.结论 动脉损伤距修复时间的长短对血管通畅率不构成影响,对远端血循环及功能与结构的改善有明显影响.陈旧性动脉损伤的修复应尽早(力争3个月内)进行,以达到功能与结构的满意恢复,其中肱动脉、尺动脉的修复尤为重要.     

Treatment of limb arterial in juries caused by traffic accidents

Objective:To analyze the features,diagonosis and treatment of limb arterial injuries caused by traffic accidents.Methods:A total of 43 patients with limb arterial injury admitted in our department over the past 30years(about50%of them happened during the last10 years)were analyzed retrospectively in this article.The popliteal,femoral and brachial arteries were mainly involved,accounting for 432%,20.5%and20.5%respectively of all the involvements.There were 35cases of open injury and9of close injury,The involved vessels were transected in 43.2%of the cases and contused in 40.9%,All the patients had various complications,such as fractures,dislocations and severe soft tissue injuries.The injured vessels were repaired by means of end-to-end anastomosis in 10cases,autogenous vein graft in 23cases and intraluminal hydraulic dilatation in 4cases.Results:Successful limb salvage was achieved in 34cases initially,whereas10amputations were carried out due to injuries to popliteal arteries in7,femoral arteries in2and humeral artery in 1and severe soft tissue damages in9 cases.Twenty-nine patients were followed up for 1-156months,with the averageof48.8months.There was good circulation in 22 cases and certain ischemia in 5cases.Two amputations were carried out in the late stage because of popliteal artery thrombosis after repair in 2cases.There was no death in this series.Conclusions:The limb arterial injuries caused by traffic accidents are severe and complicated.It is proposed that particulatr attentions should be paid to the features in diagnosis and treatment for this type of injury and special efforts should be made for both life saving and limb salvage.     

Surgical experience with expanded polytetrafluoroethylene (PTFE) as a replacement graft for traumatized vessels.

With the increased nationwide incidence of major vascular injuries, the need for interposition grafting has become quite common in major trauma centers. Despite extensive experience with such injuries, the choice of a substitute conduit remains controversial. Recent studies have demonstrated the potential of expanded polytetrafluoroethylene (PTFE) as a replacement graft for small arteries and veins. The surgical services at the Ben Taub General Hospital began to use PTFE grafts in traumatic vascular wounds approximately 2 years ago. Eight axillary arteries and 12 brachial arteries have had interposition grafting with PTFE prostheses. Eleven patients have required PTFE interposition grafts in repair of traumatized common, superficial, and profunda femoris arteries and common femoral veins; eight patients had reconstruction in the popliteal artery or vein. Three patients had renal artery revascularization procedures following blunt abdominal trauma, three patient had segmental replacement of the superior mesenteric artery following gunshot wounds, and one carotid artery, one iliac vein, and two axillary veins were grafted with PTFE. All patients with segmental repair of axillary, brachial, femoral, and popliteal vessels have maintained good distal pulses and viable extremities. No grafts have thrombosed, nor become infected, in spite of soft-tissue injury encountered at time or repair. In situations requiring interposition graft placement for reestablishment of distal flow in small arteries and veins, PTFE grafts appear to be an acceptable prosthesis.     

The problem of vascular shotgun injuries: Diagnostic and management strategy

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.     

A temporary arteriovenous shunt (Scribner) in the management of traumatic venous injuries of the lower extremity

The use of a temporary arteriovenous shunt distal to the repair of a traumatic venous injury of the lower extremity in eight patients is reported. Three patients sustained injury to the superficial femoral vein, three had common femoral vein injuries, one had a through-and-through injury of common iliac vein, and one had a popliteal venous injury. Seven patients had associated arterial injuries. Venous repairs included four vein patches, two end-to-end anastomoses, a single venography, and one autogenous vein interposition graft. At the end of each operation, a distal A-V shunt utilizing the posterior tibial artery and vein was constructed. In two patients the shunt clotted within hours after insertion and could not be reopened. In the remaining six patients, the temporary A-V shunt was left in place an average of 10 days (range, 3-15). Followup venograms obtained 2 to 15 days postoperatively revealed patent venous repairs in all patients whose shunt remained functional for 72 hours or more. Noninvasive Doppler studies were obtained in four patients 3 to 8 months post repair and revealed no evidence of deep venous obstruction. No patient with a functioning distal A-V shunt had significant limb edema following repair. This technique appears to improve patency rates of venous repairs and has several distinct advantages over previously described A-V anastomotic fistulas.     

Modification of pedicle lengthening through perforator transposition in free anterolateral thigh flaps with pedicle size discrepancy: A case report

In spite of thorough presurgical planning, emergency situations requiring longer pedicle length may arise during anterolateral thigh (ALT) free flap surgeries. While performing vessel graft for pedicle lengthening, discrepancy may occur because of a certain genetic predisposition or vascular variation at the anastomosis site of the graft vessel and the flap pedicle. A 76‐year‐old male patient with neurofibromatosis type I had a 15 x 10 cm defect, which was caused by radical excision of a malignant peripheral nerve sheath tumor on his back. A 15 x 10 cm sized free ALT flap was obtained. The distance between the recipient vessels and the defect area was 20 cm. The diameters of vessels in the harvested flap were as follows: proximal end of the descending branch of the lateral circumflex femoral artery (LCFA)—artery/vein: 3.0/2.5 mm, distal end of the descending branch of the LCFA—artery/vein: 1.0/1.0 mm, and perforator in the ALT flap—artery/vein: 0.8/1.0 mm. The conventional method requires transfer of the distal portion of the LCFA (below the bifurcation) which mandates us to perform anastomoses with a vessel diameter discrepancy of 2 mm. As an alternative, a bifurcating perforator‐including flap was transposed to the most distal part of the descending branch of the LCFA. An ALT flap with a pedicle having a total length of 20 cm was constructed. The flap survived without any complications. This technique may provide an option for resolving size discrepancy between the graft vessel and the ALT pedicle.     

Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts

Traumatic limb injuries requiring free tissue transfer for coverage, often lack healthy recipient vessels adjacent to the defect. In these patients, vein grafts are required to bridge the gap of either the artery, vein or both. For the latter situation, a temporary arteriovenous fistula (AVF) can be created and allowed to mature and then divided and used as recipient artery and veins for the free flap. These cases are challenging and several variables including vein graft length, vein graft diameter, and arterial inflow affect the patency of the vessels and the final outcome of the reconstruction. Sixty-five defects were reconstructed with free tissue transfers using vein grafts of significant length (>20 cm for the arterial gap). The ipsilateral or contralateral great saphenous veins were used for vessel lengthening in all cases. Inflow arteries were either major arteries (superficial femoral, popliteal or brachial), or lesser arteries (sural, anterior or posterior tibial, thoracodorsal, or superior gluteal). The patients were divided into those that underwent AVF followed by free tissue transfer in two stages (n = 6), AVF followed by free tissue transfer in one stage (n = 28) and patients that underwent vein grafting for the arterial defect only with (n = 6) or without (n = 25) a simultaneous bypass graft for lower limb revascularization. In the two-stage AVF group, the rate of occlusion of the graft after AVF creation was 50% (3/6); re-exploration rate was 33.3% (2/6); free flap failure rate was 33.3% (2/6); and limb salvage rate was 83.3% (5/6). In the one-stage AVF group: re-exploration rate was 28.6% (8/28); free flap success rate was 89.3% (25/28); and limb salvage rate was 92.9% (26/28). In the long vein graft group for arterial defects only: re-exploration rate was 25.8% (8/31); free flap success rate was 96.8% (30/31); and limb salvage rate was 87.1% (27/31). In patients where the graft was anastomosed to a major artery the re-exploration rate and free flap failure rate were 22.4% (11/49) and 8.2% (4/49). In patients where the graft was anastomosed to a lesser artery, the re-exploration rate and free flap failure rate were 43.4% (7/16) and 12.5% (2/16). The limb salvage rate was comparable in both groups (89.8%, 44/49, versus 87.5%, 14/16). In all groups, patients undergoing re-exploration were noted to have a an arterial gap of 31.78 cm as compared with the patients that did not require re-exploration which had an arterial gap of 26.26 cm. Vein grafting for bridging vascular defects is a safe procedure when proper indications and techniques are followed. Although a longer graft length seemed to be associated with a higher re-exploration rate, there was no statistical significance. One-stage AVFs can be used with good results, however, two-stage AVFs are associated with a high graft occlusion rate, wound failure rate and limb amputation rate. In all cases, a large caliber graft such as the great saphenous vein provided a large (relatively low resistance) conduit for bridging the defect.     

Injuries of large vessels in high stage neuroblastoma surgery. A case report

Complete resection of the primary lesion in stage III neuroblastoma improves survival Neuroblastoma has a tendency towards surrounding and infiltrating the large vessels, leading to injuries during tumor resection. We operated on a stage III neuroblastoma, which resulted in the right and left common iliac artery and vein damage. The right common iliac artery and, veins were repaired by end to end anastomosis. There was a long gap between the two ends of the left common iliac artery and it was repaired using a mesenteric vein (marginal vein of the colon) graft. Digital subtraction angiography performed 6 months after the operation did not reveal any stenosis or aneurysmatic changes in the anastomoses. We conclude that short segments of large vessels may be sacrificed during the resection of neuroblastomas invading the vessel wall, and the resulting defects may be repaired by end to end anastomosis, or even by substituting mesenteric vein grafts, for the purpose of total or near total removal