经皮肾镜术中误入下腔静脉伴血栓形成一例并文献复习

目的探讨经皮肾镜碎石取石术（percutaneous nephrolithotomy, PCNL）中穿刺误入下腔静脉，留置肾造瘘管后出现下腔静脉血栓的处理办法。 方法结合文献复习，回顾性分析2017年5月我院收治的1例左肾铸型结石患者的临床资料。患者男，59岁，于全麻下行左PCNL。术中穿刺建立通道后出血汹涌，视野不清，中止手术，留置并夹闭肾造瘘管。术后第3日复查CT提示肾造瘘管经左肾静脉、下腔静脉至肝脏，下腔静脉内血栓形成。行经皮下腔静脉及左肾动脉造影，置入下腔静脉滤器及溶栓导管，透视监视下拔出左肾造瘘管。 结果拔出肾造瘘管后，患者无不良反应，血流动力学状态稳定，反复经导管造影，未见造影剂外溢。经溶栓治疗后，术后第11日再次行下腔静脉造影未见充盈缺损，顺利回收滤器。 结论PCNL术中穿刺误入下腔静脉，留置肾造瘘管伴下腔静脉血栓形成时，在血管造影辅助下分步缓慢拔出肾造瘘管并行溶栓治疗的方法安全、可靠，可避免外科手术的二次伤害及血栓相关并发症的发生。

Intravenous misplacement of nephrostomy tube with inferior vena cava thrombosis following percutaneous nephrolithotomy: a case report and literature review

ObjectiveTo investigate the management of intravenous misplacement of nephrostomy tube with thrombosis of the inferior vena cava in patient underwent percutaneous nephrolithotomy. MethodsCombined with literature review, the clinical data of 1 case with left kidney cast stone admitted to our hospital in May 2017 was analyzed retrospectively. The male patient aged 59 years. Left side PCNL was performed under general anesthesia. After puncture and establishment of the channel, the field of vision was unclear due to excessive bleeding, we immediately discontinued the surgery, inserted and closed the nephrostomy tube. CT reexamination on the 3rd day after surgery indicated that the nephrostomy tube reached the liver via the left renal vein and inferior vena cava, and thrombosis in the inferior vena cava occurred. Subcutaneous vena cava and left renal artery angiography were performed, and inferior vena cava filter and thrombolytic catheter were inserted, and the nephrostomy tube was extracted under fluoroscopic monitoring. ResultsAfter the extraction of nephrostomy tube, the patient had no adverse reactions, hemodynamic status was stable, repeated transcatheter angiography showed no extravasation of contrast agent. After thrombolytic therapy, no filling defect was found in inferior vena cava when angiography performed again on the 11th day after surgery, and the filter was recovered successfully. ConclusionsIn percutaneous nephrolithotomy, when nephrostomy tube was intravenous misplaced and with thrombosis of the inferior vena cava, with the help of angiography, the method of gradual and slow extraction of renal tubule and thrombolytic therapy is safe and reliable, which can avoid the secondary injury of surgery and the occurrence of thrombotic related complications.