破裂性腹主动脉瘤的处理及影响预后的因素

摘要：目的 探讨破裂性腹主动脉瘤及时有效的诊断方法、治疗措施及影响预后的主要因素。方法 回顾分析6年间收治的15例破裂性腹主动脉瘤的临床资料。临床表现为腹痛和/或腰背痛, 血压下降或休克，腹部可触及搏动性肿块。8例行DSA和/或sCTA检查确诊，２例彩色多普勒超声检查提示腹主动脉瘤破裂，２例破裂前明确有腹主动脉瘤病史，３例剖腹探查发现。所有患者均行手术治疗。13例成功钳夹腹主动脉瘤颈上端的主动脉（4例在膈肌下方阻断，9例在肾动脉下阻断）控制出血，行人工血管重建。结果 术中和术后死亡7例（46.67%）：２例破入游离腹腔，打开腹腔后失血过多死于术中；1例术后5d死于心肌梗死；2例分别于术后3d和7d死于呼吸衰竭；２例术后４d及８d死于急性肾衰竭。其余病例未出现严重并发症。结论 对同时有突发性腹痛和/或腰背痛、血压下降或休克、腹部搏动性肿块三联征的患者可明确诊断；CT、多普勒超声等检查适于生命体征相对稳定的疑似病例。手术是治疗的有效方法；选择不同的阻断破裂口近端腹主动脉以控制出血是手术的关键。破入游离腹腔或并发急性心肌梗死、急性肾衰竭和肺部并发症者，预后不佳。

Prognostic factors and management of ruptured abdominal aortic aneurysm

Objective To discuss the diagnostic methods and management of ruptured abdominal aortic (aneurysm)(AAA) and to analyse the main factors that influence prognosis.Methods The clinical data of 15 cases of ruptured infrarenal AAA treated in our hospital from 1998~2004 were retrospectively analysed. The main clinical manifestations were abdominal pain and/or back pain,low blood pressure or shock, and (pulsating) abdominal mass. 8 cases were diagnosed by DSA and/or sCTA; Doppler ultrasonic examination (suggested) rupture of abdominal aortic aneurysm in 2 cases; 2 cases had known history of AAA prior to (rupture); and 3 cases were diagnosed during operation. All of the patients underwent surgical operation. (Successful) clamping of the abdominal aorta above the neck of AAA was accomplished in 13 cases. Of these, the aorta was occluded below the diaphragm in 4 cases, and below the renal arteries in 9 cases.Results Seven cases(46.6%) died in the perioperative period. 2 died of blood loss from aneurysm that ruptured into the free abdominal cavity, 1died of myocardial infarction 5 days postoperatively, 2 died of respiratory failure 3 days and 7 days postoperatively, and 2 died of renal failure 4 days and 8 days after operation. Severe (complications) did not develop in the remaining patients.Conclusions Patients who present with the trilogy of abdominal pain and/or back pain, low blood pressure or shock and pulsating abdominal mass can be (diagnosed) easily. CT and Doppler ultrasonic examination are indicated for patients with questionable diagnosis and have stable vital signs. Operation is effective treatment for ruptured AAA. The crux of the operation is to mack an aortic occlusion proximal to the site of rupture of aorta to effectively control bleeding. Patients with rupture of AAA into the free peritoneal cavity or those with acute myocardial infarction, acute renal failure or respiratory complications had poor prognosis.