腔内隔绝术治疗胸主动脉夹层动脉瘤对心肝肾功能的影响
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摘要
目的：通过比较胸主动脉夹层动脉瘤腔内隔绝术治疗前后的心肝肾功能变化，探讨腔内隔绝术对心肝肾功能的影响。
方法：螺旋CT血管造影(CTA)、磁共振造影(MRA)、数字减影血管造影(DSA)确诊胸主动脉夹层动脉瘤。根据患者影像评估的具体情况，选择合适移植物。在DSA监视、全麻气管插管下，经股动脉将带膜支架置入12例胸主动脉夹层动脉瘤，进行腔内治疗。全自动生化分析仪和超声心动图仪分别进行手术前后心肝肾功能测定。
结果：
1．肾功能测定结果：术后48-72小时与术前肌酐、尿素均无显著性差异。术后一月肌酐、尿素下降明显，肾功能有一定程度改善，与术前和术后48-72小时比较有统计学意义(P＜0.05)。
2．肝功能测定结果：术后48-72小时血清总蛋白、白蛋白、球蛋白数值明显下降，与术前比较有统计学意义(P＜0.01)，术后一月血清蛋白又回复至术前水平。手术前后总胆红素、间接胆红素无显著性差别，但直接胆红素术后48-72小时明显增加(P＜0.05)，术后一月恢复至术前水平。手术前后谷丙转氨酶、谷草转氨酶均无明显变化。
3．心功能测定结果：术后左室射血分数EF较术前明显增加(P＜0.01)，左室收缩功能得到改善；术后24-48小时和术前比较，二尖瓣舒张早期血流峰值速度E峰和E／A值无显著性差别；术后三月E峰和E／A比值均有一定程度增加，与术后24-48小时和术前比较有显著性差异(P＜0.05)，术后三月左室舒张功能也得到一定改善。
昆明医学院研究生论文
结论：带膜支架腔内隔绝术对胸主动脉夹层动脉瘤患者的心肝肾功能影响轻微。
该技术是一种适合胸主动脉夹层动脉瘤，尤其是同时合并高龄及一定脏器功能不
全患者的比较安全的微创治疗方法。
To investigate the influence of endovascular graft exclusion(EVGE) by comparing the change of the function of heart ,liver and kidney before and after the EVGE of thoracic aortic dissection (TAD, Stanford B).
Methods: Computed tomography angiography (CTA), magnetic resonance imaging (MRA)or digital subtraction angiography (DSA) were used as preoperative evaluation methods of thoracic aortic dissection aneurysm. According to the specific situation of patients, the suitable stent-grafts were selected. The stent-grafts were inserted from the femoral artery to exclude the tear of dissection of 12 cases, and all operations were performed by general anesthesia under DSA guidance. The function of heart, liver and kidney was measured before and after operation by using the automatic apparatus of serum biochemical analysis and echocardiography. Results.
1. Kidney function measurement: There was no significant difference between the parameters of creatinine (Cr) and blood urea (BU) before and 48-72 hours after operation. Cr and BU significantly decreased one month after operation (P< 0. 05).There was a certain improve on the function of heart.
2. Liver function measurement. 48-72 hours after operation, the serum contents of total protein, albumin, globulin decreased significantly and connect bilirubin , recovering the level of before operation one month after operation, increased significantly compared with those before operation. There was no significant change in the total bilirubin, unconnect bilirubin , ALT, AST, pre-and post operation. 3. Heart function measurement: EF increased significantly 24-48 hours after operation
3
compared with that of preoperation. No difference in peak of E and E/A24-48 hours after operation. Peak of E and E/A increased three months after operation too. Conclusion: EVGE has minimal influence on the function of heart, liver and kidney, and is a microinvasive theropy to treat TAD(Stanford B) with elder advanced and organ dyefunction.
方法：螺旋CT血管造影(CTA)、磁共振造影(MRA)、数字减影血管造影(DSA)确诊胸主动脉夹层动脉瘤。根据患者影像评估的具体情况，选择合适移植物。在DSA监视、全麻气管插管下，经股动脉将带膜支架置入12例胸主动脉夹层动脉瘤，进行腔内治疗。全自动生化分析仪和超声心动图仪分别进行手术前后心肝肾功能测定。
结果：
1．肾功能测定结果：术后48-72小时与术前肌酐、尿素均无显著性差异。术后一月肌酐、尿素下降明显，肾功能有一定程度改善，与术前和术后48-72小时比较有统计学意义(P＜0.05)。
2．肝功能测定结果：术后48-72小时血清总蛋白、白蛋白、球蛋白数值明显下降，与术前比较有统计学意义(P＜0.01)，术后一月血清蛋白又回复至术前水平。手术前后总胆红素、间接胆红素无显著性差别，但直接胆红素术后48-72小时明显增加(P＜0.05)，术后一月恢复至术前水平。手术前后谷丙转氨酶、谷草转氨酶均无明显变化。
3．心功能测定结果：术后左室射血分数EF较术前明显增加(P＜0.01)，左室收缩功能得到改善；术后24-48小时和术前比较，二尖瓣舒张早期血流峰值速度E峰和E／A值无显著性差别；术后三月E峰和E／A比值均有一定程度增加，与术后24-48小时和术前比较有显著性差异(P＜0.05)，术后三月左室舒张功能也得到一定改善。
昆明医学院研究生论文
结论：带膜支架腔内隔绝术对胸主动脉夹层动脉瘤患者的心肝肾功能影响轻微。
该技术是一种适合胸主动脉夹层动脉瘤，尤其是同时合并高龄及一定脏器功能不
全患者的比较安全的微创治疗方法。
To investigate the influence of endovascular graft exclusion(EVGE) by comparing the change of the function of heart ,liver and kidney before and after the EVGE of thoracic aortic dissection (TAD, Stanford B).
Methods: Computed tomography angiography (CTA), magnetic resonance imaging (MRA)or digital subtraction angiography (DSA) were used as preoperative evaluation methods of thoracic aortic dissection aneurysm. According to the specific situation of patients, the suitable stent-grafts were selected. The stent-grafts were inserted from the femoral artery to exclude the tear of dissection of 12 cases, and all operations were performed by general anesthesia under DSA guidance. The function of heart, liver and kidney was measured before and after operation by using the automatic apparatus of serum biochemical analysis and echocardiography. Results.
1. Kidney function measurement: There was no significant difference between the parameters of creatinine (Cr) and blood urea (BU) before and 48-72 hours after operation. Cr and BU significantly decreased one month after operation (P< 0. 05).There was a certain improve on the function of heart.
2. Liver function measurement. 48-72 hours after operation, the serum contents of total protein, albumin, globulin decreased significantly and connect bilirubin , recovering the level of before operation one month after operation, increased significantly compared with those before operation. There was no significant change in the total bilirubin, unconnect bilirubin , ALT, AST, pre-and post operation. 3. Heart function measurement: EF increased significantly 24-48 hours after operation
3
compared with that of preoperation. No difference in peak of E and E/A24-48 hours after operation. Peak of E and E/A increased three months after operation too. Conclusion: EVGE has minimal influence on the function of heart, liver and kidney, and is a microinvasive theropy to treat TAD(Stanford B) with elder advanced and organ dyefunction.
引文
[1] 吴清玉．心脏外科学．山东济南：山东科学技术出版社，2003．707～710
[2] Dake MD, Miller C, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms [J]. N Engl J Med, 1994, 331(26):1729～1734
[3] Kato M, Matsuda T, Kaneko M, et al. Outcomes of stent-graft treatment of false lumen in aortic dissection. Circulation, 1998,98 (19 Suppl) : 305～312
[4] Girardi LN, Bush HL. Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm. J Vasc Surg, 1999, 29:936～938
[5] Parodi JC, Palmaz JC, Barone HD, et al.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg,1991, 5:491～499
[6] 金旦年．体外循环心脏手术后早期并发症的病因．北京医学，1994，16(5)：284
[8] Behrendt P, Do D, Baumgartner I, et al. Renal artery stenting following acute dissection implantation and follow up [J].Vasa, 2000, 29 (2) : 138～140
[9] 王鸿利，等．实验诊断学．北京：人民卫生出版社，2001．118～120
[10] 张延龄．有关多器官衰竭的近代研究．实用外科杂志，1992，12：487
[11] 夏东文，等．肝功能的检查方法与评价．中国实用妇科与产科杂志，2001，17(6)：43
[12] CrawfordES, et al.The diagnosis and management of aortic dissection. JAMA, 1990, 264(19):253
[13] Zile MR, Brutsaert DL. New concepts in diastolic dysfunction diastolic heart failure: part Ⅰ.Circulation, 2002,105
[14] Little WC, Cheng CP. D iastolic dysfunction. Cardiology in Review, 1998, 6 (4): 231
[15] 徐美英，等．腔内隔绝术治疗大动脉瘤的围手术期管理．临床麻醉学杂志，2002，18(10)：54
[16] Dake, MD, kato N, Mitchell RS, et al. Endovascular stent-graft placement for the
treament of acute aortic dissection N Engl J Med,1999,340:154 6
[17] ACC?A HA Task Force. Guidelines for the evaluation and management of heart failure.Report of the American College of Cardio logy? American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation, 1995, 92:2764
[18] Tresch DD, Mc Gough MF. Heart failure with normal systolic function: A common disorder in older people. Am J Geriat tics Society, 1995, 43:103 5
[19] 于全德，等．卡托普利和吲哒帕胺对高血压患者左室肥厚和舒张功能影响的对比研究．临床心血管杂志，1993，9(1)：9
[20] Januzzi JL, Sabatine M S, Cho i JC, et al. Refractory system ichypertension following type B aortic dissection [J]. Am J Cardiol, 2001, 88 (7): 686
[21] 石光璞，等．长期高血压病人容量刺激后LVEF和血浆ANP变化．中华核医学杂志，1991，11(1)：23
[22] 景在平,Muller Wiefel H,Raithel D，等．腔内隔绝术治疗腹主动脉瘤．中华外科学杂志，1998，36(4)：212．
[23] Boyle J R, Thompson J P, Thompaon MM, et al. Improve drespiratory function and analgesia control after endovascular AAA repair. J Endovasc Surg, 1997,4(1):62.
[2] Dake MD, Miller C, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms [J]. N Engl J Med, 1994, 331(26):1729～1734
[3] Kato M, Matsuda T, Kaneko M, et al. Outcomes of stent-graft treatment of false lumen in aortic dissection. Circulation, 1998,98 (19 Suppl) : 305～312
[4] Girardi LN, Bush HL. Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm. J Vasc Surg, 1999, 29:936～938
[5] Parodi JC, Palmaz JC, Barone HD, et al.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg,1991, 5:491～499
[6] 金旦年．体外循环心脏手术后早期并发症的病因．北京医学，1994，16(5)：284
[8] Behrendt P, Do D, Baumgartner I, et al. Renal artery stenting following acute dissection implantation and follow up [J].Vasa, 2000, 29 (2) : 138～140
[9] 王鸿利，等．实验诊断学．北京：人民卫生出版社，2001．118～120
[10] 张延龄．有关多器官衰竭的近代研究．实用外科杂志，1992，12：487
[11] 夏东文，等．肝功能的检查方法与评价．中国实用妇科与产科杂志，2001，17(6)：43
[12] CrawfordES, et al.The diagnosis and management of aortic dissection. JAMA, 1990, 264(19):253
[13] Zile MR, Brutsaert DL. New concepts in diastolic dysfunction diastolic heart failure: part Ⅰ.Circulation, 2002,105
[14] Little WC, Cheng CP. D iastolic dysfunction. Cardiology in Review, 1998, 6 (4): 231
[15] 徐美英，等．腔内隔绝术治疗大动脉瘤的围手术期管理．临床麻醉学杂志，2002，18(10)：54
[16] Dake, MD, kato N, Mitchell RS, et al. Endovascular stent-graft placement for the
treament of acute aortic dissection N Engl J Med,1999,340:154 6
[17] ACC?A HA Task Force. Guidelines for the evaluation and management of heart failure.Report of the American College of Cardio logy? American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation, 1995, 92:2764
[18] Tresch DD, Mc Gough MF. Heart failure with normal systolic function: A common disorder in older people. Am J Geriat tics Society, 1995, 43:103 5
[19] 于全德，等．卡托普利和吲哒帕胺对高血压患者左室肥厚和舒张功能影响的对比研究．临床心血管杂志，1993，9(1)：9
[20] Januzzi JL, Sabatine M S, Cho i JC, et al. Refractory system ichypertension following type B aortic dissection [J]. Am J Cardiol, 2001, 88 (7): 686
[21] 石光璞，等．长期高血压病人容量刺激后LVEF和血浆ANP变化．中华核医学杂志，1991，11(1)：23
[22] 景在平,Muller Wiefel H,Raithel D，等．腔内隔绝术治疗腹主动脉瘤．中华外科学杂志，1998，36(4)：212．
[23] Boyle J R, Thompson J P, Thompaon MM, et al. Improve drespiratory function and analgesia control after endovascular AAA repair. J Endovasc Surg, 1997,4(1):62.