CAJ | 학술논문

目的总结放置腔静脉滤器预防根治性肾切除和下腔静脉(IVC)瘤栓取出术中肺栓塞的经验. 方法回顾性分析2008年1月至2011年4月20例恶性肾肿瘤合并IVC瘤栓的患者资料.患者术前均放置腔静脉滤器,其中经颈内静脉或股静脉途径放置Tempofilter滤器8例,CookTulip滤器7例,国产Aegisy可回收滤器5例,滤器放置当日或1～11d后手术.行单纯根治性肾切除4例,其中T4N0M0期(瘤栓Ⅲ级)1例,T3bN2M0(瘤栓Ⅱ级)1例,T3cN0M0期(瘤栓Ⅳ级)2例；2例T4N2M0期肿瘤(瘤栓Ⅱ级)行剖腹探查+活检术；根治性肾切除+ IVC切开取栓术14例.18例术后1～14 d拔除滤器.对滤器放置方法、取栓技术和相关并发症进行讨论. 结果 20例患者均未发生肺栓塞或与放置滤器有关的并发症.术中输血10例,输血量500 ～ 5000 ml[(1930±1405) ml].IVC阻断不完全、腰静脉等侧支静脉开放是术中失血的重要原因.术后并发急性肾衰竭1例,下肢深静脉血栓1例,拔除滤器当天发生肺栓塞1例,3例均与软血栓栓塞有关,经抗凝等保守治疗治愈.结论放置腔静脉滤器可以有效防止根治性肾切除和IVC取栓术中肺栓塞并发症的发生.该法安全易行、移除方便,对于0级以上、合并软血栓和侧支循环开放的高危患者,可作为常规预防措施.出血是取栓术最常见的并发症,充分游离并阻断瘤栓上、下方IVC、避免侧支静脉损伤是减少输血量的关键.
목적 총결방치강정맥려기예방근치성신절제화하강정맥(IVC)류전취출술중폐전새적경험. 방법 회고성분석2008년1월지2011년4월20례악성신종류합병IVC류전적환자자료.환자술전균방치강정맥려기,기중경경내정맥혹고정맥도경방치Tempofilter려기8례,CookTulip려기7례,국산Aegisy가회수려기5례,려기방치당일혹1～11d후수술.행단순근치성신절제4례,기중T4N0M0기(류전Ⅲ급)1례,T3bN2M0(류전Ⅱ급)1례,T3cN0M0기(류전Ⅳ급)2례；2례T4N2M0기종류(류전Ⅱ급)행부복탐사+활검술；근치성신절제+ IVC절개취전술14례.18례술후1～14 d발제려기.대려기방치방법、취전기술화상관병발증진행토론. 결과 20례환자균미발생폐전새혹여방치려기유관적병발증.술중수혈10례,수혈량500 ～ 5000 ml[(1930±1405) ml].IVC조단불완전、요정맥등측지정맥개방시술중실혈적중요원인.술후병발급성신쇠갈1례,하지심정맥혈전1례,발제려기당천발생폐전새1례,3례균여연혈전전새유관,경항응등보수치료치유.결론 방치강정맥려기가이유효방지근치성신절제화IVC취전술중폐전새병발증적발생.해법안전역행、이제방편,대우0급이상、합병연혈전화측지순배개방적고위환자,가작위상규예방조시.출혈시취전술최상견적병발증,충분유리병조단류전상、하방IVC、피면측지정맥손상시감소수혈량적관건.
Objective To summarize the experience of implantation of inferior vena cava (IVC) filter for pulmonary embolism prevention during radical nephrectomy and IVC thrombus resection for malignant renal tumor.Methods Total 20 patients with malignant renal tumor and IVC tumor thrombus were performed IVC filter implantation via superior vena caval approach (right internal jugular vein) or right femoral vein approach from January 2008 to April 2011,including Tempofilter (B.Braun Medical Inc,USA) in 8 cases,Cook Tulip (Cook company,USA) in 7 cases and Aegisy temporary IVC filter (Shenzhen,China) in 5 cases.The filter was inserted at the morning of surgery or 1-11 days prior to nephrectomy under local anesthesia.Radical nephrectomy was performed in 4 cases,including 1 T4N0M0 (tumor thrombus level grade Ⅲ),1 T3bN2M0 (grade Ⅱ),and 2 T3cN0M0 (grade Ⅳ).Laparotomy and biopsy were done in 2 cases whose tumors were T4N2M0 (grade Ⅱ),and radical nephrectomy plus IVC thrombus resection were done in the other 14 cases.IVC filters were removed 1-14 days after operation in 18 cases or remain indwelling in 2 cases.The methods of filter implantation,technique of nephrectomy and IVC thrombus resection and complications were discussed.Results There were no complications related to the filter implantation or intraoperative pulmonary embolism occurred.The intraoperation blood transfusion were required in 10 patients (50％),and amount ranged from 500-5000 ml,with mean (1930 ± 1405) ml.Incompletely IVC control and unrecongnized venous branches such as lumbar veins were the important risk factor of blood loss.Postoperative acute renal failure and deep femoral vein thrombosis occurred in 1 patient.Pulmonary embolism occurred in 1 case in the day of IVC filter removed.All these postoperative complications were relative with bland thrombus and cured by conservative methods such as anticoagulation.Conclusions The IVC filter is effective in preventing pulmonary embolism during resection of renal tumor and IVC tumor thrombus.It could be insert and removal easily and securely,and appropriate for level ＞0 thrombus,especially for those who has bland thrombus and venous branches.Hemorrhage was the most frequent perioperative complication.The complete clamping of the IVC Inferior or superior to tumor thrombus,or keeping the vein branches from divulsion can decrease blood loss.