CAJ | 학술논문

目的探讨肝移植术后脾动脉盗血综合征(SASS)的诊断标准、预防规范、治疗手段及其临床效果.方法 2004年1月至2013年12月,在武警总医院收治的全部1 385例肝硬化肝移植患者中,有318例(23.0％)为术前脾脏增大且脾动脉(SA)口径肝总动脉(CHA)口径比值≥1.5的SASS高风险患者.术中针对多普勒超声(DUS)肝动脉血流迟缓(＜30 cm/s)甚或没有血流对患者采用预防性脾动脉环阻(干预组,127例,39.9％),与其余191例(对照组)比较,观察其预防SASS效果及安全性.对发生SASS的患者根据发生时机和程度分别采取脾动脉栓塞(SAE)、脾动脉结扎(SAL)、脾脏切除(SPT)、肝动脉与腹主动脉重建(HTA)或再次肝移植手术(re-OLT).结果干预组患者预防性脾动脉环阻后CHA血流量[环阻前(19.3±5.5) cm/s、环阻后(45.9 ±9.1)cm/s,P＜0.05]立即改善,阻力指数(RI)全部恢复到正常水平(0.5 ～0.8),无SASS发生、也未观察到其他动脉或胆道相关并发症.对照组发现SASS 17例(8.9％):5例急诊实施脾动脉栓塞CHA血流立即改善;12例患者(含11例继发肝动脉血栓形成)分别HTA(4例)、SAL(3例)、SPT(5例);其中3例接受再次肝移植;2例因肝功能衰竭死亡.结论 SASS是肝移植术后严重并发症,高风险患者预防性脾动脉环阻具有可靠的疗效和安全性,及时诊断移植物早期SASS并实施脾动脉栓塞是有效的补救措施.
목적 탐토간이식술후비동맥도혈종합정(SASS)적진단표준、예방규범、치료수단급기림상효과.방법 2004년1월지2013년12월,재무경총의원수치적전부1 385례간경화간이식환자중,유318례(23.0％)위술전비장증대차비동맥(SA)구경간총동맥(CHA)구경비치≥1.5적SASS고풍험환자.술중침대다보륵초성(DUS)간동맥혈류지완(＜30 cm/s)심혹몰유혈류대환자채용예방성비동맥배조(간예조,127례,39.9％),여기여191례(대조조)비교,관찰기예방SASS효과급안전성.대발생SASS적환자근거발생시궤화정도분별채취비동맥전새(SAE)、비동맥결찰(SAL)、비장절제(SPT)、간동맥여복주동맥중건(HTA)혹재차간이식수술(re-OLT).결과 간예조환자예방성비동맥배조후CHA혈류량[배조전(19.3±5.5) cm/s、배조후(45.9 ±9.1)cm/s,P＜0.05]립즉개선,조력지수(RI)전부회복도정상수평(0.5 ～0.8),무SASS발생、야미관찰도기타동맥혹담도상관병발증.대조조발현SASS 17례(8.9％):5례급진실시비동맥전새CHA혈류립즉개선;12례환자(함11례계발간동맥혈전형성)분별HTA(4례)、SAL(3례)、SPT(5례);기중3례접수재차간이식;2례인간공능쇠갈사망.결론 SASS시간이식술후엄중병발증,고풍험환자예방성비동맥배조구유가고적료효화안전성,급시진단이식물조기SASS병실시비동맥전새시유효적보구조시.
Objective To study the diagnosis,prophylaxis and treatment of splenic artery steal syndrome (SASS),and to evaluate their clinical outcomes in recipients who underwent orthotopic liver transplantation (OLT).Methods 1 385 consecutive patients who suffered from liver cirrhosis and had undergone OLT in our hospital between Jan,2004 and Dec,2013 were studied.We hypothesized that patients were at risk of SASS when the calibre of the splenic artery (SA) was 1.5 times larger than the common hepatic artery (CHA) together with splenomegaly (318 patients,23.0％).Further surveillance with Doppler ultrasound (DUS) was carried out immediately at CHA reperfusion during operation.When a sluggish peak systolic velocity (PSV) ＜ 30 cm/s or no flow was detected in a patent hepatic artery,prophylactic SA banding (SAB) was considered.127 patients (39.9％) who fulfilled these criteria were recruited to the intervention group to undergo SAB.Eventually,patients who developed SASS were treated with coil-embolization of the SA (SAE),re-anastomosis of the HA to aorta (HTA),ligation of SA (SAL) or splenectomy (SPT),or retransplantation.Results SAB resulted in immediately increase in the mean PSV of the HA from 19.3 ±5.5 cm/s to 45.9 ± 9.1 cm/s (P ＜ 0.05),and resistance index (RI) of the HA rehabilitated to reasonable levels (0.5 ～0.8),without any HA or biliary related complication in all the 127 patients.17 patients in the control group were identified to have SASS (8.9％).5 of these 17 patients required emergency treatment by coil-embolization.Of the remaining 12 patients,11 who developed hepatic artery thrombosis secondary to SASS required to undergo embolectomy or thrombolysis followed by HTA (4 patients),SAL (3 patients),SPT (5 patients).Three of these patients finally required re-OLT.All these patients obtained acceptable results by these salvage strategies,except 2 out of the 12 patients who died from liver failure.Conclusions SASS is an important but it is often and under-diagnosed cause of graft ischemia after OLT.Prophylactic SAB should be introduced to patients at risk of developing SASS in order to obtain satisfactory results.Coil-embolization of SA shortly after diagnosis is an effective salvage intervention to prevent further progression to develop devastating consequences.