肝移植术后脾动脉盗血综合征的诊断和防治  

Diagnosis, prophylaxis and treatment of splenic arterial steal syndrome after orthotopic liver transplantation

作　　者：邹卫龙[1] 张薇[2] 任秀昀[3] 曾镕[4] 陈新国[1] 沈中阳[1] 

机构地区：[1]武警总医院肝移植和肝胆胰外科,北京100039 [2]武警总医院检验科,北京100039 [3]武警总医院超声诊断科,北京100039 [4]武警总医院放射介入治疗科,北京100039

出　　处：《中华肝胆外科杂志》2015年第6期382-387,共6页Chinese Journal of Hepatobiliary Surgery

基　　金：科技部863计划资助项目（2012AA021006）;武警总医院临床创新项目（WZ2014030）

摘　　要：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.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 importan

关 键 词：脾动脉盗血综合征 肝移植 血管并发症 肝动脉 低灌注 缓冲效应 

分 类 号：R743.310.4[医药卫生—神经病学与精神病学]