冠状动脉旁路移植术后应用体外膜肺氧合下肢缺血并发症的防治  

Prevention and treatment of lower limb ischemia for extracorporeal membrane oxygenation support after coronary artery bypass grafting surgery

作　　者：唐小斌[1] 侯晓彤[2] 陈忠[1] 王晓娜[1] 杨峰[2] 何楠[1] 邢家林[2] 刘丹[1] 张腾飞[1] 吴庆华[1] 

机构地区：[1]首都医科大学附属北京安贞医院-北京市心肺血管疾病研究所血管外科,100029 [2]首都医科大学附属北京安贞医院-北京市心肺血管疾病研究所体外循环,100029

出　　处：《心肺血管病杂志》2016年第7期547-550,共4页Journal of Cardiovascular and Pulmonary Diseases

摘　　要：目的:总结并分析冠状动脉旁路移植术围手术期经股动脉插管建立体外膜肺氧合(ECMO)支持治疗过程中,出现严重下肢缺血并发症的临床特点和防治经验。方法:回顾性分析我院2014年1月至2014年12月,行冠状动脉旁路移植术且经股动脉插管建立ECMO辅助治疗的41例患者,总结其临床特点,探讨严重下肢缺血并发症的发生率、病因及对ECMO治疗预后的影响以及防治措施。结果:41例患者中,18例完成ECMO脱机并顺利出院(43.9%),另23例患者病情危重,在ECMO辅助支持过程中或脱机后循环衰竭死亡(56.1%),全体患者发生重度下肢缺血者18例(43.9%)。病情好转出院的患者中,2例在术后出现显著的下肢缺血表现(11.1%),但在ECMO脱机拔管后缺血情况均得以恢复(100%)。围手术期死亡的23例患者,ECMO支持过程中循环衰竭时间长且血管活性药物用量大,16例患者出现了重度下肢缺血表现(69.6%),其中2例(12.5%)ECMO脱机者在动脉插管拔除后末梢血运得到改善,但因脱机后脏器功能逐渐衰退,家属放弃治疗。结论:冠状动脉旁路移植术患者经股动脉插管建立ECMO后发生严重下肢缺血的风险较高,对于这类高危人群,术前应优先评估、积极干预双髂动脉及双下肢动脉病变,旨在优化ECMO插管方式的选择。经股动脉插管ECMO建立后,应严密监测肢体缺血的征兆,及时进行相关处理从而降低下肢缺血并发症的发生率,提高ECMO的整体疗效。Objective： To summarize and analyze the clinical characteristics of critical limb ischemia occurred during femoral eannulation for ECMO support in the coronary artery bypass, in order to further prevent limb associated complications and improve the ECMO outcome. Methods： 41 patients with ECMO support were retrospectively reviewed during the perioperative period of their coronary artery bypass grafting （CABG） in Beijing Anzhen hospital, from Jan. 2014 to Dec. 2014. The incidence, etiology, and clinical features of critical limb ischemia complication were investigated, as well as its impact upon prognosis and prevention measures were summarized. Results： Among all the 41 patients, 18 cases （43.9%） weaned off successfully from ECMO and discharged, while other 23 patients remained in critical condition and eventually died with a mortality rate of 56. 1%. 18 patients were complicated with critical lower limb isehemia（43.9% ） in the total population. Of all the cured patients, two developed notable limb ischemia （ 11.1% ） after the surgery but fully recovered as soon as the ECMO system was removed. Among the 23 deceased patients, 16 cases presented with critical limb isehemia （69. 6% ） partly due to the uncontrollable circulatory collapse and masses of the vasoaetive agent application, and two of them （ 12. 5% ） once experienced the improvement of the blood flow in the lower limb, died at last because of multiple organs failure and the family members given up any further treatment. Conclusion： High risk of critical limb ischemia can be seen in CABG patients with ECMO established through the femoral artery. For this kind of population, it＇ s of great importance to evaluate the iliac arteries and lower limb arteries preoperatively and deal with the stenotic lesions when necessary so as to optimize ECMO implantation. As long as the ECMO system is established through the femoral artery, signs of lower limb ischemia should be kept under close surveillance. Once it happens, the timely and ap

关 键 词：冠状动脉旁路移植术 体外膜肺氧合 股动脉 下肢缺血 并发症 

分 类 号：R54[医药卫生—心血管疾病]