颈部血管大出血分型与救治方法分析  

Analysis of types and treatment methods of cervical massive hemorrhage

作　　者：吴鉴今 向斌[2] 柏骏 李文波 刘英军[4] 向华[2] 曲乐丰 Wu Jianjin;Xiang Bin;Bai Jun;Li Wenbo;Liu Yingjun;Xiang Hua;Qu Lefeng(Department of Vascular&Endovascular Surgery,Changzheng Hospital Affiliated to Naval Medical University,Shanghai 200003,China;Department of Interventional Vascular Surgery,Hunan Provincial People′s Hospital,Changsha 410005,China;Department of Vascular&Endovascular Surgery,Longkou People′s Hospital,Longkou 265701,China;Department of Cardiovascular Surgery,Laizhou People′s Hospital,Laizhou 261400,China)

机构地区：[1]海军军医大学附属长征医院血管外科,上海200003 [2]湖南省人民医院介入血管外科,长沙410005 [3]山东省龙口市人民医院血管外科,龙口265701 [4]山东省莱州市人民医院心脏血管外科,莱州261400

出　　处：《中华医学杂志》2021年第29期2283-2287,共5页National Medical Journal of China

基　　金：上海市优秀学术带头人基金(20XD1404900);长征医院军事医学科研专项重点项目(2019CZJS101)。

摘　　要：目的总结多中心颈部血管大出血病例分型与临床救治经验。方法回顾性分析2012年4月至2020年10月国内多中心收治的42例颈部血管大出血患者的临床资料,其中上海长征医院27例,湖南省人民医院7例,龙口市人民医院4例,莱州市人民医院4例。根据出血部位(position,P)、出血血管(vessel,V)、头向供血(cerebral,C)以及有无合并伤(associated,A)对42例患者进行PVCA分型,并总结基于解除气道压迫(airway rebuild,A)、有效动脉止血及血运重建(bleeding stop,B)以及时间窗内恢复大脑血供(cerebral blood flow reconstruction,C)的ABC救治原则指导下的院前急救和院内治疗的方法。结果42例颈部血管大出血患者中,P1型(环状软骨以下)3例,P2型(环状软骨-下颌角)28例,P3型(下颌角-颅底)11例;V1型(大动脉性出血)22例,V2型(大静脉性出血)11例,V3型(单纯浅表静脉或细小动脉出血)7例,V4型(动静脉混合出血)2例;C0型(无头向缺血及头颅神经功能障碍表现)5例;C1型(有头颅一过性缺血表现、但无肢体感觉障碍)33例,C2型(存在头颅缺血、神经功能障碍表现)4例;A0型(不合并其他系统损伤)39例,A1型(合并其他系统损伤)3例。42例患者均接受手术,25例行开放手术血管重建修复+血肿/异物清除(7例血管结扎、14例直接缝合修补、4例血管间置),17例接受复合手术治疗(颈动脉造影+覆膜支架腔内修复+血肿/异物清除)。手术成功率为100%,失血性休克均得到纠正,血肿压迫全部解除,头向缺血症状改善。围手术期局部颅神经损伤4例,切口血肿1例,术后高灌注表现6例。平均随访14.3个月,未发生与手术相关的心肌梗死、脑卒中或死亡,无再次破裂、夹层发生。1例行覆膜支架腔内修复患者于术后1年发现50%无症状再狭窄。结论基于“PVCA”分型及“ABC”救治原则,可安全、有效地用于颈部血管大出血的救治。Objective To summarize the classification and clinical treatment experience of cervical massive hemorrhage in multiple centers.Methods From April 2012 to October 2020,clinical data of 42 patients with cervical massive hemorrhage were retrospectively analyzed,including 27 cases from Shanghai Changzheng Hospital,7 cases from Hunan Provincial People′s Hospital,4 cases from Longkou People′s Hospital and 4 cases from Laizhou People′s Hospital.According to bleeding position(P),bleeding vessel(V),cerebral blood supply(C),and the presence or absence of associated injury(A),42 patients were classified as"PVCA",and summarize the methods of pre-hospital emergency and in-hospital treatment based on the"ABC"treatment principles:airway rebuild(A),effective arterial hemostasis and bleeding stop(B),and cerebral blood flow reconstruction within the time window(C).Results Within the 42 cases of cervical massive hemorrhage,there were 3 cases of type P1(below cricoid cartilage),28 cases of type P2(cricoid cartilage-mandibular angle),11 cases of type P3(mandibular angle-skull base);22 cases of type V1(arterial hemorrhage),11 cases of type V2(main venous hemorrhage),7 cases of type V3(simple superficial vein or small artery hemorrhage),2 cases of type V4(mixed arteriovenous hemorrhage);5 cases of type C0(no symptoms of cerebral ischemia and neurological dysfunction),33 cases of type C1(transient cerebral ischemia without sensory disturbance),4 cases of type C2(symptoms of cerebral ischemia and neurological dysfunction);39 cases of type A0(no other system damage was involved)and 3 cases of type A1(combined with other system damage).All 42 patients received operations,25 patients received open surgery of vascular reconstruction+hematoma/foreign body removal(7 cases of vascular ligation,14 cases of direct suture repair,4 cases of vascular interposition),17 patients received hybrid surgery(carotid angiography+covered stent repair+hematoma/foreign body removal).The surgical technique success rate the was 100%.All the hemorrhagic shoc

关 键 词：颈部损伤 血管 出血 PVCA分型 ABC救治原则 

分 类 号：R654.3[医药卫生—外科学]