肠系膜上动脉支架植入后再狭窄诊疗的研究进展  

Research advances in diagnosis and treatment of in-stent restenosis after superior mesenteric artery stent implantation

作　　者：胡松杰[1] 尹孝亮 郎德海[1] HU Songjie;YIN Xiaoliang;LANG Dehai(Department of Vascular Surgery,Ningbo No.2 Hospital,Ningbo,Zhejiang 315010,China)

机构地区：[1]浙江省宁波市第二医院血管外科,浙江宁波315010

出　　处：《中国普通外科杂志》2023年第6期936-942,共7页China Journal of General Surgery

基　　金：浙江省卫生健康科技计划基金资助项目(2021KY299);浙江省宁波市医学重点学科建设基金资助项目(2022-F21)。

摘　　要：肠系膜上动脉(SMA)出现狭窄或闭塞导致血液灌注不足,引起肠组织缺血、缺氧,最终可能导致肠黏膜损伤、肠缺血坏死。解除管腔狭窄、恢复血流是避免肠坏死的重要保障。腔内支架植入术作为一种微创治疗技术,相对于开放性血运重建,具有住院时间短,降低住院并发症及死亡风险的优势,近年来已成为治疗SMA狭窄性病变的主要治疗方式之一。因该手术方式获得了良好的近期临床治疗效果,得到指南一致推荐。随着支架在临床上广泛开展使用,SMA支架植入术后支架内再狭窄(ISR)的发生逐渐引起关注,且相关研究指出,接受支架治疗的SMA狭窄患者,相对于开放性血运重建出现ISR的概率更高。因此,SMA支架植入术后的管理显得特别重要,包括维持药物治疗以期获得支架的远期通畅性,ISR的超声及影像学检查等的早期识别和诊断,再干预治疗时机选择等。双功能超声(DUS)和SMA计算机断层扫描血管造影(CTA)检查用于ISR诊断具有较高的敏感度和特异度,目前已替代数字减影血管造影(DSA)检查成为术前诊断和筛查的首选。由于SMA缺血性病变造成的危害严重,若处理不及时可能造成肠管坏死,因此对因ISR出现相关临床症状的患者推荐尽快进行二次手术再干预治疗。手术方式可以选择二次腔内血管成形和(或)支架植入术,而针对那些易复发的病变或因解剖结构不利于进行二次腔内修复的患者,可以选择传统的外科开放手术,SMA旁路术是一种更加持久的选择,在高风险患者中以降低病死率。笔者针对SMA支架植入术后ISR的文献进行回顾,进而针对ISR的预防、诊疗策略和治疗进展进行归纳总结。Intestinal ischemia and hypoxia can occur when the superior mesenteric artery(SMA)becomes narrowed or occluded,leading to insufficient blood perfusion.This condition can result in mucosal damage and ischemic necrosis of the intestinal tissue.Restoring blood flow and relieving luminal stenosis is crucial for preventing intestinal necrosis.In recent years,endovascular stent implantation has become one of the primary treatment modalities for SMA stenosis due to its minimally invasive nature compared to open surgical revascularization.It offers advantages such as shorter hospitalization,reduced risk of complications,and lower mortality rates.The procedure has demonstrated favorable short-term clinical outcomes and is consistently recommended in guidelines.However,as stent implantation has become more widely used,in-stent restenosis(ISR)has gained attention after SMA stent implantation.Studies have indicated that patients with SMA stenosis treated with stents are more likely to develop ISR than those who undergo open surgical revascularization.Therefore,managing patients after SMA stent implantation is essential,including maintaining medication therapy to achieve long-term stent patency,early identification and diagnosis of ISR through ultrasound and imaging examinations,and selecting appropriate timing for reintervention.Dual-function ultrasound(DUS)and computed tomography angiography(CTA)demonstrate high sensitivity and specificity for ISR diagnosis and have replaced digital subtraction angiography(DSA)as the preferred preoperative diagnostic and screening tools.Due to the severe consequences of SMA ischemic lesions,such as intestinal necrosis,timely intervention is crucial.Therefore,patients presenting with relevant clinical symptoms of ISR should undergo secondary surgery as soon as possible.The surgical approach can involve repeating endovascular angioplasty and/or stent implantation.For patients with recurring lesions or anatomical constraints that make repeat endovascular repair difficult,traditional open surgi

关 键 词：肠系膜上动脉 缩窄 病理性 支架 移植物闭塞 血管 综述 

分 类 号：R654.3[医药卫生—外科学]