肢体移植物感染诊治策略  

Strategies for the diagnosis and treatment of limb graft infections

作　　者：张福先[1] 刘军乐 ZHANG Fu-xian;LIU Jun-le(Department of Vascular Surgery,Beijing Shijitan Hospital,Capital Medical University,Beijing 100038,China)

机构地区：[1]首都医科大学附属北京世纪坛医院血管外科,北京100038 [2]新疆维吾尔自治区人民医院克拉玛依医院(克拉玛依市中心医院)血管外科,新疆克拉玛依834000

出　　处：《中国实用外科杂志》2024年第12期1374-1378,共5页Chinese Journal of Practical Surgery

基　　金：国家自然科学基金面上项目(No.81570431);北京市科技计划课题(No.Z101107050210022)。

摘　　要：肢体动脉疾病主要包括血管狭窄、闭塞、扩张、外伤及外部侵犯等类型,严重威胁肢体功能及病人生命安全。治疗通常以药物为基础,传统开放手术或腔内介入手术为辅,其中血管移植物在血管重建中具有不可或缺的地位。现代血管移植物技术涵盖生物组织型、人工合成型、生物混合型、组织工程型及腔内介入型,虽在组织相容性、抗感染性及长期通畅性方面取得显著进展,但移植物感染仍是血管外科面临的重大挑战。传统开放手术中,自体静脉移植物因较强的抗感染能力而被优先选择。然而,当自体静脉不足时,需使用人工移植物(如涤纶、膨体聚四氟乙烯),但其感染发生率达1%~6%,并伴随高截肢率和死亡率。感染常由术区链球菌、葡萄球菌引起,多发性基础疾病及感染坏死切口也是感染发生的重要诱因。腔内手术因微创特点,感染发生率较低,但仍有罕见病例报告,如药物涂层支架感染可导致动脉血栓、假性动脉瘤等严重并发症。感染的诊断需结合临床表现、实验室检查及影像学评估。早期感染通常表现为发热、局部炎症及急性缺血,迟发感染则症状隐匿。影像学中,正电子发射计算机断层扫描(PET/CT)相较CT扫描在诊断敏感度(93%)和特异度(70%)方面更具优势。治疗策略以广谱抗生素联合外科手术为主,需彻底清除感染组织,移除受感染移植物,并重建血液循环。抗生素应优选能够穿透生物膜的药物(如利福平),疗程通常为4~6周或更长。外科重建方法包括原位重建及解剖旁路重建,其中自体静脉或同种异体血管为优选材料。通过综合多学科协作、围手术期严格的感染预防措施及新材料的研发,肢体血管移植物感染的诊治效果有望进一步改善。Limb arterial diseases,including vascular stenosis,occlusion,dilation,trauma,and external invasion,pose significant threats to limb function and patient survival.Treatment is typically based on pharmacological therapy,supplemented by traditional open surgery or endovascular interventions,with vascular grafts playing an indispensable role in vascular reconstruction.Modern vascular graft technologies encompass biological tissue,synthetic,biohybrid,tissue-engineered,and endovascular grafts.While significant progress has been made in biocompatibility,antiinfective properties,and long-term patency,graft infections remain a major challenge in vascular surgery.In traditional open surgery,autologous vein grafts are preferred due to their strong resistance to infection.However,when autologous veins are insufficient,synthetic grafts such as Dacron and expanded polytetrafluoroethylene(ePTFE) are used,though these carry an infection rate of 1%-6%,along with high amputation and mortality rates.Infections are commonly caused by streptococci or staphylococci at the surgical site,while multiple comorbidities and infected necrotic wounds are also significant risk factors.Endovascular procedures,due to their minimally invasive nature,have a lower infection rate,but rare cases have been reported,such as infections of drug-coated stents leading to severe complications like arterial thrombosis and pseudoaneurysms.The diagnosis of graft infections requires a combination of clinical presentation,laboratory tests,and imaging evaluations.Early infections typically manifest as fever,localized inflammation,and acute ischemia,while late-onset infections are often insidious.Among imaging modalities,positron emission tomography-computed tomography(PET/CT) demonstrates superior sensitivity(93%)and specificity(70%) compared to CT scans.The primary treatment strategy involves broad-spectrum antibiotics combined with surgical intervention,requiring thorough debridement of infected tissue,removal of infected grafts,and revascularization.Antibiotic

关 键 词：血管移植物 肢体动脉重建 感染防治 传统开放手术 腔内手术 抗生素治疗 外科清创 生物膜 

分 类 号：R6[医药卫生—外科学]