血管腔内胸腹主动脉瘤修复术后的全身炎症、凝血病和急性肾功能不全。
Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair.
作者信息
Chang Catherine K, Chuter Timothy A M, Niemann Claus U, Shlipak Michael G, Cohen Mitchell J, Reilly Linda M, Hiramoto Jade S
机构信息
Department of Surgery, Division of Vascular Surgery, University of California at San Francisco, San Francisco, Calif. 94143-0222 , USA.
出版信息
J Vasc Surg. 2009 May;49(5):1140-6. doi: 10.1016/j.jvs.2008.11.102.
OBJECTIVE
To characterize the inflammatory and coagulopathic response after endovascular thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the effect of the response on postoperative renal function.
METHODS
From July 2005 to June 2008, 42 patients underwent elective endovascular repair of a TAAA using custom designed multi-branched stent-grafts at a single academic institution. Four patients were excluded from the analysis. White blood cell count (WBC), platelet count, prothrombin time (PT), and creatinine were measured in all patients. In the last nine patients, interleukin-6 (IL-6), protein C, Factor V, d-dimers, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) levels were also measured. Change in lab values were expressed as a percentage of baseline values.
RESULTS
The 30-day mortality rate was 5% (2/38). All patients (n = 38) had a higher WBC (mean +/- SD: 139 +/- 80%, P < .0001), lower platelet count (56 +/- 15%, P < .0001), and higher PT (median: 17%, Interquartile range (IQR) 12%-22%, P < .0001) after stent-graft insertion. Twelve of 38 patients (32%) developed postoperative acute renal insufficiency (>50% rise in creatinine). Patients with renal insufficiency had significantly larger changes in WBC (178 +/- 100% vs 121 +/- 64%, P = .04) and platelet count (64 +/- 17% vs 52 +/- 12%, P = .02) compared with those without renal insufficiency. All patients (n = 9) had significant increases in NGAL (182 +/- 115%, P = .008) after stent-graft insertion. Six of nine patients (67%) had increased cystatin C (35 +/- 43%, P = .04) after stent-graft insertion, with a greater rise in those with postoperative renal insufficiency (87 +/- 32% vs 8 +/- 13%, P = .02). IL-6 levels were markedly increased in all patients (n = 9) after repair (9840 +/- 6160%, P = .008). Protein C (35 +/- 10%, P = .008) and Factor V levels (28 +/- 20%, P = .008) were uniformly decreased, while d-dimers were elevated after repair in all patients (310 +/- 213%, P = .008).
CONCLUSIONS
Leukocytosis and thrombocytopenia were uniform following endovascular TAAA repair, and the severity of the response correlated with post-operative renal dysfunction. Elevation of a sensitive marker of renal injury (NGAL) suggests that renal injury may occur in all patients after stent-graft insertion.
目的
描述血管腔内胸腹主动脉瘤（TAAA）修复术后的炎症反应和凝血功能障碍，并评估该反应对术后肾功能的影响。
方法
2005年7月至2008年6月，42例患者在单一学术机构接受了使用定制多分支支架型人工血管的择期血管腔内TAAA修复术。4例患者被排除在分析之外。对所有患者测量白细胞计数（WBC）、血小板计数、凝血酶原时间（PT）和肌酐。在最后9例患者中，还测量了白细胞介素-6（IL-6）、蛋白C、因子V、D-二聚体、胱抑素C和中性粒细胞明胶酶相关脂质运载蛋白（NGAL）水平。实验室值的变化以基线值的百分比表示。
结果
30天死亡率为5%（2/38）。所有患者（n = 38）在植入支架型人工血管后白细胞计数升高（平均值±标准差：139±80%，P <.0001），血小板计数降低（56±15%，P <.0001），PT升高（中位数：17%，四分位间距（IQR）12%-22%，P <.0001）。38例患者中有12例（32%）发生术后急性肾功能不全（肌酐升高>50%）。与无肾功能不全的患者相比，肾功能不全患者的白细胞计数（178±100%对121±64%，P =.04）和血小板计数（64±17%对52±12%，P =.02）变化更为显著。所有患者（n = 9）在植入支架型人工血管后NGAL均显著升高（182±115%，P =.008）。9例患者中有6例（67%）在植入支架型人工血管后胱抑素C升高（35±43%，P =.04），术后肾功能不全患者升高幅度更大（87±32%对8±13%，P =.02）。修复术后所有患者（n = 9）的IL-水平均显著升高（9840±6160%，P =.008）。蛋白C（35±10%，P =.008）和因子V水平（28±20%，P =.008）均降低，而所有患者修复后D-二聚体升高（310±213%，P =.008）。
结论
血管腔内TAAA修复术后白细胞增多和血小板减少较为常见，反应的严重程度与术后肾功能障碍相关。肾损伤敏感标志物（NGAL）升高表明植入支架型人工血管后所有患者均可能发生肾损伤。
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