Šarac Momir, Marjanović Ivan, Bezmarević Mihailo, Šarac Sanja, Milić Rade, Obradović Slobodan, Tomić Aleksandar
Vojnosanit Pregl. 2016 Jul;73(7):643-50. doi: 10.2298/VSP150510123S.
INTRODUCTION/AIM: The disturbances in hemostasis are often in open surgical repair (OR) and endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA). These changes may influence the perioperative and early postoperative period inducing serious complications. The aim of this study was to compare the impact of OR and EVAR of AAA on clot quality assessed by rotational thromboelastometry (ROTEM®) tests.
The study included 40 patients who underwent elective AAA surgery and were devided into two groups (the OR and the EVAR group - 20 patients in each group). The ROTEM ® test was performed in 4 points: point 1 - 10 min before starting anesthesia in both groups; point 2 - 10 min after aortic clapming in the OR group and 10 min after the stent-graft trunk release in the EVAR group; point 3 - 10 min after the releasing of aortic clamp in the OR group and 10 min after stentgraft placement and releasing the femoral clamp in the EVAR group; point 4 - one hour after the procedure in both groups. Three ROTEM® tests were performed as: extrinsically activated assay with tissue factor (EXTEM), intrinsically activated test using kaolin (INTEM), and extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (FIBTEM). All tests included the assessment of the maximum clot firmness (MCF) and the platelet component of clot strength was presented as maximal clot elasticity (MCE).
No significant difference in age, gender and diameter of AAA between groups was found. The time required for the procedure was significantly longer and loss of blood was greater in the OR group than in the EVAR group (p < 0.001). The significant deviation of MCF values in EXTEM test was found mainly in the point 3 (p ≤ 0.004) with significant difference between groups (p < 0.001). A significant difference of MCF values in INTEM test between groups was found in the points 3 and 4 (p < 0.001), which were dose-dependent by heparin sulfate. The MCF values in FIBTEM test were more prominent in the OR group than in the EVAR group without significant difference. The significant changes of MCF values in the FIBTEM test were found during time in both groups (p < 0.001). The values of MCE were lower in both groups, but without significant changes and difference between groups (p = 0.105).
The disorders of hemostatic parameters assessed by ROTEM® tests are present in both the OR and the EVAR groups being more prominent in OR of AAA. Vigilant monitoring of hemostatic parameters evaluated by ROTEM® tests could help in administration of the adequate and target therapy in patients who underwent EVAR or OR of AAA.
引言/目的：在腹主动脉瘤（AAA）的开放手术修复（OR）和血管腔内修复（EVAR）中，止血功能常常出现紊乱。这些变化可能会影响围手术期和术后早期，引发严重并发症。本研究的目的是比较AAA的OR和EVAR对通过旋转血栓弹力图（ROTEM®）测试评估的血凝块质量的影响。
该研究纳入了40例行择期AAA手术的患者，分为两组（OR组和EVAR组，每组20例患者）。在4个时间点进行ROTEM®测试：时间点1——两组均在麻醉开始前10分钟；时间点2——OR组在主动脉夹闭后10分钟，EVAR组在支架移植物主干释放后10分钟；时间点3——OR组在主动脉夹松开后10分钟，EVAR组在支架移植物置入并松开股动脉夹后10分钟；时间点4——两组均在手术后1小时。进行三项ROTEM®测试，分别为：使用组织因子的外源性激活检测（EXTEM）、使用高岭土的内源性激活检测（INTEM）以及使用组织因子和血小板抑制剂细胞松弛素D的外源性激活检测（FIBTEM）。所有测试均包括对最大血凝块硬度（MCF）的评估，血凝块强度的血小板成分以最大血凝块弹性（MCE）表示。
两组在年龄、性别和AAA直径方面未发现显著差异。OR组的手术所需时间明显长于EVAR组，失血量也更多（p < 0.001）。EXTEM测试中MCF值的显著偏差主要出现在时间点3（p≤0.004），两组之间存在显著差异（p < 0.001）。INTEM测试中，两组在时间点3和4的MCF值存在显著差异（p < 0.001），且呈硫酸肝素剂量依赖性。FIBTEM测试中，OR组的MCF值比EVAR组更显著，但无显著差异。两组在FIBTEM测试中，MCF值随时间均有显著变化（p < 0.001）。两组的MCE值均较低，但无显著变化且组间无差异（p = 0.105）。
通过ROTEM®测试评估的止血参数紊乱在OR组和EVAR组中均存在，在AAA的OR中更为突出。通过ROTEM®测试对止血参数进行密切监测有助于对接受AAA的EVAR或OR治疗的患者进行适当的靶向治疗。
