Humar A, Johnson E M, Payne W D, Dunn D L, Wrenshall L E, Najarian J S, Gruessner W G, Matas A J
Department of Surgery, University of Minnesota, Minneapolis, USA.
Surgery. 1998 Mar;123(3):344-50.
The purpose of this study was to review arterial thromboembolic complications presenting with an acutely ischemic lower extremity after a kidney (KTx) or simultaneous kidney-pancreas transplantation (SPK) and to describe an approach to their management.
We retrospectively reviewed all such transplantations (a total of 2109) performed between January 1985 and August 1995. We identified 16 recipients (incidence, 0.76%) in whom an acutely ischemic leg developed during the immediate postoperative period (within the first 48 hours).
Of the 16 recipients, eight underwent a KTx (incidence, 0.45%) and eight underwent an SPK transplantation (incidence, 2.90%). Median age was 38 years (range, 15 months to 61 years). Thirteen had insulin-dependent diabetes mellitus (IDDM), a significantly higher incidence than in the control group (i.e., transplant recipients without this complication) (p < 0.01). Peripheral vascular disease (PVD) was documented before operation in eight (50%) of the recipients (vs 8.9% in the control group) (p < 0.01). Ten were uremic (on chronic dialysis) before transplantation; six were nonuremic (not on dialysis). Intraoperatively, 14 had moderate to severe atherosclerotic disease affecting the iliac vessels, seven of whom required some manipulation of the artery (either endarterectomy or tacking of the intima) to make it suitable for anastomosis. Heparin was administered systemically during cross clamping to only four. Most of the 16 recipients showed symptoms or signs of arterial occlusion within the first few hours after operation. The most common symptom was pain; the most common physical finding was loss of femoral and distal pulses. Thirteen recipients had moderate to severe ischemia, as judged by physical examination; 15 returned to the operating room for surgical exploration. Eight underwent thrombectomy through an inguinal incision, with successful restoration of flow. Seven underwent exploration through the initial incision because of concern regarding the viability of the transplanted organ; five of them required transplant nephrectomy because of simultaneous thrombosis of the renal artery. No patient needed a bypass procedure to restore flow. Long-term morbidity as a result of the arterial occlusion was related to the severity and length of ischemia.
On the basis of these results, we suggest the following recommendations: (1) all patients should undergo a thorough peripheral vascular examination before and after transplantation; (2) patients at higher risk for arterial thromboembolic complications (e.g., those with significantly diseased vessel at intraoperative examination, nonuremic patients) should receive intraoperative systemic heparin before cross clamping of the artery; and (3) patients with signs or symptoms suggesting arterial occlusion after operation should undergo prompt surgical exploration.
本研究旨在回顾肾移植（KTx）或同期肾胰联合移植（SPK）后出现急性下肢缺血的动脉血栓栓塞并发症，并描述其处理方法。
我们回顾性分析了1985年1月至1995年8月期间进行的所有此类移植手术（共2109例）。我们确定了16例受者（发生率为0.76%），他们在术后即刻（48小时内）出现了急性下肢缺血。
16例受者中，8例行KTx（发生率为0.45%），8例行SPK移植（发生率为2.90%）。中位年龄为38岁（范围为15个月至61岁）。13例患有胰岛素依赖型糖尿病（IDDM），其发生率显著高于对照组（即无此并发症的移植受者）（p<0.01）。8例（50%）受者术前有外周血管疾病（PVD）记录（对照组为8.9%）（p<0.01）。10例移植前为尿毒症患者（接受慢性透析）；6例为非尿毒症患者（未透析）。术中，14例有中度至重度动脉粥样硬化疾病累及髂血管，其中7例需要对动脉进行某种操作（内膜切除术或内膜固定术）以使其适合吻合。交叉钳夹期间仅4例全身使用肝素。16例受者中的大多数在术后最初几小时内出现动脉闭塞的症状或体征。最常见的症状是疼痛；最常见的体格检查发现是股动脉和远端脉搏消失。根据体格检查判断，13例受者有中度至重度缺血；15例返回手术室进行手术探查。8例通过腹股沟切口行血栓切除术，血流成功恢复。7例因担心移植器官的存活情况通过原切口进行探查；其中5例因肾动脉同时血栓形成而需要行移植肾切除术。没有患者需要行旁路手术来恢复血流。动脉闭塞导致的长期发病率与缺血的严重程度和持续时间有关。
基于这些结果，我们提出以下建议：（1）所有患者在移植前后均应进行全面的外周血管检查；（2）动脉血栓栓塞并发症风险较高的患者（如术中检查血管病变严重的患者、非尿毒症患者）在动脉交叉钳夹前应接受术中全身肝素治疗；（3）术后出现提示动脉闭塞的症状或体征的患者应立即进行手术探查。
