急性主动脉夹层围手术期凝血与纤溶反应

摘要

目的 分析急性主动脉夹层围手术期凝血与纤溶反应的变化与夹层发生和手术过程的相关性,探讨其对手术结果的影响.方法 2011年8月至12月,30例患者在深低温停循环下(DHCA)行孙氏手术(主动脉弓部替换加象鼻支架手术),男22例,女8例;年龄(43±9.13)岁.术前诊断Stan-ford A型主动脉夹层26例;慢性动脉瘤4例.将病例分为急性组(A组)20例;慢性组(C组)10例.所有患者于围手术期各时间点检测血小板计数(PLT)纤维蛋白降解产物(FDP)、D-二聚体(D-dimer)、凝血酶-抗凝血酶Ⅲ复合物(TAT)、可溶性纤维蛋白单体(SFMC)等指标.对两组的观察指标进行独立样本t检验和配对样本t检验,计数资料做λ 2检验.结果 A组FDP术前、术后峰值水平均较C组显著升高[(57.3±75.1)mg/L、(63.5±53.8)mg/L对(3.7±4.1) mg/L、(14.2±6.7)mg/L,P＜0.05]; D-dimer术前、术后峰值均较C组显著升高[(2202.0 ±2518.8) μg/L、(4027.7±1830.7) μg/L对(377.9±376.4) μg/L( 1114.8±848.8) μg/L,P＜0.05].A组SFMC和TAT术前[(61.2±31.3) pg/ml和(9.4±5.2) ng/ml]及术后多个时间点水平均较C组[(29.9±6.3)pg/ml和(5.2±2.1)ng/ml]显著升高(P＜0.05).PLT A组术前(156.0±58.1)×109/L显著低于C组(239.3±99.1)×109/L(P ＜0.05),术后两组较术前均明显降低(P＜0.05).两组病例术后早期并发症的发生率差异有统计学意义(P＜0.05).结论 急性主动脉夹层围手术期凝血与纤溶活性增强与夹层病变本身和手术过程相关,会增加出凝血并发症发生的风险,影响手术结果.%Objective To studied perioperative changes in blood coagulation and the fibrinolytic system in patients undergoing acute aortic disec tion repair analyse the reason and outcome for these changes.Methods Between August 2011 and December 2011,30 patientsk[22 male and 8 female,mean aged (43.0±9.13) years] had undergone open repairs of aortic dissection or aneurysm with DHCA.Indications for surgical intervention were type A sortic dissection in 26 patients and aortic aneurysm in 4 patients.According to the time from clinical onset of the dissection to operation,acute group(less than 7 days,A group) 20 patients; chronic group (more than 30 days and aortic aneurysm,C group) 10 patients.Data were gathered for muhiple preoperative and intraoperative factors including age,sex,diagnosis,aortic dissection type,preoperative ejection fraction,aortic surgery history,surgical intervention type,cardiopulmonary bypass (CPB) time,aortic cross-clamp time,blood transfusion volume (PRBC),mechanic ventilation time,ICU length of stay and hospital length of stay.Platelet (PLT),fibrin degredation product (FDP),D-dimmer,thrombin-antithrombin (TAT),and soluble fibrin monomer complex (SFMC) were assayed before and after operation,as well as 0 h,24 h,48 h,72 h.These valuables were recorded and compared statistically between two groups.Results Preoperative serum level and postoperative peak level of FDP and D-dimmer in group A were significant higher than in gnoup C (P ＜ 0.05)and postopertive serum peak level in group C were significant higher than preoperative level (P ＜ 0.05 ).Preoperative snd postoperative most hours there was significant intergroup difference on the serum levels of SFMC and TAT (P ＜ 0.05 ).Preoperative level of PLT in group A is lower than in group C significantly (P ＜ 0.05 ).The level of PLT in each hour after surgery were much lower than the level before surgery in both group (P ＜0.05 ).In addition,thromhus fonantion in ascending aortic falsc lumen in group A was much moee common than in group C (P ＜0.05 ).There was significant difference on incidence of postoperative complications between two groups (P ＜ 0.05 ).Conclusion Activation of coagulation and fibrinolysis which results from acute aortic dissection and surgical procedure was obscrved before and after surgery to treat acute aortic dissection.There is increasing risk for consumption coagulopathy and thromboembolism during perioperative period.