临床医学进展  >> Vol. 11 No. 2 (February 2021)

彩色多普勒超声在预测肝移植术后动脉并发症中的临床价值
Clinical Value of Color Doppler Ultrasound in Predicting Arterial Complications after Liver Transplantation

DOI: 10.12677/ACM.2021.112089, PDF, HTML, XML, 下载: 34  浏览: 110 

作者: 何 博:青岛大学,山东 青岛;王 峰, 王 新, 臧运金:青岛大学附属医院,山东 青岛

关键词: 动脉并发症彩色多普勒超声肝移植Arterial Complication Color Doppler Ultrasound Liver Transplantation

摘要: 目的:评价彩色多普勒超声(CD-US)血流动力学参数在肝移植术后肝动脉并发症中的预测价值。方法:将11例术后发生动脉并发症受者列为观察组,429例无动脉并发症受者列为对照组,采用两独立样本t检验或Wilcoxon符号秩和检验比较两组术后第1天血流动力学参数,通过受试者工作特征(ROC)曲线评价术后肝动脉直径、肝动脉收缩期峰值流速(PSV)、肝动脉阻力指数(RI)在预测术后动脉并发症的价值。P < 0.05差异有统计学意义。结果:观察组与对照组肝动脉直径(P = 0.002)、PSV (P = 0.04)、RI (P = 0.003)差异具有统计学意义。ROC曲线分析得出:当肝动脉直径 ≤ 0.31 cm、PSV ≤ 58.1 cm/s、RI ≤ 0.58时,预测动脉并发症的灵敏度分别为72.7%、81.8%、72.7%,特异度分别为71.8%,48.9%,85.1%,曲线下面积(AUC)分别为0.752 (95%CI: 0.588~0.917)、0.635 (95%CI: 0.481~0.790)、0.794 (95%CI: 0.643~0.945)。结论:术后彩色多普勒超声对动脉并发症具有良好的预测价值,术后应密切监测肝动脉血流动力学变化。
Abstract: Objective: We purposed to evaluate the value of hemodynamic parameters of color Doppler ultrasound (CD-US) in predicting hepatic artery complications after liver transplantation. Method: 11 patients with postoperative arterial complications were included in the observation group and 429 patients without arterial complications were included in the control group. Two independent samples t test or Wilcoxon signed rank sum test were used to compare the hemodynamic parameters of CD-US on the first day after operation. The value of postoperative arterial diameter, PSV and RI in predicting postoperative arterial complications was evaluated by receiver operating characteristic (ROC) curve. Result: There were statistical differences in hepatic artery diameter (P = 0.002), PSV (P = 0.04), RI (P = 0.003) between the observation group and the control group. Taking a hepatic artery diameter ≤ 0.31 cm, PSV of ≤ 58.1 cm/s and RI ≤ 0.6 as threshold to predict artery complications, the sensitivity and specificity were 72.7%, 81.8%, 72.7%, and 71.8%, 48.9%, 85.1%, respectively. AUC value of hepatic artery diameter, PSV and RI were 0.752 (95%CI: 0.588~0.917), 0.635 (95%CI: 0.481~0.790) and 0.794 (95%CI: 0.643~0.945), respectively. Conclusion: Postoperative CD-US has a good predictive value for arterial complications. The hemodynamic changes of hepatic artery should be routinely monitored after operation by CD-US.

文章引用: 何博, 王峰, 王新, 臧运金. 彩色多普勒超声在预测肝移植术后动脉并发症中的临床价值[J]. 临床医学进展, 2021, 11(2): 611-616. https://doi.org/10.12677/ACM.2021.112089

1. 引言

动脉并发症是肝移植术后最严重的并发症之一,主要包括肝动脉血栓形成、肝动脉狭窄、动脉吻合口漏等,可引起胆漏、败血症、肝功能衰竭,严重威胁受者预后 [1] [2] [3]。移植术后动脉并发症的早期预测有助于临床医师尽早采取措施,改善受者预后,降低死亡率。CD-US是监测肝移植术后动脉血流的首选方法,其对肝移植(LT)术后血管并发症的诊断价值已有报道 [4] [5] [6] [7]。但很少有研究应用CD-US血流动力学参数来早期预测动脉并发症。本研究分析了受者术后第1天肝脏血流动力学变化与动脉并发症的关系,评估了术后CD-US参数对动脉并发症的预测价值。现报道如下。

2. 资料与方法

2.1. 受者资料

2015年1月至2019年4月本中心共完成440例成人肝移植手术。其中男性369例,女性71例,平均年龄51 ± 10.0岁;原发病为肝恶性肿瘤229例,非肝恶性肿瘤211例;终末期肝病模型(MELD)评分中位数为8.5分(范围:0.2~44.5);身高体重指数(BMI)平均为24.11 ± 3.48;经典原位肝移植术421例,劈离式肝移植术19例。有11例受者发生了动脉并发症(4例肝动脉栓塞,5例肝动脉狭窄,2例动脉吻合口漏)。具体临床资料见表1。本研究经医院伦理委员会审核通过。

Table 1. Basic clinical data of patients

表1. 受试者一般资料

注:PT:凝血酶原时间(s)、INR:国际标准化比值、ALB:白蛋白(g/L)、TBil:总胆红素(umol/L)。

2.2. 研究方法

采用飞利浦iU Elite多功能彩色多普勒超声诊断仪凸阵变频C5-1探头(探头频率1.0~5.0 MHz,机械指数0.06)。术后第一周常规每日1次肝脏CD-US检查,第二周每2~3天1次,根据病情需要随时检查。高度怀疑动脉并发症时,可进一步行超声造影或肝动脉造影进行确诊。将11例术后动脉并发症受者列为观察组,429例无动脉并发症受者列为对照组,统计观察组与对照组术后第1天CD-US肝动脉直径(D)、PSV、RI,比较两组有无差别;采用ROC曲线评估CD-US血流动力学参数在预测术后动脉并发症中的价值。

2.3. 统计方法

使用R语言统计软件进行数据处理。计量资料先进行Kolmogorov-Smirnov正态性检验,符合正态分布的计量资料以均值 ± 标准差(x ± s)表示,组间比较采用两独立样本t检验。非正态分布计量资料以中位数(M)表示,组间比较采用Wilcoxon符号秩和检验。计数资料采用c2检验或Fisher确切概率法检验。采用受试者工作特征ROC曲线寻找最佳截断值来预测术后动脉并发症。P < 0.05差别具有统计学意义。

3. 结果

观察组与对照组术后动脉直径中位数分别为0.3 cm、0.4 cm,两组之间存在统计学差异(P = 0.002);术后PSV平均值分别为49.49 ± 18.32 cm/s、62.4 ± 25.74 cm/s,差异具有统计学意义(P = 0.04);术后RI平均值分别为0.56 ± 0.12、0.71 ± 0.12,差异具有统计学意义(P = 0.003)。ROC曲线分析显示肝动脉直径、PSV、RI的Cut-off值分别为0.31 cm (灵敏度:72.7%,特异度:71.8%,AUC值为0.752,95%CI:0.588~0.917)、58.1 cm/s (灵敏度:81.8%,特异度:48.9%,AUC值为0.635,95%CI:0.481~0.79)、0.58 (灵敏度:72.7%,特异度:85.1%,AUC值为0.794,95%CI:0.643~0.945) (表2)。RI显示出了最佳的预测效果(图1)。

Table 2. Prediction of arterial complications after transplantation by CD-US parameters

表2. 超声参数对移植术后动脉并发症的预测

注释:D:肝动脉直径(cm),PSV:动脉收缩期峰值流速(cm/s),RI:阻力指数((动脉收缩期峰值流速 − 舒张期末期流速)/动脉收缩期峰值流速)。

Figure 1. ROC curve showed the value of CD-US in predicting arterial complications after liver transplantation. It can be seen that the AUC value of RI is the largest, which has the best prediction effect

图1. ROC曲线显示术后彩色多普勒超声在预测肝移植术后动脉并发症中的价值。可见RI曲线下面积最大,具有最佳的预测效果

本研究中当受者肝动脉直径 ≤ 0.31 mm,PSV ≤ 58.1 cm,RI ≤ 0.58,其术后动脉并发症发生率分别为6.1% (8/130),3.9% (9/229),10.9% (8/73)。当受者肝动脉直径 > 0.31 mm,PSV > 58.1 cm,RI > 0.58,其术后动脉并发症发生率分别为0.9% (3/310),0.9% (2/212),0.8% (3/367) (表3)。

Table 3. Relation between postoperative CD-US parameters and arterial complications

表3. 术后超声参数与动脉并发症的关系

4. 讨论

肝移植术后动脉并发症是导致移植物功能丢失和受体死亡的主要原因之一,有文献统计成人原位肝移植术后动脉并发症的发生率在3%~9% [8]。目前认为动脉并发症与外科吻合技术、ABO血型不符、供受体血管质量、术前血红蛋白水平、CMV感染、动脉直径 < 3.5 mm、动脉变异等因素有关 [2] [9] [10] [11]。动脉并发症会引起肝坏死、肝脓肿、胆管并发症、肝功能衰竭,严重影响病人预后。动脉并发症的治疗方法包括外科血管重建、介入治疗、再次肝移植和保守治疗 [12]。本文中4例肝动脉栓塞受者均在介入下溶栓后再通;2例肝动脉狭窄受者在介入下行肝动脉球囊扩张 + 支架置入,血流恢复良好;余下3例狭窄受者行保守治,恢复满意;2例肝动脉吻合口漏,行手术止血,恢复良好。CD-US在评估肝移植术中、术后血流动力学变化中具有举足轻重的地位。已有文献通过分析术中肝动脉、门静脉血流与术后动脉并发症的关系,来评估其术后发生风险 [13]。我们的研究发现观察组和对照组的术后第一天肝动脉直径、PSV、RI差异均存在统计学意义,提示这些参数具有一定的临床指导意义。

肝动脉直径是术后动脉并发症的一个重要危险因素,动脉直径过细,易导致吻合口狭窄,进而导致动脉栓塞 [14]。本研究中动脉直径 ≤ 0.31 cm时,动脉并发症的发生风险是直径 > 0.31 cm的6.67倍。术后肝动脉PSV低,会导致门静脉血流代偿性增加,进一步影响肝动脉的血流,增加动脉并发症的发生风险 [15]。文中当PSV ≤ 58.1 cm/s时,其术后动脉并发症的发生风险是PSV > 58.1 cm/s的4.3倍。因此当术后超声提示动脉直径过细、肝动脉PSV水平较低时,应警惕动脉并发症的发生。RI是衡量血管阻力和顺应性的常用参数,反映了肝动脉收缩期与舒张期血流速度的变化梯度,是判断肝动脉血流的重要参数 [16]。正常的肝动脉RI在0.6~0.8之间,RI降低表明动脉血管壁弹性降低。Kaneko等人分析了术后肝动脉RI,认为肝动脉栓塞发生前2天RI逐渐下降,RI最佳截断值为0.6时,预测肝动脉栓塞的敏感性和特异性分别为83%和85% [5]。本文中,术后肝动脉RI ≤ 0.58预测动脉并发症的敏感性和特异性分别为72.7%和85.1%。ROC曲线分析显示RI曲线下面积最大,提示RI较动脉直径、PSV有更高的预测价值。

5. 结论

综上所诉,肝移植术后CD-US在预测动脉并发症中具有重要价值,术后采用CD-US监测肝动脉血流动力学变化十分重要。当移植术后超声提示肝动脉直径 ≤ 0.31 cm,PSV ≤ 58.1 cm/s,RI ≤ 0.58时,临床医师应保持警惕,谨防动脉并发症的发生。

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