Advances in Clinical Medicine
Vol.08 No.02(2018), Article ID:24335,4 pages
10.12677/ACM.2018.82020

Poor Wound Healing after the STA-MCA Bypass: One Case Report

Yao Li, Yi Cao*, Juan Bao

Department of Cerebrovascular Disease, The Second Affiliated Hospital of Kunming Medical University, Kunming Yunnan

Received: Mar. 4th, 2018; accepted: Apr. 2nd, 2018; published: Apr. 9th, 2018

ABSTRACT

Superficial temporal artery-middle cerebral artery bypass surgery (STA-MCA) refers to the surgery that makes the vascular anastomosis between superficial temporal artery branches and middle cerebral artery. In 1967, the father of microneurosurgery, professor Yasargil first used this surgery to cure cerebral ischemic diseases and achieved great success. Its wide indications make this surgery widely used all over the world and continue to improve. Nowadays this surgery has been increasingly mature. One of the postoperative complications of it is poor wound healing. But this complication is not often to see in clinical work, here we report a case of poor wound healing after STA-MCA surgery.

Keywords:STA-MCA Bypass, Poor Wound Healing

颞浅动脉–大脑中动脉搭桥术后切口愈合不良一例

李尧,曹毅*,鲍娟

昆明医科大学第二附属医院脑血管病科,云南 昆明

收稿日期:2018年3月4日;录用日期:2018年4月2日;发布日期:2018年4月9日

摘 要

颞浅动脉–大脑中动脉搭桥术(STA-MCA)是指将颞浅动脉分支吻合于大脑中动脉的一种术式,1967年由显微神经外科之父Yasargil教授首次应用于治疗脑缺血疾病并获得成功,其广泛的适应症使得该术式在世界各国广泛普及并获得不断改进,目前该术式已日趋成熟。其术后并发症之一即是手术切口的愈合不良,但临床工作中该并发症较为少见,本文现报告一例搭桥术后切口愈合不良病例。

关键词 :颞浅动脉–大脑中动脉搭桥术,切口愈合不良

Copyright © 2018 by authors and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

1. 引言

脑血管搭桥术是指将两支脑血管进行吻合,保障脑组织的血液供应,从而防止脑梗死的发生,常见于颞浅动脉与大脑中动脉的搭桥,用以治疗颅内复杂动脉瘤(包括巨大动脉瘤)、脑肿瘤、烟雾病等疾病 [1] 。治疗颅内巨大动脉瘤时,由于无法直接行夹闭术,而栓塞术则花费巨大,较为理想的治疗方式是将载瘤动脉断离,使血液不能流入动脉瘤内而避免其发生破裂,然后将颞浅动脉搭桥于大脑中动脉,以保持脑组织的正常血流灌注。

2. 临床资料

患者女,43岁,因“反复头昏1月余”入院,行头颈动脉CTA示大脑中动脉M2段巨大动脉瘤。入院查体未见明显阳性体征,入院后行“超选性右侧大脑中动脉M2段动脉瘤造影术”,见动脉瘤呈梭形,大小约1.4 cm × 1.5 cm × 1.6 cm,瘤腔内可见明显造影剂滞留,远端自动脉瘤发出后分为两支血管,考虑为复杂动脉瘤。排外禁忌后行“右侧颞浅动脉–大脑中动脉M3段搭桥+右侧大脑中动脉M2段动脉瘤孤立切除术”;术中沿颞浅动脉走形作直切口并分离颞浅动脉顶支,解剖侧裂后见动脉瘤位于大脑中动脉下干起始部,选动脉瘤远端大脑中动脉M3段与分离好的颞浅动脉顶支行“端–侧吻合术”,夹闭动脉瘤近、远端后切除动脉瘤。术后给予常规切口换药,7天后发现切口愈合不良,部分皮缘发生皱缩坏死,可见皮下颅骨,予双氧水、生理盐水、聚维酮碘溶液行局部清创,切除坏死皮缘,敞开切口放置纱条引流,予庆大霉素局部冲洗预防感染,并敷涂重组人表皮生长因子、磺胺嘧啶银乳膏促进肉芽组织生长,持续每日换药30天后肉芽组织基本覆盖切口,皮缘未见坏死,行二期缝合,继续换药7天,患者手术切口愈合良好并拆线后出院(图1~4)。

3. 讨论

传统认为颞浅动脉–大脑中动脉搭桥术后手术切口的愈合不良主要与糖尿病、动脉硬化、营养状况、切口缝合方式、颞浅动脉额顶支同时用于搭桥等因素有关。糖尿病可作为影响术后切口愈合的一大重要因素,其确切机制目前尚不清楚,可能是多种复杂因素共同作用的结果 [2] ;动脉硬化可作为切口愈合不良的独立危险因素 [3] ;营养状况的不佳可导致切口愈合缓慢 [4] ;而切口缝合的层次、距离、组织对位亦可对切口愈合造成影响;颞浅动脉额顶支同时用于搭桥可明显减少同侧颞部血液供应而致头皮坏死。而年龄、性别、高血压和高脂血症与切口愈合未见明显相关 [5] 。近来,韩国学者Chung Y等人 [6] 对此提出了新的观点,其认为传统颞浅动脉分离技术沿颞浅动脉额顶支切开皮肤会直接破坏毛囊和皮脂腺,从而

Figure 1. Making a straight incision along STA

图1. 沿颞浅动脉走形作直切口

Figure 2. Separating parietal branch of STA

图2. 分离颞浅动脉顶支

使寄居于内的细菌释放出来,对周围组织造成感染;如果采用一种全新的术式(In-To-Out术式,简称ITO术式),即先切取颞浅动脉及其额顶支所属的弧形皮瓣,后由内向外地分离颞浅动脉将不会对毛囊和皮脂腺造成破坏。该种术式可显著降切口愈合不良的几率。该患者住院期间一般情况佳,否认糖尿病病史,围手术期血糖正常;术中DSA造影未见动脉硬化征象;营养状况可(BMI指数约21.5);手术切口缝合组织层次严密,无残腔,切口创面对合良好,缝合创缘边距、针距适可,缝合处张力适中;术中仅取颞浅动脉顶支参与搭桥。笔者认为患者术后发生手术切口愈合不良的原因可能为采取传统的颞浅动脉分离法,使毛囊和皮脂腺内细菌暴露于周围组织,从而使手术切口处发生严重感染;而对于术后发生的切口感染,临床医师更应采取积极有效的措施,如早期切口清创,清除坏死组织,消除局部病原菌,加强换药以预防病原菌再生,促进肉芽组织生长,待感染消退后行二期缝合;同时也应该关注患者全身情况如血糖、营养状况等,促使感染切口早日愈合。

4. 体会

该病例提示,颞浅动脉-大脑中动脉搭桥术后切口的愈合不良常较少见,因而往往得不到临床医师的

Figure 3. Patient with poor wound healing after STA-MCA bypass surgery

图3. 患者术后出现切口愈合不良

Figure 4. Patient with wound healing well

图4. 患者手术切口愈合

重视,其不仅为患者带来痛苦,加重经济负担,手术切口处的局部感染甚至可加重发展为严重的颅内感染,危及患者生命 [6] ;临床医师应在术前对患者进行全方位的病情评估,排外手术禁忌及潜在风险,并可尝试应用如ITO新术式,从而减少患者术后切口愈合不良等相关并发症的发生。

文章引用

李 尧,曹 毅,鲍 娟. 颞浅动脉–大脑中动脉搭桥术后切口愈合不良一例
Poor Wound Healing after the STA-MCA Bypass: One Case Report[J]. 临床医学进展, 2018, 08(02): 115-118. https://doi.org/10.12677/ACM.2018.82020

参考文献

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  2. 2. 褚月颉, 王鹏华. 糖尿病伤口愈合不良的相关机制[J]. 国际内分泌代谢杂志, 2014, 34(2): 131-134.

  3. 3. Katsuta, T., Inoue, T., Arakawa, S., et al. (2001) Cutaneous Necrosis after Superficial Temporal Artery-to-Middle Cerebral Artery Anastomosis: Is It Predictable or Avoidable? Neurosurgery, 49, 879-882.

  4. 4. Kavalukas, S.L. and Barbul, A. (2011) Nutrition and Wound Healing: An Update. Plastic & Reconstructive Surgery, 127, 38S-43S.

  5. 5. Takanari, K., Araki, Y., Okamoto, S., et al. (2015) Operative Wound-Related Complications after Cranial Revascularization Surgeries. Journal of Neurosurgery, 123, 1145-1150.

  6. 6. Chung, Y., Lee, S.H. and Choi, S.K. (2017) Fundamental Basis of Scalp Layering Techniques to Protect against Wound Infection: A Comparative Study between Conventional and In-to-Out Dissection of the Superficial Temporal Artery. World Neurosurgery, 97, 304-311.

  7. NOTES

    *通讯作者。

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