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。 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.
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。
动脉并发症,彩色多普勒超声,肝移植
Bo He1, Feng Wang2, Xin Wang2, Yunjin Zang2
1Qingdao University, Qingdao Shandong
2Affiliated Hospital of Qingdao University, Qingdao Shandong
Received: Jan. 17th, 2021; accepted: Feb. 2nd, 2021; published: Feb. 23rd, 2021
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.
Keywords:Arterial Complication, Color Doppler Ultrasound, Liver Transplantation
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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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 [
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。
观察组(n = 11) | 对照组(n = 429) | P | |
---|---|---|---|
年龄[(x ± s), y] | 48 ± 11 | 51 ± 10 | 0.33 |
性别 | 0.39 | ||
男 | 8 | 288 | |
女 | 3 | 53 | |
住院时间[(x ± s), d] | 60 ± 15 | 37 ± 17 | 0.12 |
BMI (x ± s) | 22.89 ± 3.48 | 24.14 ± 3.47 | 0.26 |
PT [M(Min, Max), s] | 14.7 [10.1, 50.9] | 14.6 [8.4, 79.1] | 0.7 |
INR [M(Min, Max)] | 1.25 [0.94, 4.7] | 1.21 [0.77, 8.08] | 0.56 |
ALB [(x ± s), g/L] | 32.76 ± 4.59 | 34.35 ± 11.85 | 0.31 |
TBil [M(Min, Max), umol/L] | 35.3 [13.6, 606] | 32 [4, 980] | 0.32 |
Child-Pugh评分(x ± s) | 8 ± 2 | 8 ± 2 | 0.42 |
MELD评分[M(Min, Max)] | 9.8 [6, 27] | 8.5 [2.2, 44.5] | 0.13 |
手术时间[(x ± s), min] | 555 ± 119 | 491 ± 105 | 0.10 |
无肝期时间[(x ± s), min] | 67 ± 25 | 57 ± 17 | 0.23 |
冷缺血时间[(x ± s), min] | 390 ± 112 | 347 ± 114 | 0.23 |
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)。
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。
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。
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)。
超声参数 | 观察组 | 对照组 | P值 | Cut-off值 | 敏感度 | 特异度 | AUC值 |
---|---|---|---|---|---|---|---|
D [M(Min, Max)] | 0.3 [0.2, 0.6] | 0.4 [0.28, 0.68] | 0.002 | 0.31 | 72.7% | 71.8% | 0.752 |
PSV [(x ± s), cm/s] | 49.49 ± 18.32 | 62.4 ± 25.74 | 0.04 | 58.1 | 81.8% | 48.9% | 0.623 |
RI (x ± s) | 0.56 ± 0.12 | 0.71 ± 0.12 | 0.003 | 0.58 | 72.7% | 85.1% | 0.794 |
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)。
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)。
超声参数 | 病例数 | 动脉并发症发生率(%) | OR |
---|---|---|---|
D (cm) | |||
≤0.31 | 130 | 6.1 | 6.67 |
>0.31 | 310 | 0.9 | |
PSV (cm/s) |
≤58.1 | 228 | 3.9 | 4.3 |
---|---|---|---|
>58.1 | 212 | 0.9 | |
RI | |||
≤0.58 | 73 | 10.9 | 14.78 |
>0.58 | 367 | 0.8 |
表3. 术后超声参数与动脉并发症的关系
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% [
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 [
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。
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Clinical Value of Color Doppler Ultrasound in Predicting Arterial Complications after Liver Transplantation[J]. 临床医学进展, 2021, 11(02): 611-616. https://doi.org/10.12677/ACM.2021.112089