Diagnosis and treatment strategies for vascular complications after kidney transplantation
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摘要: 随着肾移植供受者评估标准、器官获取保存方案、手术技术等不断进步，肾移植术后血管并发症的发生率有所下降，但仍是肾移植较为严重的手术并发症之一，可导致移植物丢失及受者死亡，严重影响肾移植效果。因此，本文就肾移植术后常见血管并发症，包括血管狭窄、动脉夹层、假性动脉瘤、血管破裂、血栓等的发生概况、临床表现、诊断和治疗策略进行综述，并结合西安交通大学第一附属医院肾移植术后血管并发症发生和诊治情况，总结肾移植术后常见血管并发症的诊疗策略，以期为肾移植术后血管并发症的临床诊断和治疗提供参考，降低血管并发症的发生率，提高肾移植疗效和受者生存率。Abstract: With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.
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图 1 不同类型移植肾动脉狭窄的治疗方式
注：A、B图为1例38岁男性患者，肾移植术后8个月，DSA示移植肾动脉主干全段狭窄，呈条索状，放置动脉支架移植肾功能恢复正常；C、D图为1例43岁男性患者，肾移植术后6个月，血清肌酐201 μmol/L，DSA示移植肾动脉分支重度狭窄，球囊扩张后放置动脉支架，术后血清肌酐降至120 μmol/L；E、F图为1例39岁女性患者，肾移植术后1年8个月，尿量减少，血清肌酐360 μmol/L，DSA示移植肾髂外动脉吻合处狭窄80%以上，放置动脉支架，移植肾血供正常化，血清肌酐降至155 μmol/L。
Figure 1. Treatment for different types of artery stenosis in renal allograft
图 2 肾移植术中髂外动脉夹层的治疗
注：1例33岁男性患者，术中发生髂外动脉夹层，切除血管夹层部分，行髂外动脉人工血管置换术，直径8 mm（白色箭头），移植肾动脉改与髂内动脉吻合（白色虚线箭头），肾功能恢复正常；术后3个月复查髂动脉CT血管造影，见置换部分的血管走行自然，近心端吻合口轻度狭窄。
Figure 2. Treatment of external iliac artery dissection during kidney transplantation
图 3 移植肾动脉和静脉血栓的治疗
注：A图为1例男性患者，肾移植术后少尿，移植肾超声示血流灌注差，移植肾动脉舒张期反向，考虑动脉血栓，行移植肾探查术，提示移植肾质软色苍白，动脉搏动消失；切除移植肾，剖开移植肾动脉可见条索状血栓形成（白色箭头）。B、C图为1例男性患者，肾移植术后7 d，DGF，尿量减少，移植肾超声示血流灌注差，血管树稀疏，皮质无血流，行移植肾探查术，移植肾色暗紫，提示移植肾静脉血栓，切除移植肾，剖开可见微血管血栓形成。
Figure 3. Treatment of artery and vein thrombosis in renal allograft
图 4 移植肾动脉破裂的治疗
注：1例男性患者，39岁，伤口泛耐药铜绿假单胞菌感染，肾移植术后2周出现伤口疼痛和引流量增多（血性液体），行移植肾探查，术中见移植肾动脉吻合口破裂，创面有感染征象，考虑为“感染性动脉炎”致破裂。切除移植肾和部分髂外动脉，结扎髂外动脉残端，行股动脉（白色虚线箭头）-人工血管（白色箭头+黑色虚线）-对侧股动脉转流术，术后监测双下肢血流及皮温基本正常。
Figure 4. Treatment of artery rupture in renal allograft
图 5 肾外型假性动脉瘤的治疗
注：1例男性患者，33岁，肾移植术后6个月，尿少伴肾功异常。A图为移植肾超声检查示灌注良好，右髂外动脉可见大小约25 mm×22 mm的囊性包块，与肾动脉相连，通道开口宽度约7 mm，彩色多普勒血流显像可见动脉血流，呈涡流状。B图为DSA示右髂外动脉假性动脉瘤。C、D图为放置一个Viabahn 直径10~50 mm覆膜支架，再次造影可见假性动脉瘤覆盖完全。
Figure 5. Treatment of extrarenal pseudoaneurysm
表 1 肾移植术后血管并发症概况
Table 1. Overview of vascular complications after kidney transplantation
血管并发症类型 n 术后发生时间 治疗方案 发生率（%） 移植肾动脉狭窄 36 0.5~7.0个月 PTA：球囊扩张术（3例），血管内支架植入术（33例） 1.56 髂外动脉夹层 5 <1 d（4例），
3个月（1例）人工血管置换术（3例），供者髂动脉搭桥术（1例），PTA（1例） 0.22 肾动脉破裂 4 2~18 d 肾切除术（3例），动脉修补术（1例） 0.17 肾静脉血栓 3 7~15 d 肾切除术（3例） 0.13 肾动脉血栓 2 7 d 肾切除术（1例），PTA（1例） 0.09 假性动脉瘤 2 4.5个月 PTA（2例） 0.09 肾动脉夹层 1 3 d PTA 0.04 肾动脉扭结 1 2 d 肾切除术 0.04 
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