可降解微型支架吻合鼠尾小血管的实验研究
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摘要
背景:微小血管吻合修复风险很高,已有许多实心、非可降解支架辅助小血管吻合的研究,但仍存在暂时性、创伤性等问题,因而可降解网格状血管内支架成为目前研究的热点。目的:探讨聚乳酸微型血管内支架吻合修复微小血管的可行性。方法:将聚乳酸纤维环经多向热拉伸、成形,制备"M"形微型支架,支架直径分为0.5 mm和1 mm 2种。将24只SD大鼠(上海西普尔-必凯实验动物有限责任公司提供)随机分为2组,实验组分别在大鼠尾根部与中部切断尾动脉,每个部位12只,随后在2部位断端分别植入直径1,0.5mm的聚乳酸微型支架,进行血管吻合;对照组同样在大鼠尾根部与中部切断尾动脉,每个部位12只,随后以传统显微缝合线吻合血管。记录2组血管吻合时间、吻合血管即时通畅率及再植断尾成活率;术后2周行超声Doppler检测,观察尾动脉通畅情况;术后4周,行尾动脉吻合口两端血管组织学检测。实验方案获得上海市第六人民医院奉贤分院伦理委员会批准,伦理批准号:20160225124025。结果与结论:①两组吻合血管即时通畅率为100%;实验组血管吻合时间少于对照组[(3.0±0.5),(5.0±0.6) min,P <0.05],再植断尾成活率高于对照组[(95.8±1.5)%,(91.7±1.7)%,P <0.05];②术后2周超声Doppler显示,实验组血管吻合口及其远、近侧尾动脉内均有血流通过,对照组血管吻合口及远侧尾动脉血栓形成,管腔闭塞;③苏木精-伊红染色显示,实验组尾动脉无血栓附壁,支架及吻合口完全被覆内膜,管腔通畅;对照组管腔呈扁圆形,可见附壁血栓形成,管腔部分狭窄;④结果表明,聚乳酸微型支架可满足微小血管吻合再植要求,明显缩短血管吻合手术时间,提高吻合缝合效果,提高再植断尾成活率。
BACKGROUND: Microvascular anastomosis is very risky. There have been many studies of solid,non-degradable stent-assisted small vessel anastomosis, but there are still temporary, traumatic issues.Thereafter, degradable woven-type stent becomes an issue of concern.OBJECTIVE: To investigate the feasibility of polylactic acid microvascular stent anastomosis for repairing micro vessels.METHODS: Polylactic acid fiber-loops were multi-directionally hot-stretched and formed to prepare micro-stent of"M" shape. The diameter of the stent was 0.5 or 1 mm. It was applied to the root and middle of the tail artery of 24 Sprague-Dawley rats(provided by Shanghai Xipuer-Beikai Experimental Animal Co., Ltd.). These rats were randomly divided into a stent anastomosis(group A)and a non-stent anastomosis(group B). The time of vascular anastomosis, the immediate patency rate of anastomotic vessels and the survival rate in both groups were recorded. Ultrasound Doppler observation was performed to observe the tail artery circulation at postoperative 2 weeks. The tail artery was histologically observed at postoperative 4 weeks. The experiment was approved by the Animal Ethics Committee of Fengxian Branch of the Sixth People's Hospital of Shanghai(approval number: 20160225124025).RESULTS AND CONCLUSION:(1) The immediate patency rate of anastomotic vessels in both groups was 100%. The anastomosis time in the group A was significantly shorter than that in the group B [(3.0±0.5) vs.(5.0±0.6) minutes, P < 0.05]. The survival rate of replantation in the group A was significantly higher than that in the control group [(95.8±1.5)% vs.(91.7±1.7)%, P < 0.05].(2) Ultrasound Doppler examination showed blood flow passed through the anastomotic orifice and its distal and proximal side in the group A, while in the group B, there was thrombosis at the anastomotic orifice and distal side, and the lumen was occluded.(3) Hematoxylin-eosin staining showed that there was no thrombus in the tail artery in the group A, the stent and the anastomosis were completely covered with the intima, and the lumen was smooth.The lumen in the group B was oblate, which showed a thrombus formation and a narrow lumen.(4) These results suggest that polylactic acid micro-stent can meet the requirements of microvascular anastomosis replantation, and can significantly shorten the time of vascular anastomosis, improve the effect of anastomosis and suture, and increase the survival rate of replantation.
BACKGROUND: Microvascular anastomosis is very risky. There have been many studies of solid,non-degradable stent-assisted small vessel anastomosis, but there are still temporary, traumatic issues.Thereafter, degradable woven-type stent becomes an issue of concern.OBJECTIVE: To investigate the feasibility of polylactic acid microvascular stent anastomosis for repairing micro vessels.METHODS: Polylactic acid fiber-loops were multi-directionally hot-stretched and formed to prepare micro-stent of"M" shape. The diameter of the stent was 0.5 or 1 mm. It was applied to the root and middle of the tail artery of 24 Sprague-Dawley rats(provided by Shanghai Xipuer-Beikai Experimental Animal Co., Ltd.). These rats were randomly divided into a stent anastomosis(group A)and a non-stent anastomosis(group B). The time of vascular anastomosis, the immediate patency rate of anastomotic vessels and the survival rate in both groups were recorded. Ultrasound Doppler observation was performed to observe the tail artery circulation at postoperative 2 weeks. The tail artery was histologically observed at postoperative 4 weeks. The experiment was approved by the Animal Ethics Committee of Fengxian Branch of the Sixth People's Hospital of Shanghai(approval number: 20160225124025).RESULTS AND CONCLUSION:(1) The immediate patency rate of anastomotic vessels in both groups was 100%. The anastomosis time in the group A was significantly shorter than that in the group B [(3.0±0.5) vs.(5.0±0.6) minutes, P < 0.05]. The survival rate of replantation in the group A was significantly higher than that in the control group [(95.8±1.5)% vs.(91.7±1.7)%, P < 0.05].(2) Ultrasound Doppler examination showed blood flow passed through the anastomotic orifice and its distal and proximal side in the group A, while in the group B, there was thrombosis at the anastomotic orifice and distal side, and the lumen was occluded.(3) Hematoxylin-eosin staining showed that there was no thrombus in the tail artery in the group A, the stent and the anastomosis were completely covered with the intima, and the lumen was smooth.The lumen in the group B was oblate, which showed a thrombus formation and a narrow lumen.(4) These results suggest that polylactic acid micro-stent can meet the requirements of microvascular anastomosis replantation, and can significantly shorten the time of vascular anastomosis, improve the effect of anastomosis and suture, and increase the survival rate of replantation.
引文
[1] Turan T,Kuran I,Sadikoglu B,et al. Eversion with four sutures:an easy, fast, and reliable technique for microvascular anastomosis.Plast Reconstr Surg.2001;107(2):463-470.
[2] Cordeiro PG.Re:combined microvascular anastomosis.Ann Plast Surg. 2002;49(2):217.
[3] Zeebregts CJ,Heijmen RH,van den Dungen JJ.Non-suture methods of vascular anastomosis.Br J Surg.2003;90(3):261-271.
[4] Jab?onska B.End-to-end ductal anastomosis in biliary reconstruction:indications and limitations.Can J Surg. 2014;57(4):271-277.
[5]王欢,顾玉东,董震,等.大鼠断尾再植模型[J].中国手外科志, 1998,14(2):108-109.
[6] Assersen K,S?rensen J.Intravascular stenting in microvascular anastomoses.J Reconstr Microsurg.2015;31(2):113-118.
[7]范启申.断指再植新进展与展望[J].实用手外科杂志, 2006,20(3):131-137.
[8]宋建星,郭恩覃.微型血管吻合夹与针线吻合方法的比较研究[J].中国修复重建外科杂志,2001,15(5):312-314.
[9]宋建星,郭恩覃.机械血管吻合技术[J].中华整形外科杂志, 2002,18(3):184-185.
[10] Senthil-Kumar P,Ng-Glazier JH,Randolph MA,et al.An intraluminal stent facilitates light-activated vascular anastomosis.J Trauma Acute Care Surg.2017;83(1 Suppl 1):S43-S49.
[11]张怡五,郭云玲,刘萍,等.Nakayama血管吻合器在四肢主要血管损伤修复中的运用[J].实用骨科杂志, 2002,8(6):455.
[12] Schohn T,Lequint T,Naito K,et al. A trick to improve the technique of the Intra Vascular Stent(IVa S):"Clip Stent".Ann Chir Plast Esthet. 2011;56(6):512-517.
[13]曾宪森,张保贵,高雅,等.可溶性血管内支架辅助小血管缝合的实验研究[J].中华显微外科杂志,1998,21(2):129-131.
[14]郝永玉,梁向党,孙赓.血管黏合吻合用速溶支架血液相容性实验研究[J].医疗卫生装备,2012,33(4):7-9.
[15] Sadeghi-Avalshahr AR,Khorsand-Ghayeni M,Nokhasteh S.Physical and mechanical characterization of PLLA interference screws produced by two stage injection molding method.Prog Biomater. 2016;5(3-4):183-191.
[16] Lizundia E,Petisco S,Sarasua JR.Phase-structure and mechanical properties of isothermally melt-and cold-crystallized poly(L-lactide).J Mech Behav Biomed Mater.2013;17:242-251.
[17] Agrawal CM,Haas KF,Leopold DA,et al.Evaluation of poly(L-lactic acid)as a material for intravascular polymeric stents.Biomaterials.1992;13:176-182.
[18]肖越勇,张金山.崔福斋,等.生物可降解性血管内支架的制备及其性能研究[J].中华放射学杂,2003,37(11):1136-1142.
[19] Tamai H,Igaki K,Kyo E,et al.Initial and 6-month results of biodegradable poly-l-lactic acid coronary stents in humans.Circulation. 2000;102:399-404.
[20] Nakano Y,Hori Y,Sato A,et al.Evaluation of a poly(L-lactic acid)stent for sutureless vascular anastomosis.Ann Vasc Surg. 2009;23(2):231-238..
[21] Bünger CM,Grabow N,Sternberg K,et al.Iliac anastomotic stenting with a biodegradable poly-L-lactide stent:a preliminary study after1 and 6 weeks.J Endovasc Ther.2006;13(4):539-548.
[22] Khorgami Z,Shoar SAminian A,et al. Stent-and-glue sutureless vascular anastomosis.Med Hypotheses. 2011;77(1):94-96.
[23]张金山.现代腹部介入放射学[M].北京:科学出版社,2000:239-241.
[24] Grabow N,Schlun M,Sternberg K,et al.Mechanical properties of laser cut poly(L-lactide)micro-specimens:implications for stent design, manufacture, and sterilization. J Biomech Eng. 2005;127:25-31.
[25]粟爽,李万甫.三种不同材料血管内支架的生物相容性[J].中国组织工程研究与临床康复,2008,12(17):3293-3232.
[26]姚军燕,秦能,杨青芳.生物医用高分子材料聚乳酸的成型方法研究[J].塑料工业,2004,32(10):6-8.
[27] Younes B,Fotheringham A,El-Dessouky HM,et al.Factorial optimization of the effects of melt-spinning conditions on as-spun aliphatic-aromatic copolyester fibers I. Spin draw ratio,overall orientation and drawability.Int J Polym Mater.2011;60:316-339.
[28] Maria P,Sung-Woo C,Mikael S.The effect of process variables on the properties of melt-spun poly(lactic acid)fibres for potential use as scaffold matrix materials.J Mater Sci.2013;48:3055-3066.
[29] Kim MS,Kim JC,Kim YH.Effects of take-up speed on the structure and properties of melt-spun poly(L-lactic acid)fibers.Polym Adv Technol. 2008;19:748-755.
[30] Moskovtz MJ,Browne E,Kononov A.Microvascular anastomosis ulilizing new intravascular stents.Ann Plast Sury.1994;32(6):44-49.
[31] Miyamoto S,Sakuraba M,Asano T,et al.Optimal technique or microvascular anastomosis of very small vessels:Comparative study of three techniques in a rat superficial inferior epigastric arterial flap model.J Plast Reconstr Aesthet Surg. 2010;63(7):1196-1201.
[32] Bauer F,Fichter AM,Loeffelbein DJ,et al.Microvascular anastomosis using modified micro-stents:a pilot in vivo study.J Craniomaxillofac Surg.2015;43(2):204-207.
[33] Narushima M,Koshima I,Mihara M,et al.Intravascular stenting(IVa S)for safe and precise supermicrosurgery.Ann Plast Surg.2008;60(1):41-44.
[34] Bossut C,Barbier O.Exploration of the intravascular stenting method for sub 1-mm vessels. J Reconstr Microsurg. 2011;27(8):461-468.
[35] Narushima M,Mihara M,Koshima I,et al.Intravascular stenting(IVa S)method for fingertip replantation.Ann Plast Surg. 2009;62(1):38-41.
[36]高洪,何鹤皋,曾炳芳,等.血管吻合技术与微栓子形成关系的实验研究[J].上海第二医科大学学报,2002,22(6):509-510.
[2] Cordeiro PG.Re:combined microvascular anastomosis.Ann Plast Surg. 2002;49(2):217.
[3] Zeebregts CJ,Heijmen RH,van den Dungen JJ.Non-suture methods of vascular anastomosis.Br J Surg.2003;90(3):261-271.
[4] Jab?onska B.End-to-end ductal anastomosis in biliary reconstruction:indications and limitations.Can J Surg. 2014;57(4):271-277.
[5]王欢,顾玉东,董震,等.大鼠断尾再植模型[J].中国手外科志, 1998,14(2):108-109.
[6] Assersen K,S?rensen J.Intravascular stenting in microvascular anastomoses.J Reconstr Microsurg.2015;31(2):113-118.
[7]范启申.断指再植新进展与展望[J].实用手外科杂志, 2006,20(3):131-137.
[8]宋建星,郭恩覃.微型血管吻合夹与针线吻合方法的比较研究[J].中国修复重建外科杂志,2001,15(5):312-314.
[9]宋建星,郭恩覃.机械血管吻合技术[J].中华整形外科杂志, 2002,18(3):184-185.
[10] Senthil-Kumar P,Ng-Glazier JH,Randolph MA,et al.An intraluminal stent facilitates light-activated vascular anastomosis.J Trauma Acute Care Surg.2017;83(1 Suppl 1):S43-S49.
[11]张怡五,郭云玲,刘萍,等.Nakayama血管吻合器在四肢主要血管损伤修复中的运用[J].实用骨科杂志, 2002,8(6):455.
[12] Schohn T,Lequint T,Naito K,et al. A trick to improve the technique of the Intra Vascular Stent(IVa S):"Clip Stent".Ann Chir Plast Esthet. 2011;56(6):512-517.
[13]曾宪森,张保贵,高雅,等.可溶性血管内支架辅助小血管缝合的实验研究[J].中华显微外科杂志,1998,21(2):129-131.
[14]郝永玉,梁向党,孙赓.血管黏合吻合用速溶支架血液相容性实验研究[J].医疗卫生装备,2012,33(4):7-9.
[15] Sadeghi-Avalshahr AR,Khorsand-Ghayeni M,Nokhasteh S.Physical and mechanical characterization of PLLA interference screws produced by two stage injection molding method.Prog Biomater. 2016;5(3-4):183-191.
[16] Lizundia E,Petisco S,Sarasua JR.Phase-structure and mechanical properties of isothermally melt-and cold-crystallized poly(L-lactide).J Mech Behav Biomed Mater.2013;17:242-251.
[17] Agrawal CM,Haas KF,Leopold DA,et al.Evaluation of poly(L-lactic acid)as a material for intravascular polymeric stents.Biomaterials.1992;13:176-182.
[18]肖越勇,张金山.崔福斋,等.生物可降解性血管内支架的制备及其性能研究[J].中华放射学杂,2003,37(11):1136-1142.
[19] Tamai H,Igaki K,Kyo E,et al.Initial and 6-month results of biodegradable poly-l-lactic acid coronary stents in humans.Circulation. 2000;102:399-404.
[20] Nakano Y,Hori Y,Sato A,et al.Evaluation of a poly(L-lactic acid)stent for sutureless vascular anastomosis.Ann Vasc Surg. 2009;23(2):231-238..
[21] Bünger CM,Grabow N,Sternberg K,et al.Iliac anastomotic stenting with a biodegradable poly-L-lactide stent:a preliminary study after1 and 6 weeks.J Endovasc Ther.2006;13(4):539-548.
[22] Khorgami Z,Shoar SAminian A,et al. Stent-and-glue sutureless vascular anastomosis.Med Hypotheses. 2011;77(1):94-96.
[23]张金山.现代腹部介入放射学[M].北京:科学出版社,2000:239-241.
[24] Grabow N,Schlun M,Sternberg K,et al.Mechanical properties of laser cut poly(L-lactide)micro-specimens:implications for stent design, manufacture, and sterilization. J Biomech Eng. 2005;127:25-31.
[25]粟爽,李万甫.三种不同材料血管内支架的生物相容性[J].中国组织工程研究与临床康复,2008,12(17):3293-3232.
[26]姚军燕,秦能,杨青芳.生物医用高分子材料聚乳酸的成型方法研究[J].塑料工业,2004,32(10):6-8.
[27] Younes B,Fotheringham A,El-Dessouky HM,et al.Factorial optimization of the effects of melt-spinning conditions on as-spun aliphatic-aromatic copolyester fibers I. Spin draw ratio,overall orientation and drawability.Int J Polym Mater.2011;60:316-339.
[28] Maria P,Sung-Woo C,Mikael S.The effect of process variables on the properties of melt-spun poly(lactic acid)fibres for potential use as scaffold matrix materials.J Mater Sci.2013;48:3055-3066.
[29] Kim MS,Kim JC,Kim YH.Effects of take-up speed on the structure and properties of melt-spun poly(L-lactic acid)fibers.Polym Adv Technol. 2008;19:748-755.
[30] Moskovtz MJ,Browne E,Kononov A.Microvascular anastomosis ulilizing new intravascular stents.Ann Plast Sury.1994;32(6):44-49.
[31] Miyamoto S,Sakuraba M,Asano T,et al.Optimal technique or microvascular anastomosis of very small vessels:Comparative study of three techniques in a rat superficial inferior epigastric arterial flap model.J Plast Reconstr Aesthet Surg. 2010;63(7):1196-1201.
[32] Bauer F,Fichter AM,Loeffelbein DJ,et al.Microvascular anastomosis using modified micro-stents:a pilot in vivo study.J Craniomaxillofac Surg.2015;43(2):204-207.
[33] Narushima M,Koshima I,Mihara M,et al.Intravascular stenting(IVa S)for safe and precise supermicrosurgery.Ann Plast Surg.2008;60(1):41-44.
[34] Bossut C,Barbier O.Exploration of the intravascular stenting method for sub 1-mm vessels. J Reconstr Microsurg. 2011;27(8):461-468.
[35] Narushima M,Mihara M,Koshima I,et al.Intravascular stenting(IVa S)method for fingertip replantation.Ann Plast Surg. 2009;62(1):38-41.
[36]高洪,何鹤皋,曾炳芳,等.血管吻合技术与微栓子形成关系的实验研究[J].上海第二医科大学学报,2002,22(6):509-510.