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男性,59岁,高血压病二十年,近一月血压突然明显升高,肾功能减退,药物效差,超声提示:双臂动脉狭窄,双臂墙小.左肾明显。行选择性肾动脉造影(股动脉穿刺三次),右臂动脉近段狭窄90%,压差12KPa,左肾动脉中段狭窄80%.压差8KPa.行经皮腔内肾动脉成形术后造影,右侧残余狭窄10%,压差0.8KPa。左侧残余狭窄80%,压差2.6KPa,术后3小时出现脑缺氧症状.血压为零,应用多巴胺无效,改用肾上腺素后血压不稳定.10小时后查血色素明显降低,超声见腹后血肿、腹腔积液,腹穿抽出少许不血,经输血2200ml,补液等治疗48小时,血压稳定,但血色素不升.考虑(1)穿刺部位出血;(2)肾脏出血。由外科探查穿刺部位,术中见腹股沟韧带后、股动脉前一直径的1.5 mm小动脉听断增活动性出血,,即予结扎,股动脉穿刺口已无法辩认,腹腔留置引流管后返回病房,术中、术后共输血800ml,血色素由42g/L 升到65g/L,四周后出院,随访3个月血压正常.肾功接近正常.讨论:本例肾动脉成形术后腹膜后.腹腔同时出血.以肾脏损伤出血无法解释.穿刺部位出血可能性最大-出血进入腹腔原因则与股动脉穿刺破腹膜(穿刺点偏上)有关,同时穿刺针进入股动脉切听一小动脉,由于为动脉断增,压追不能止血,出血在流向腹膜后同时流入腹腔,而由于局部加压包扎及平卧放未形成血肿。提示股动脉穿刺点应谨防偏上,最好一次成功,术后要严密监测生命体征。
Male, 59 years old, Hypertension twenty years, Suddenly a sudden increase in blood pressure in recent January, renal dysfunction, poor drug efficacy, ultrasound prompted: arms and stenosis, small arms and left kidney. Row selective renal artery angiography (femoral artery puncture three times), right arm artery proximal stenosis 90%, pressure 12KPa, left middle renal artery stenosis 80%, pressure difference 8KPa. Percutaneous transrenal renal angioplasty angiography, right Residual stenosis 10%, pressure 0.8KPa. Left residual stenosis 80%, pressure 2.6KPa, 3 hours after the onset of cerebral hypoxia symptoms. Blood pressure is zero, the application of dopamine ineffective, use epinephrine blood pressure instability .10 hours after the check hemoglobin decreased significantly ultrasound see the abdomen After the hematoma, ascites, abdomen to draw a little blood, transfusion 2200ml, rehydration and other treatment for 48 hours, stable blood pressure, but the hemoglobin does not rise. Considering (1) puncture site bleeding; (2) renal bleeding. Surgical exploration of the puncture site, intraoperative see the inguinal ligament, the femoral artery diameter of 1.5 mm before the hearing of the arteriole hemorrhage hearing, that is to ligation, femoral artery puncture has been unable to identify the abdominal cavity after the drainage tube to return Ward, intraoperative and postoperative blood transfusion 800ml, hemoglobin rose from 42g / L to 65g / L, was discharged after four weeks, followed up for 3 months and normal blood pressure .Retine function is near normal .Discussion: In this case after renal artery angioplasty retroperitoneal. Intraperitoneal bleeding at the same time to kidney injury bleeding can not explain the puncture site bleeding the most likely cause of bleeding into the abdominal cavity with the femoral artery perforation of the peritoneum (puncture point on), while the puncture needle into the femoral artery to listen to a small artery, due to For the arterial cut-off, pressure chase can not stop the bleeding, bleeding into the peritoneal flow to the peritoneal at the same time, and as a result of local pressure bandaging and lying flat did not form hematoma. Tip femoral artery puncture point should beware of bias, the best a successful postoperative monitoring of vital signs must be closely monitored.