作者：宋强，高楚淇，杨睿博，胡志，张曈欣，杨林，强薇

单位：

1.710061陕西省西安市，西安交通大学第一附属医院结构性心脏病科 2.710061陕西省西安市，西安交通大学第一附属医院内分泌科 3.710061陕西省西安市，西安交通大学第一附属医院心血管内科 4.710061陕西省西安市，西安交通大学第一附属医院血管外科 通信作者：强薇，E-mail：weiqiang@xjtufh.edu.cn

Units：

1.Department of Structural Heart Disease, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China 2.Department of Endocrinology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China 3.Department of Cardiovascular Disease, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China 4.Department of Vascular Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China Corresponding author: QIANG Wei, E-mail: weiqiang@xjtufh.edu.cn

关键词：

横纹肌溶解; 急性动脉闭塞; 临床特征;

Keywords：

Rhabdomyolysis; Acute arterial occlusion; Clinical features

CLC：

DOI：

10.12114/j.issn.1008-5971.2022.00.072

Funds：

陕西省重点研发计划项目（2021SF-322）；陕西省自然科学基础研究计划项目（2020JQ-501）

摘要：

背景多种物理及非物理因素均可导致横纹肌溶解综合征(RM),其病因分布具有年龄特异性,对于青年及中年患者,运动为最常见的病因;而对于65岁以上患者,急性动脉闭塞是最常见的病因。目前急性动脉闭塞致RM的相关报道较少。目的 分析急性动脉闭塞致RM的临床特征。方法 选取2008年6月至2019年3月西安交通大学第一附属医院收治的急性动脉闭塞致RM患者17例为研究对象。收集患者基线资料、临床表现(包括急性动脉闭塞严重程度、持续性疼痛、患侧肢体苍白、无脉、感觉异常、运动障碍、肌肉疼痛、肌无力、茶色尿情况)、实验室检查指标〔包括肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、乳酸脱氢酶(LDH)、羟丁酸脱氢酶(HBDH)、肌红蛋白(MYO)、血钾、胱抑素C〕、治疗情况〔包括手术方式,二次手术情况,补液、碱化尿液治疗情况,连续性肾脏替代治疗(CRRT)情况〕、并发症〔包括再灌注损伤、急性肾损伤(AKI)、多器官功能障碍综合征(MODS)〕发生情况、转归。结果 17例患者中,男8例,女9例;平均年龄(67.4±9.9)岁;主诉主要为肢体疼痛〔14例(82.4%)〕;主要为下肢受累〔14例(82.4%)〕;平均起病至就诊时间(4.5±3.3)d;血管闭塞原因:下肢动脉硬化闭塞症合并急性血栓形成4例(23.5%),心房颤动栓塞13例(76.5%);闭塞血管部位主要为腹主动脉〔7例(41.2%)〕;8例(47.1%)患者存在感染;5例(29.4%)患者使用钙通道拮抗剂;11例(64.7%)患者使用调脂药。17例患者急性动脉闭塞严重程度主要为ⅡB级〔9例(52.9%)〕;17例患者中,出现持续性疼痛、肌肉疼痛17例(100.0%),患侧肢体苍白和感觉异常15例(88.2%),无脉13例(76.5%),肌无力4例(23.5%),无一例患者出现运动障碍和茶色尿。17例患者中,CK均升高,CK-MB升高13例(76.5%),AST升高14例(82.4%),ALT升高12例(70.6%),LDH升高12例(70.6%),HBDH升高13例(76.5%);有5例(29.4%)患者检测了MYO,其中MYO升高4例;血钾升高1例(5.9%)、降低1例(5.9%);胱抑素C升高5例(29.4%)。17例患者均进行了置管溶栓术,其中1例患者由于血管严重狭窄接受二次手术;16例患者接受了补液、碱化尿液治疗;3例患者进行了CRRT。6例患者发生了再灌注损伤;2例患者发生了AKI;2例患者发生了MODS。转归:治愈11例,截肢4例,死亡2例。结论 急性动脉闭塞致RM多见于65岁以上人群,其血管闭塞原因多为心房颤动栓塞,由于临床表现不典型易被漏诊,且多数患者就医不及时;除手术治疗外,应针对RM施治,必要时启用CRRT;对于肢体血供难以恢复或伴有严重感染的患者,必要时应截肢以保全生命。

Abstract：

【Abstract】　Background A variety of physical and non-physical factors can lead to rhabdomyolysis syndrome (RM) ,and its etiology distribution is age-specific. For young and middle-aged patients, exercise is the most common etiology, while forpatients over 65 years old, acute arterial occlusion is the most common etiology. At present, there are few reports on RM causedby acute arterial occlusion. Objective To analyze the clinical features of RM caused by acute arterial occlusion. MethodsSeventeen patients with RM caused by acute arterial occlusion who were admitted to the First Affiliated Hospital of Xi'an JiaotongUniversity from June 2008 to March 2019 were selected as the research objects. Baseline characteristics, clinical manifestations(including severity of acute arterial occlusion, persistent pain, pallor of the affected limb, pulselessness, paresthesia, dyskinesia,muscle pain, muscle weakness, and tea-colored urine) , laboratory test indicators [including creatine kinase (CK) , creatinekinase isoenzyme (CK-MB) , aspartate aminotransferase (AST) , alanine aminotransferase (ALT) , lactate dehydrogenase (LDH) ,hydroxybutyrate dehydrogenase (HBDH) , myoglobin (MYO) , serum potassium, cystatin C] , treatment [including surgery methods,secondary operation, rehydration and alkalized urine treatment, continuous renal replacement therapy (CRRT) ] , complications[including reperfusion injury, acute kidney injury (AKI) , multiple organ dysfunction syndrome (MODS) ] and outcomes of patientswere collected. Results Among the 17 patients, there were 8 males and 9 females and the average age was (67.4±9.9) yearsold. The main complaints were limb pain (14 cases, 82.4%) and lower limb involvement was observed in 14 cases (82.4%) . Theaverage duration from onset to visit was (4.5±3.3) d. The cause of vascular occlusion included lower extremity arterioscleroticocclusion complicated with acute thrombosis (4 cases, 23.5%) , and atrial fibrillation embolism (13 cases, 76.5%) . Aortaabdominalis was the mot frequently involved (7 cases, 41.2%) . Infection was present in 8 (47.1%) patients; calcium channelantagonists and lipid-lowering drugs were used in 5 (29.4%) and 11 (64.7%) patients, respectively. The severity of acute arterialocclusion in 17 patients was mainly grade ⅡB (9 cases, 52.9%) . All the 17 patients (100.0%) reported persistent pain and musclepain. Pallor and paresthesia of the affected limb were reported in 15 patients (88.2%) , pulseless in 13 cases (76.5%) and muscleweakness in 4 cases (23.5%) . None of the patients reported dyskinesia and tea-colored urine. CK elevated in all the 17 patientsand CK-MB elevated in 13 cases (76.5%) . AST and ALT increased in 14 cases (82.4%) and 12 cases (70.6%) , respectively.LDH elevated in 12 cases (70.6%) , and HBDH elevated in 13 cases (76.5%) . MYO was detected in 5 patients (29.4%) andelevation was observed in 4 of them. Serum potassium increased in 1 patient (5.9%) and decreased in 1 patient (5.9%) . CystatinC was elevated in 5 cases (29.4%) . All 17 patients underwent catheter thrombolysis, of which 1 patient underwent secondaryoperation due to severe vascular stenosis. Sixteen patients received rehydration and alkalized urine treatment, and 3 patientsunderwent CRRT. Reperfusion injury occurred in 6 patients. AKI and MODS occurred in 2 patients. Outcome: 11 cases werecured, 4 cases were amputated, and 2 cases died. Conclusion RM caused by acute arterial occlusion is more common in peopleover 65 years old, and the cause of vascular occlusion is mostly atrial fibrillation embolism. Atypical clinical manifestations oftenresult in missed diagnosis. Further, most patients do not seek medical treatment in time. In addition to surgical intervention, RMshould be addressed and CRRT should be used when necessary. For patients with limbs difficult for restoration of blood supply, oraccompanied with severe infection, amputation should be adopted to save life if necessary.

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